Guest Editorial
Jules M. Rothstein, PHD, PT
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 healthcare 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 importance of relaying case reports.] A second
benefit of [publishing] case reports is the opportunity for
discussion.
Case reports are too rare in [Physical Therapy] 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 it does
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 (out
come). 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 [they] 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
published 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. [The Journal of Prosthetics and Orthotics]
awaits your attempts and welcomes them.
Jules M. Rothstein, PhD, PT
Editor's Note: "The Case for Case Reports," originally
published in the August 1993 issue of Physical Therapy, is
reprinted with permission of the American Physical
Therapy Association.
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