A step-by-step guide for documenting and submitting your most interesting cases when performing research in the small office
Chiropractic research has given the profession legitimacy. It has opened the door to inclusion in various insurance programs, hospitals, military health care and sports medicine. A research study and accumulated research also allows the profession to acquire grants to perform more research.
For example, a randomized controlled trial on low-back pain was published in the British Medical Journal in 1990.1 This trial was large (741 subjects), where outcomes of two years were reported. The group under chiropractic care improved with significant advantage over the group treated by physical therapists.
Due to substantially better outcomes in the chiropractic-treated group, the British government included chiropractic in the national health system. There is a link between research and practice.
It’s easy for someone in practice to feel disconnected from the world of research. But incorporating a research study into your practice can yield you and the profession tangible benefits.
Research isn’t a single entity. There are several variations of research designs, and some will be applicable to your practice.
Here are the various categories of research design, with randomized controlled trial (RCT) having the most status and descending to the study designs of the least status.
As top-of-pyramid research designs require significant infrastructure (institution review board, statistician and large patient numbers), the RCT, cohort study and case control study are impractical for small practices.
Case report and presentation
During every chiropractic seminar that I’ve attended I have heard at least one doctor relate an anecdote. A patient came in with XYZ, he/she was adjusted this or that way, which then had an excellent outcome. Sound familiar?
The difference between an anecdote and a research study case report is the level of detail. An anecdote is often told in a manner similar to a SOAP note:
Subjective: Patient came in with XXX.
Objective: On examination, I found XXX.
Assessment/Action: I did XXX.
Plan/Outcome/Prognosis: The result was XXX.
A case report follows a similar format; however, the details are greatly expanded. For example, for the subjective, you begin with: “A well-conditioned 41-year-old white female with the chief complaint of headaches was seen.”
Descriptors as to the onset, duration, frequency, and quality and locations of pain are stated. Headaches are provoked by XXX and relieved with YYY. All of the pertinent positives and negatives elicited during the patient intake are reported.
A similar detailed discussion of the examination findings is described in the objective section. This includes your observations (e.g. gait, posture, pain behavior), physical examination findings, imaging and laboratory. These results may have taken place over days or weeks, therefore the chronology should be reported.
The composite of the subjective and objective should be drawn together to express your hypothesis or working diagnosis. You might also state why other possible diagnoses were ruled out or considered improbable.
Research study: tell the story
The case report is a story, an in-depth discussion of a particular situation rather than a sweeping statistical survey. It reflects the way in which doctors in the field practice — one patient at a time.
Continuing to build your case report, you would then describe the chosen treatment or treatments in detail. This can be aided with photographs as long as the patient’s identity is protected. Rather than saying, “I adjusted C2,” describe the technique (how often, for how many visits, the response, measurements of improvement, effect on activities of daily living if applicable). Or, if this was an athlete, how did their performance change pre- vs. post-treatments, and were there any other factors that may have influenced this?
Details about how the patient responded after the initial treatments must be stated. Ideally, follow-up after weeks or months should also be described with objective findings as well as the patient’s reported subjective changes.
Once the story is complete, a case report often includes a review of the relevant literature, other studies and cases discussing headaches. This need not be a complete literature review. These are some common sites used for internet searches: Grateful Med, Medscape, PubMed, Google Scholar.
The last section of the report is often called discussion. Here is where you summarize your reported case and editorialize about some aspect of the subject: the incidence, impacts, medical treatments, and/or a discussion of how you believe the treatment rendered was effective. There are no hard-and- fast rules here other than making the distinction between your hypotheses and what is known as per other studies.
Case reports can help identify new clinical issues and lead to development of hypotheses. However, they are normally regarded as low-level evidence as the observations may be subject to bias. But don’t understate the value of the case report.
If you observe a new way to diagnose or treat a given patient or condition and other case reports are written citing similar findings, the composite of evidence may prompt a more in-depth research trial.
This type of research study, the case report, is perfectly matched to the small chiropractic practice. After collecting your information — data, photographs, lab reports, etc. — and writing your paper, it should be edited and formatted. Each of the journals has authors’ guidelines.
These are found on the journal’s website under headings such as submissions, authors’ guidelines or writers’ guidelines. The guidelines for case reports differ from randomized control trials. The journal will state their preferred font, the format for photos and graphs, as well as the footnotes and the body of the paper.
As long as you follow the instructions, your paper will pass through the initial phase of the review. Ignoring the journals’ stated preferences often invites a rejection and avoidable frustrations.
If this is your first manuscript, there is a good source of how to write a case report, consider having it edited by someone from the chiropractic school you attended. If they make minor edits, include their name in the acknowledgements. However, if major edits are needed, you should invite them to become the secondary or tertiary author. Also, it’s always a good idea to get written permission from the patient while assuring them that their identity will be protected.
Once accomplished, you are ready to submit your manuscript in the journal’s preferred manner. A few more clicks on the computer and you are on your way to being published.
Submission and the journal review process
As the journal receives your manuscript, it is prepared for their editorial board, where it will be sent to two or three reviewers. The reviewers receive the paper but are not told the identity of the author. They make their comments and recommend either: reject, accept as-is, or accept pending revision. The last cate- gory is the most common. This process will take 4-12 weeks.
The revisions may include specific comments for greater detail or questions about other case reports on this topic.
If you disagree with the requested revisions, submit your rebuttal in a respectful and thorough cover letter.
Once the revisions are made, your second submission will be reviewed. The second review typically takes less time than the initial review. It’s possible that an additional revision will be asked for, but it is just as likely that the first revision will lead to acceptance. If the reviewers recommend to accept, they will inform the editor who, in turn, will inform you of the acceptance.
Actual publication may be months following the date of acceptance. The editor will tell you the planned date and send you an agreement about signing over the copyright to the journal. Yes, you give up your rights. The process is the same whether the journal is in print or online.
Keep the research study case report in mind
The next time a patient enters your office with a long-standing chronic condition that you believe can be helped by your treatment, think case report.
Be sure to take a thorough history and document. The same is true for your objective findings and treatments; and use a measurement system applicable to the patient’s condition (e.g. Oswestry, visual analog pain scale). The most important step is to begin.
ALAN COOK, DC, has been in practice since 1989. He ran the Osteoporosis Diagnostic Center (1996-2019), participated in four clinical trials, and lectured nationally. He is currently working with the Open Door Clinic system in a multi-disciplinary setting and is providing video-based continuing education with EasyWebCE.com.
- Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. BMJ 1990;300:1431.
- Green BN, Johnson CD. How to Write a Case Report for Publication. J Chiro Med 2006;5:72-82.