The case for case reports.

One day in late spring I examined three children with idiopathic juvenile osteoporosis, a condition rare in most institutions, but unfortunately too common in the Warsaw hospital I was visiting. The rehabilitation of these children provides a unique challenge, and the caregivers were trying desperately to provide the best possible care, but in many areas they were stymied. I suggested to the health care team that a case report would open up a dialogue and allow others to share the more extensive experiences of the Warsaw group and to possibly offer suggestions to them.

Describing unusual patients, or unusual forms of patient management, has often been used as a rationale for the production of case reports. Novelty certainly plays a role in the two case reports by Carmick in this issue. The use of neuromuscular electrical stimulation for children with cerebral palsy is uncommon and, for some, may seem controversial. Therefore, we are delighted that Ms Carmick has chosen to discuss her treatments within the pages of the Journal, and that we could accompany those articles with commentaries. In this way we see a second benefit of case reports--an opportunity for discussion.

Case reports are too rare in this journal and in the physical therapy literature in general. There is no other way in which routine treatment can be described. How can any profession hope to generate a scientific basis if we do not have a common body of knowledge and a functional description of practice and practice behaviors? Too often, case reports are seen as appropriate only for the unusual patient or the unusual approach. Wrong! A profession's literature should contain case reports on all types of patients. If a patient type has not been described extensively in the literature, there is room for a case report on that patient type, particularly multiple-subject case reports, in which many persons with a given diagnosis are described in a single report (reports of a series of patients).

Case reports are a means by which practice is documented, and they lay the groundwork for experimental studies. Case reports even share many of the characteristics of more formal scientific inquiry. In experimental research, theoretical bases are used to generate an approach to patient intervention (evaluation, diagnosis, and treatment) and a means to evaluate outcome. But what most dramatically characterizes experimental studies is the use of controls, which allows us to make strong statements about the relationship between cause (treatment) and effect (outcome). Case reports lack controls, but they still require theory and careful documentation of intervention and outcome. Case reports, therefore, help indicate the possibility of treatment effects, but cannot directly prove the effectiveness of treatments.

In single-subject research designs, treatment is provided and baselines are established. There is then some form of treatment and withdrawal of treatment, depending on the type of design being used. Although single-subject research is a legitimate and useful form of inquiry, it does not deal with routine treatment. Too often people confuse the single-subject design with the case report. The former is a type of quasi-experimental research requiring manipulation of variables, whereas the latter is a description of practice. In case reports, the patient is given routine treatment. Case reports, which every clinician should be able to write, are nothing more than documentation of practice. In practice, we too often fail to operationally define terms and to explicitly state our rationales for examination, treatment, and measurements of outcome. In case reports, these are critical elements. This highlights an additional benefit of case reports. Through the writing of case reports and ensuing discussion, we clarify clinical terminology, concepts, and approaches to problem solving.

I have previously suggested that entry-level students would be better trained if they were not required to do research projects, but rather were obligated to prepare publishable case reports. I reaffirm that belief and extend the view. All of us who practice owe it to one another and to our patients and our profession to write about what we do in a credible fashion that can pass through the peer-review process. This journal awaits your attempts and welcomes them.