guidelines

J Can Chiropr Assoc 2008; 52(4) 199

Commentary

Guidelines to the writing of case studiesDr. Brian Budgell, DC, PhD*

Dr. Brian Budgell, DC, PhDJCCA Editorial Board

IntroductionCase studies are an invaluable record of the clinical prac-tices of a profession. While case studies cannot providespecific guidance for the management of successive pa-tients, they are a record of clinical interactions whichhelp us to frame questions for more rigorously designedclinical studies. Case studies also provide valuable teach-

ing material, demonstrating both classical and unusualpresentations which may confront the practitioner. Quiteobviously, since the overwhelming majority of clinicalinteractions occur in the field, not in teaching or researchfacilities, it falls to the field practitioner to record andpass on their experiences. However, field practitionersgenerally are not well-practised in writing for publica-tion, and so may hesitate to embark on the task of carry-ing a case study to publication. These guidelines areintended to assist the relatively novice writer practition-er or student in efficiently navigating the relatively easycourse to publication of a quality case study. Guidelinesare not intended to be proscriptive, and so throughout thisdocument we advise what authors may or should do,rather than what they must do. Authors may decide thatthe particular circumstances of their case study justify di-gression from our recommendations.

Additional and useful resources for chiropractic casestudies include:1 Waalen JK. Single subject research designs. J Can Chirop

Assoc 1991; 35(2):9597.2 Gleberzon BJ. A peer-reviewers plea. J Can Chirop Assoc

2006; 50(2):107.3 Merritt L. Case reports: an important contribution to

chiropractic literature. J Can Chiropr Assoc 2007; 51(2):7274.

Portions of these guidelines were derived from BudgellB. Writing a biomedical research paper. Tokyo: SpringerJapan KK, 2008.

General InstructionsThis set of guidelines provides both instructions and atemplate for the writing of case reports for publication.You might want to skip forward and take a quick look at

* Dpartement chiropratique, Universit du Qubec Trois-Rivires, 3351, boul des Forges, Trois-Rivires, Qc, Canada G9A 5H7. JCCA 2008

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200 J Can Chiropr Assoc 2008; 52(4)

the template now, as we will be using it as the basis foryour own case study later on. While the guidelines andtemplate contain much detail, your finished case studyshould be only 500 to 1,500 words in length. Therefore,you will need to write efficiently and avoid unnecessarilyflowery language.

These guidelines for the writing of case studies are de-signed to be consistent with the Uniform Requirementsfor Manuscripts Submitted to Biomedical Journals ref-erenced elsewhere in the JCCA instructions to authors.

After this brief introduction, the guidelines below willfollow the headings of our template. Hence, it is possibleto work section by section through the template to quick-ly produce a first draft of your study. To begin with, how-ever, you must have a clear sense of the value of the studywhich you wish to describe. Therefore, before beginningto write the study itself, you should gather all of the ma-terials relevant to the case clinical notes, lab reports, x-rays etc. and form a clear picture of the story that youwish to share with your profession. At the most superfi-cial level, you may want to ask yourself What is inter-esting about this case? Keep your answer in mind asyour write, because sometimes we become lost in ourwriting and forget the message that we want to convey.

Another important general rule for writing case studiesis to stick to the facts. A case study should be a fairlymodest description of what actually happened. Specula-tion about underlying mechanisms of the disease processor treatment should be restrained. Field practitioners andstudents are seldom well-prepared to discuss physiologyor pathology. This is best left to experts in those fields.The thing of greatest value that you can provide to yourcolleagues is an honest record of clinical events.

Finally, remember that a case study is primarily achronicle of a patients progress, not a story about chiro-practic. Editorial or promotional remarks do not belongin a case study, no matter how great our enthusiasm. It isbest to simply tell the story and let the outcome speak foritself. With these points in mind, lets begin the processof writing the case study:

1. Title page:a) Title: The title page will contain the full title of the

article. Remember that many people may find ourarticle by searching on the internet. They mayhave to decide, just by looking at the title, whether

or not they want to access the full article. A titlewhich is vague or non-specific may not attracttheir attention. Thus, our title should contain thephrase case study, case report or case seriesas is appropriate to the contents. The two mostcommon formats of titles are nominal and com-pound. A nominal title is a single phrase, for ex-ample A case study of hypertension whichresponded to spinal manipulation. A compoundtitle consists of two phrases in succession, for ex-ample Response of hypertension to spinal manip-ulation: a case study. Keep in mind that titles ofarticles in leading journals average between 8 and9 words in length.

