Case reports: still a priority. (Editor's Note).

When I became Editor of this Journal 13 years ago, I devoted part of my first Editor's Note to making a plea for case reports. Before that time, the Journal's policy was that case reports were reserved for unusual or unique patients or novel interventions. As the new Editor, I held that case reports were indeed reserved for the unique--but I suggested a new operational definition of what is "unusual" or "novel." Our philosophy about case reports remains the following:

   Any patient or patient management scheme that has not been previously
   described in the literature is novel and worthy of reporting in a case
   report.

Perhaps it seems odd that we would consider almost any type of patient to be "fair game" for a case report, but it reflects a practical necessity. In physical therapy, we lack a literature that describes--in replicable detail--what we do with patients. Without such a literature, 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.

Since 1989, the number of case report submissions to the Journal has grown, and, thanks to our Editor for Case Reports, Dr Irene McEwen, this element of the journal is thriving. In 1996, Dr McEwen, our Managing Editor Jan Reynolds, and a very capable team of contributors developed Writing Case Reports: A How-to Manual for Clinicians, a resource that can help authors prepare and successfully submit case reports. Thanks to these efforts--as well as those of our Editorial Board members, our reviewers, and, of course, our authors--case reports in this Journal remain illustrative and have never become, as some had predicted, a less-than-credible form of communication.

With the arrival of the first edition of APTA's Guide to Physical Therapist Practice (Guide) in 1997, practitioners and especially potential authors of case reports were given a framework on which they could build their case reports. Although we do not make the Guide binding on Journal authors, the benefits of relating to the Guide should be clear. One of the brilliant aspects of the Guide is the codification of the 5 elements of patient/client management (examination, evaluation, diagnosis, prognosis, and intervention). This goes a long way toward providing physical therapists with a common language to talk about patient care. However, although the Guide gives a framework, the devil is in the details, and unless our literature addresses the 5 elements with discernible language, we will have gained little.

One reason why case reports are so vital to our profession and to other professions is that they provide a forum for communication and for refinement of language. Physical therapists, like others dealing with biomedical issues, are both blessed and cursed by a popular shorthand form of communication that I call "jargon." When new physical therapists conquer this arcane language, they feel as though they've "arrived." If they report that "the patient says she never broke her leg," they sound like an outsider; whereas if they report that "the patient denies ever breaking her leg," they sound like they're part of a professional group, able to hold their own among those who know the code.

There are many other examples of "the code." In at least one subculture within our profession, "pain" has been replaced by "pain symptoms." Many of us use "tone" without knowing how our audience defines it. We talk about measuring strength, yet give no hint whatsoever as to what we have measured. When we use these words that we believe are central to the profession's identity, we announce who we are and what we do. Shouldn't these words have real meaning--and not just to members of our profession but to the wider community of colleagues, payers, and other practitioners?

As a Journal Editor, I can be accused of pedantic excess and dismissed as a compulsive meddler looking for a task in every manuscript, but years of experience tell me that I am not alone in being perplexed by the words we use. Often we see case reports (and other types of papers) in which authors review previously published articles, but they fail to realize that in the 10 or so articles they discuss--all of which appear to deal with "strength training"--different forms of measurement or exercise were used. In other words, the common element is not what was done for training or measurement, but the noun that everyone used.

This reminds me of George Foreman, who named all of his 5 sons George. I do not know what happens in the Foreman household when someone calls out the name "George"; however, I do know that when authors use the same word for different things, readers cannot know what happened in the studies that are cited--or even what happened to the patient being described in a given case report. If a case report mentions the patient doing "strengthening exercises" but does not elaborate further, can you really replicate the intervention with a similar patient?

We often hear the complaints of physical therapists who feel that others within the health care system do not understand what we do. Unless we communicate clearly and develop a body of case report literature, how can they be expected to understand what we do? If we cannot understand each other, how can we expect anyone else to understand us?

This month's Journals contain 2 case reports. Both illustrate the value of case reports and how they can contribute to meaningful and clear communication.

Blanton and colleagues (pages 1087-1097) describe the use of an ankle-foot orthosis in the management of a patient with brain injury. Right away, before you even finish the second paragraph of their report, you know how terms are going to be used, so you can read the report with a deeper understanding of the patient and what was done. In addition, the authors provide a cogent review of the conceptual basis that guided their intervention, a review that is not obscured by jargon and that does not depend on reader assumptions.

The case report by Ekstrom and Holden (pages 1077-1086) illustrates a diagnostic process, an element of patient management that can often be best described in a case report format. You'll note that they provide a clear discussion of the issues underlying their approach. They move beyond the current popular jargon that promotes such needless terms as "neural tension testing" and offer the reader an understanding of likely pathology, based on a thoughtful review of robust and credible literature dealing with nerve entrapment.

Case reports are the currency of practice, and the Journal welcomes them. We insist, however, that they maintain the highest level of scientific credibility and clarity. That means that case report authors should share with us their reasons for the selection of examination procedures, the logic behind their evaluation of the examination findings, the reasons they arrived at a given diagnosis and prognosis, and their rationale for the choice of interventions. Authors also need to relate this information to available evidence and data. They need to differentiate procedures that are done because there are supporting data from procedures that are done because there are no supporting data or because the clinician holds a particular opinion. In this way, a case report serves everyone, including our patients.

Because we are, first and foremost, a profession of practitioners, I stand behind my belief that every physical therapist should be able to write a publishable case report and that no student should graduate from a physical therapist education program without the competence to do so. This is a far more important goal than "required student research projects," which often are poorly conceived and conducted, and whose very existence demonstrates inappropriate priorities.

Practitioners must use science; new knowledge is of little value unless it is used in practice. The Journal is committed to publishing case reports that demonstrate how we do this--and is committed to working with the authors who write them.

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