Chiropractic sits at an interesting junction in terms of research. We do indeed possess a strong evidence base when it comes to randomized control trials, especially those related to conditions like low back pain. But the evidence in the bank doesn’t yet cover every aspect of what we do. Furthering research is an expensive and time-consuming investment that is absolutely vital for the future the profession. While we wait for the big studies to hit the journals, there is something else worth our attention though: the humble case report – a clinically relevant tool that is often overlooked.
Here at Spinal Research, we recently launched our strategic goal – a bold pledge to facilitate $1,000,000 in vertebral subluxation research in the next five years. This was driven by a need acknowledged throughout the profession, and is one we are honoured to carry out.
Research does indeed carry weight – an important factor during times when the lenses of politics or media become fixed on our profession. Still, it would be a rare occasion when a patient presents at a chiropractic clinic and says, “Can I see scholarly evidence behind that maneuver before you adjust me?”
Research has the potential to silence the critics, or at least dull their roar. It has the potential to increase our certainty, clarity and confidence, and to make communicating the power of chiropractic a whole lot easier. It might seem as if we are at the beginning of a long road when it comes to research, and truly the road is one without an endpoint, but what we do have is a solid and steadily increasing body of evidence.
The Role of the Case Report in Chiropractic Evidence
One class of evidence is the case report (sometimes called the case study). It does not sit atop the hierarchy in terms of research, but it can provide guidance clinicians can use. Dana Lawrence, editor for the Chiropractic Journal of Australia and former editor for JMPT and other chiropractic journals, believes that case reports play an important role in the evidence bank. His is an academic perspective, having spent years as a journal editor and currently teaching a scientific writing course. Lawrence’s perspective is an interesting one. He says:
“I have never been one to look down at case reports: they are often the only evidence we have, since we lack higher evidence for many things we do. Even though they cannot be used as definitive evidence, they provide useful information on patient management. Case reports also demonstrate to a wider healthcare community the full scope of what we do – diagnostically, therapeutically, management-wise etc.
But we need caution – case reports, above all else, must be educational. Thus, the first question I always ask novice writers is: what do you want people to learn by reading this? What is the key take-home message? What is novel here? What gap in the literature does it fill? A case report on the successful management of a patient with low back pain treated with side-posture manipulation is useless; we have higher levels of evidence. One about co-management with medical professionals of a patient with brucellosis is justifiable since it is unexpected, novel, educational and might otherwise be easily dismissed as outside scope.”
Lawrence’s statement should provoke thought when it comes to what we do with literature gaps: We can wait until the RCT’s are funded and written, or we can contribute to the filling of the knowledge gap while we wait. The evidence could be in your clinic, simply unwritten as yet. It won’t carry the weight of an RCT, but it will indeed carry weight.
Dr. Pamela Stone, a McCoy Press editor and busy chiropractor, points out that the value of the case report lies in describing what happened, both in terms of the clinicians approach and in terms of the physiological changes experienced by the individual under care. This level of detail is something that clinicians can glean value from.
A case report allows us to do something else essential to the chiropractic paradigm: view the presenting case through the lens of a chiropractic approach to patient diagnosis and management. Instead of asking, “can chiropractic treat condition-X”, an approach many chiropractors find jarring given the treatment focus, we can be showing what happened to patient-X after a subluxation pattern was corrected.
Of course, this is a point that must come with clarification: each subluxation is unique. So too are the ways in which this may affect the physiology of the person under care. Therefore, to focus exclusively on the presence of a subluxation would offer us nothing substantial in terms of evidence.
In order for a case report to be novel and educational, it needs to have a basis for determination as to why the patient was checked and adjusted in the manner described. This comes in the form of a diagnosis. It needs to be present on the patient case file, and the same is true for a case report. This person came to you for a reason. What was that reason? This symptom (or symptoms) can be the case-reports headline and the basis for outcome measures, even if their treatment centres on the chiropractic cornerstone – the subluxation.
Far from being a step outside of our modality, it gives us a means of presenting our process and outcomes in a meaningful way for academics, patients and policy-makers alike.
Case reports do indeed hold a place in the hierarchy of evidence. They do require us to use symptoms and diagnoses as a means of presenting our findings, but they afford us the unique ability to describe how our process and the removal of subluxations fed into successful management of the person under care.
How do you Write a Case Report?
For chiropractic clinicians, the “publish or perish” mindset is wonderfully absent. Still, many of the stories that could contribute to the profession’s evidence base are walking in and out of our clinics and remain undocumented. The unfortunate thing is that many a burgeoning case-report author may have been scared off by the apparent enormity of the publication process. Encouragingly, its something Dr. Stone paints as quite achievable. “We get a lot of repeat authors. Once they learn how to do it, they’ll do a second one. They get the hang of it,” she says. So where do you start? Here are some hints from the experts.
Start with a topic that lacks higher evidence. Perhaps the best starting point is Lawrence’s question: what gap in the literature does this case report fill? What will people learn by reading this? If something springs to mind, then your first step is a to-do list. There’s no shortage of guides on how to prepare a case report for publication. McCoy Press has one on their website (here) that takes some of the mystery out of the process. In fact, most journals or universities will have a guide on how to submit such work. When spelled out in black and white, it’s not actually as difficult as one might think.