b) Other contents for the title page should be as in thegeneral JCCA instructions to authors. Rememberthat for a case study, we would not expect to havemore than one or two authors. In order to be listedas an author, a person must have an intellectualstake in the writing at the very least they must beable to explain and even defend the article. Some-one who has only provided technical assistance, asvaluable as that may be, may be acknowledged atthe end of the article, but would not be listed as anauthor. Contact information either home or insti-tutional should be provided for each authoralong with the authors academic qualifications. Ifthere is more than one author, one author must beidentified as the corresponding author the personwhom people should contact if they have ques-tions or comments about the study.

c) Key words: Provide key words under which the ar-ticle will be listed. These are the words whichwould be used when searching for the article usinga search engine such as Medline. When practical,we should choose key words from a standard listof keywords, such as MeSH (Medical subjectheadings). A copy of MeSH is available in most li-braries. If we cant access a copy and we want tomake sure that our keywords are included in theMeSH library, we can visit this address: http://www.ncbi.nlm.nih.gov:80/entrez/meshbrowser.cgi

2. Abstract: Abstracts generally follow one of twostyles, narrative or structured.

A narrative abstract consists of a short version of

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the whole paper. There are no headings within thenarrative abstract. The author simply tries to summa-rize the paper into a story which flows logically.

A structured abstract uses subheadings. Structuredabstracts are becoming more popular for basic scien-tific and clinical studies, since they standardize theabstract and ensure that certain information is includ-ed. This is very useful for readers who search for ar-ticles on the internet. Often the abstract is displayedby a search engine, and on the basis of the abstractthe reader will decide whether or not to download thefull article (which may require payment of a fee).With a structured abstract, the reader is more likelyto be given the information which they need to de-cide whether to go on to the full article, and so thisstyle is encouraged. The JCCA recommends the useof structured abstracts for case studies.

Since they are summaries, both narrative andstructured abstracts are easier to write once we havefinished the rest of the article. We include a templatefor a structured abstract and encourage authors tomake use of it. Our sub-headings will be:a) Introduction: This consists of one or two sentences

to describe the context of the case and summarizethe entire article.

b) Case presentation: Several sentences describe thehistory and results of any examinations performed.The working diagnosis and management of thecase are described.

c) Management and Outcome: Simply describe thecourse of the patients complaint. Where possible,make reference to any outcome measures whichyou used to objectively demonstrate how the pa-tients condition evolved through the course ofmanagement.

d) Discussion: Synthesize the foregoing subsectionsand explain both correlations and apparent incon-sistencies. If appropriate to the case, within one ortwo sentences describe the lessons to be learned.

3. Introduction: At the beginning of these guidelines wesuggested that we need to have a clear idea of what isparticularly interesting about the case we want to de-scribe. The introduction is where we convey this tothe reader. It is useful to begin by placing the study ina historical or social context. If similar cases havebeen reported previously, we describe them briefly. If

there is something especially challenging about thediagnosis or management of the condition that weare describing, now is our chance to bring that out.Each time we refer to a previous study, we cite thereference (usually at the end of the sentence). Our in-troduction doesnt need to be more than a few para-graphs long, and our objective is to have the readerunderstand clearly, but in a general sense, why it isuseful for them to be reading about this case.

4. Case presentation: This is the part of the paper inwhich we introduce the raw data. First, we describethe complaint that brought the patient to us. It is of-ten useful to use the patients own words. Next, weintroduce the important information that we obtainedfrom our history-taking. We dont need to includeevery detail just the information that helped us tosettle on our diagnosis. Also, we should try topresent patient information in a narrative form fullsentences which efficiently summarize the results ofour questioning. In our own practice, the history usu-ally leads to a differential diagnosis a short list ofthe most likely diseases or disorders underlying thepatients symptoms. We may or may not choose toinclude this list at the end of this section of the casepresentation.

The next step is to describe the results of our clini-cal examination. Again, we should write in an effi-cient narrative style, restricting ourselves to therelevant information. It is not necessary to includeevery detail in our clinical notes.

If we are using a named orthopedic or neurologi-cal test, it is best to both name and describe the test(since some people may know the test by a differentname). Also, we should describe the actual results,since not all readers will have the same understand-ing of what constitutes a positive or negative re-sult.

X-rays or other images are only helpful if they areclear enough to be easily reproduced and if they areaccompanied by a legend. Be sure that any informa-tion that might identify a patient is removed beforethe image is submitted.

At this point, or at the beginning of the next sec-tion, we will want to present our working diagnosisor clinical impression of the patient.

