Case reports: slices of real life to complement evidence.

With the growing emphasis on evidence-based practice, are case reports outdated relics of the professional literature? Clinicians, educators, and students increasingly ask this question when they see that case reports appear near the bottom of the hierarchy of evidence--listed above only expert opinion. (1)

It's true that case reports cannot establish cause-and-effect relationships between interventions and outcomes. It's also true that case reports cannot prove reliability or validity of measurements and cannot identify prognostic variables. What, then, do case reports contribute to evidence-based practice?

Case reports are descriptions of practice. Although most case reports published in Physical Therapy describe one or more patients, case reports can focus on any aspect of physical therapy that has not already been described well in the professional literature. Dr Jules Rothstein, our Editor in Chief, wrote that without descriptions of practice, "the world cannot possibly understand the patient management of which we are so proud, colleagues cannot engage in dialogue designed to improve patient care, and researchers are deprived of knowledge about the nuances of practice--which means that the research they conduct cannot be as applicable to practice as it needs to be." (2(p1062))

No other type of written professional communication gives the replicable, detailed, and credible descriptions of practice that case reports provide. They describe every step in the physical therapist patient/client management process: examination, evaluation, diagnosis, prognosis, and intervention. (3) Textbooks do not give this level of detail, and continuing education case examples rarely provide an evidence-based rationale for clinical decisions. Research reports often describe an intervention or the use of a measurement in replicable detail, but they almost never describe the entire decision-making process for an individual patient--and that process is the reality that clinicians and students face every day. Case reports are real life.

Case reports describe what physical therapists and physical therapists assistants ideally do. I say "ideally" because a good case report exemplifies the definition of evidence-based practice--"the integration of the best available research evidence with clinical experience and patient values." (1(p1)) Research evidence is important, but it is not the only component of evidence-based practice. Even when research evidence is available, clinicians need to consider the evidence along with their own experiences and their patients' preferences and unique circumstances.

What if research evidence is not available? This happens all the time, and it is not a barrier to writing a publishable case report. Authors just need to give solid rationale for their decisions and the necessary details about what they did and why. Perhaps the case report will stimulate research that will provide needed evidence in the future. One of the purposes of case reports is to identify relevant variables for researchers to investigate. (4)

Case reports are ideal vehicles for students, clinicians, and clinically oriented faculty to both contribute to the scholarship of the physical therapy profession and benefit from the excellent professional development experience that writing a case report offers. Publication of case reports can be particularly valuable for faculty members who are not engaged in research but need to demonstrate their scholarship to help their education programs meet the standards of the Commission on Accreditation in Physical Therapy Education (CAPTE). Good case reports illustrate the scholarship of practice.

Since 1995, we have published 65 case reports in Physical Therapy, covering almost every area of physical therapist practice. In 2003, case reports emphasized the application of research results to patients, (5) diagnosis, (6) intervention, (7) use of assistive technology, (8) a rare patient experience, (9) and the application of a general decision-making process to a specific patient. (10) Some of these case report authors had never previously written for publication; others had long lists of previous publications. But what all published case report authors have in common is the ability to clearly describe their patient management and to give good rationales for their decisions. If they are not able to do this with the first submission, they persevere through the revision process until they can meet standards for publication.

The Editorial Board, the reviewers, and I read each case report manuscript with the belief that it is publishable. Our job is to give authors the feedback required to make it publishable; the authors' job is to take the feedback and make the necessary revisions. Publication--like graduate education, athletic success, and good parenting--requires "stick-to-it-ive-ness" and an ability to accept and learn from constructive criticism. After reading every case report--and every review of every case report--submitted to Physical Therapy during the past several years, I've noted 4 problems that account for 90% of the revisions that review teams ask authors to make. Eliminating these problems before submitting the case report is the key to a positive initial review:

* Claims of cause-and-effect relationships between interventions and outcomes. Because case reports are not research and do not have the controls of research, such claims are not warranted. The first clue that an author has made such a claim is use of the word "effect" or "effectiveness" in the title of the manuscript or in the abstract.

* Lack of information about the reliability and validity of measurements. This is a particular problem for outcome measurements. Why should a reader believe that a change in scores was due to a change in the patient rather than due to measurement error? Authors need to convince readers that measurements were reliable by reporting (briefly, in just a few sentences) published reliability studies with similar patients, by conducting their own mini-reliability study, or by making a presumptive argument. (4)

* Lack of detail about the examination and the intervention. These components of patient management need to be described so thoroughly that clinicians could replicate them with similar patients.

* Lack of detail about decision making. Too often, case reports leap from the last examination measurement to the intervention, with no description of the decision making (evaluation, diagnosis, prognosis) that took place between them. The Guide to Physical Therapist Practice (3) is a good resource for authors. Writing Case Reports: A How-to Manual for Clinicians (4) explains how to avoid common and not-so-common problems.

Interested in writing a case report? Have a topic that you believe would be appropriate for a case report, but feel uncertain how to proceed? Please contact Irene McEwen, Editor for Case Reports, [e-mail].

Thanks to an increasing number of case report authors, in 2003 we met our goal of publishing an average of one case report its each issue of the Journal. When I commented about achieving this goal during a recent Editorial Board meeting, Dr Rothstein didn't pause for so much as a millisecond before he declared, "What we need is 2 case reports in each issue!"

Our job is cut out for us. Clinicians, faculty members, and students: Your case reports are needed in the quest for evidence-based physical therapist practice!

References

(1) Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. New York, NY: Churchill Livingstone Inc; 2000.

(2) Rothstein JM. Case reports: still a priority [editor's note]. Phys Ther. 2002;82:1062-1063.

(3) Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9-744.

(4) McEwen I, ed. Writing Case Reports: A How-to Manual for Clinicians. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.

(5) Bonifer N, Anderson KM. Application of constraint-induced movement therapy for an individual with severe chronic upper-extremity hemiplegia. Phys Ther. 2003;83:384-398.

(6) Cleland JA, Venzke JW. Dermatomyositis: evolution of a diagnosis. Phys Ther. 2003;83:932-945.

(7) Shrader JA, Siegel KL. Nonoperative management of functional hallux limitus in a patient with rheumatoid arthritis. Phys Ther. 2003;83:831-843.

(8) Jones MA, McEwen IR, Hansen L. Use of power mobility for a young child with spinal muscular atrophy. Phys Ther. 2003;83:253-262.

(9) Ruhland JL, van Kan PLE. Middle pontine hemorrhagic stroke. Phys Ther. 2003;83:552-566.

(10) Riddle DL, Rothstein. JM, Echternach JL. Application of the HOAC II: an episode of care for a patient with low back pain. Phys Ther. 2003;83:471-485.