Don’t just focus on the pain
A common problem with a lot of evidence that currently exists around chiropractic is that it focuses on the pain or the condition, rather than the subluxation. “We are looking things that aren’t pain based. The paper can be written so you are treating the subluxation, and the symptoms decreased, then that’s fine. We can work with that,” says Stone of the McCoy Press approach. Once again, the distinction is important: pain or symptoms must be used as a frame of reference in terms of patient management and outcomes, but the detail of the report is where the subluxation-focus comes in.
Record outcome measures throughout the process and take good notes
Dr. Stone gives some pragmatic advice when it comes to the process of undertaking a case-report. A lot of this, chiropractors will already be doing. The rest is common sense. “We are only going to publish something if there’s a good outcome,” says Stone. It’s an approach echoed in pharmaceutical and allopathically based medicine – the negative outcomes tend not to be published.
She then moves on to the process of measuring and notating the case. “There has to be some clinical analysis. They have to be, clinically, a good doctor. There have to be objective measurements, and they have to document good notes. Sometimes we have to say ‘we can’t publish that’ because the notes aren’t good. Some are very detailed which is fine. Some are not. There have to be good notes documenting what they found.”
“There are some fundamentals that all chiropractors should really have in place already in their practice,” says Dr Dave Russell, a veteran of the case-report publishing world. “The essentials are; excellent history, exam and visit notes, a specific technique and assessment protocol used routinely during patient care, and great systems to measure subjective and objective outcomes both before care starts and at regular progress exams. I think chiropractors believe these outcome measures take too long and add too much to the patient’s assessment, but that really isn’t true. Subjective measures could be as simple as a 10-point pain scale, a Likert scale or any number of validated assessment. Objective measures are just as quick and easy, measured posture and Range of Motion, sEMG, Thermography, HRV, and indicated subluxations based on a set technique protocol. If chiropractors aren’t doing this routinely already the best thing to do is to start by including these as assessments with all your patients, make it a part of your procedure and you will have the data ready to write a case report.”
Look out for common pitfalls
The most common problems with case reports are easily avoided if you can call to remembrance your university days. “Errors in grammar, inaccurate information and poor or incorrect references,” are the most common problems according to Stone. The quality of the references matter too. Websites don’t cut it. Journal articles are what editors look for in a reference list. Don’t forget to bear in mind the preferred reference style of the journal you are submitting to.
You will almost definitely get feedback from the editors, but according to Dr. Russell, this is par for the course. “When publishing don’t be disappointed with the reviewers feedback. They can seem harsh but they are trying to direct you to refine and improve your paper. Be specific and efficient with your writing and you will have a worthwhile paper to submit for publication…and don’t be afraid to use chiropractic terminology, just make sure you define the terms.”
Another common error is over-claiming. It might be tempting to let enthusiasm for a persons progress cause you to state that because this person got better, you’ve shown your treatment is effective for their condition. But to say so would require a clinical trial. Stick to the boundaries of what the case can support. In time, we may just find that the clinical trial gets done! But until then, exercising caution in our claims is prudent.
Consider Using Student Interns or Students on Placement to Help you Write it
This is a handy hint that has helped a lot of chiropractors get published. “Use students who are in chiropractic school, who are used to writing,” suggests Stone. “They can do a lot of the dirty work in terms of the literature review, and then the doctor does the notes. Students like this because then they get published, and it works for the docs because it helps them get the work done.” As many a student hour is spent in clinic towards the end of a chiropractic degree, this can be a mutually beneficial way for students to further immerse themselves in the learning experience.
A note of caution though: patient privacy must always be paramount, and their information can’t be shared without permission. Likewise, any moves to involve a student in putting together a paper must be cleared with the college the student attends in order to make sure there are no ethical or authorship issues.
Consider Rallying a Group to do a Case Series
“We have authors who will repeat similar stories with different patients. But if you can get ten different chiropractors to submit their case studies on similar situations then you have a series. says Stone of McCoy’s present drive towards case series’.
“It’s hard to use exactly the same approach, as everyone adjusts differently,” says Stone. “But if you all have a pregnant woman with low back pain and a subluxation pattern, and you correct the subluxation, then you have something that can be compared.” A case series will still be a series of individual case reports, meaning we still can’t generalize using the information, but it still adds to the evidence bank in a clinically relevant way.
There is a Place for Case Reports and Case Series in Evidence
“Case reports and series are truly a clinical result from the real world, often times they are the underpinnings of larger research projects further down the track. However, it must be stressed that each case only represents one persons response to care so that doesn’t mean the result will be the same for everyone…but it is a great place to start, and too often as a profession we shy away from celebrating the individual cases we see,” says Dr Russell.
He went on to point out that at the most recent Association of Chiropractic Colleges and World Federation of Chiropractic Research Symposium (Washington DC, USA), case studies accounted for about 40% of the clinical practice oriented papers presented, so really they aren’t insignificant at all.
Remember, not all cases have to be a miracle in order to be valid. It may simply be improvements in mobility or quality of life. These are the small miracles that we see every day, and they are certainly not insignificant. Every piece that is noted down with measurable differences and good notes can make for another piece of evidence backing chiropractic as a profession.