5. Management and Outcome: In this section, we

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should clearly describe the plan for care, as well asthe care which was actually provided, and the out-come.

It is useful for the reader to know how long the pa-tient was under care and how many times they weretreated. Additionally, we should be as specific aspossible in describing the treatment that we used. Itdoes not help the reader to simply say that the patientreceived chiropractic care. Exactly what treatmentdid we use? If we used spinal manipulation, it is bestto name the technique, if a common name exists, andalso to describe the manipulation. Remember thatour case study may be read by people who are not fa-miliar with spinal manipulation, and, even withinchiropractic circles, nomenclature for technique isnot well standardized.

We may want to include the patients own reportsof improvement or worsening. However, wheneverpossible we should try to use a well-validated meth-od of measuring their improvement. For case studies,it may be possible to use data from visual analoguescales (VAS) for pain, or a journal of medication us-age.

It is useful to include in this section an indicationof how and why treatment finished. Did we decide toterminate care, and if so, why? Did the patient with-draw from care or did we refer them to another prac-titioner?

6. Discussion: In this section we may want to identifyany questions that the case raises. It is not our duty toprovide a complete physiological explanation foreverything that we observed. This is usually impossi-ble. Nor should we feel obligated to list or generateall of the possible hypotheses that might explain thecourse of the patients condition. If there is a wellestablished item of physiology or pathology whichilluminates the case, we certainly include it, but re-member that we are writing what is primarily a clini-cal chronicle, not a basic scientific paper. Finally, wesummarize the lessons learned from this case.

7. Acknowledgments: If someone provided assistancewith the preparation of the case study, we thank thembriefly. It is neither necessary nor conventional tothank the patient (although we appreciate what theyhave taught us). It would generally be regarded as ex-cessive and inappropriate to thank others, such asteachers or colleagues who did not directly partici-pate in preparation of the paper.

8. References: References should be listed as describedelsewhere in the instructions to authors. Only use ref-erences that you have read and understood, and actu-ally used to support the case study. Do not use morethan approximately 15 references without some clearjustification. Try to avoid using textbooks as refer-ences, since it is assumed that most readers would al-ready have this information. Also, do not refer topersonal communication, since readers have no wayof checking this information.

A popular search engine for English-language ref-erences is Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

9. Legends: If we used any tables, figures or photo-graphs, they should be accompanied by a succinctexplanation. A good rule for graphs is that theyshould contain sufficient information to be generallydecipherable without reference to a legend.

10. Tables, figures and photographs should be includedat the end of the manuscript.

11. Permissions: If any tables, figures or photographs, orsubstantial quotations, have been borrowed from oth-er publications, we must include a letter of permissionfrom the publisher. Also, if we use any photographswhich might identify a patient, we will need theirwritten permission.

In addition, patient consent to publish the case re-port is also required.

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Title:

Running Header:

Authors:a) Name, academic degrees and affiliationb) Name, academic degrees and affiliationc) ...

Name, address and telephone number of correspondingauthor

Disclaimers

Statement that patient consent was obtained

Sources of financial support, if any

Key words: (limit of five)

Abstract: (maximum of 150 words) Introduction Case Presentation Management and Outcome Discussion

Introduction:Provide a context for the case and describe any similarcases previously reported.

Case Presentation:a) Introductory sentence: e.g. This 25 year old female of-

fice worker presented for the treatment of recurrentheadaches.

b) Describe the essential nature of the complaint, includ-ing location, intensity and associated symptoms: e.g.Her headaches are primarily in the suboccipital region,bilaterally but worse on the right. Sometimes there isradiation towards the right temple. She describes thepain as having an intensity of up to 5 out of ten, ac-companied by a feeling of tension in the back of thehead. When the pain is particularly bad, she feels thather vision is blurred.

c) Further development of history including details oftime and circumstances of onset, and the evolution ofthe complaint: e.g. This problem began to develop

three years ago when she commenced work as a dataentry clerk. Her headaches have increased in frequen-cy in the past year, now occurring three to four daysper week.

d) Describe relieving and aggravating factors, includingresponses to other treatment: e.g. The pain seems to beworse towards the end of the work day and is aggra-vated by stress. Aspirin provides some relieve. She hasnot sought any other treatment.

e) Include other health history, if relevant: e.g. Other-wise the patient reports that she is in good health.

f) Include family history, if relevant: e.g. There is nofamily history of headaches.

g) Summarize the results of examination, which mightinclude general observation and postural analysis, or-thopedic exam, neurological exam and chiropracticexamination (static and motion palpation): e.g. Exami-nation revealed an otherwise fit-looking young womanwith slight anterior carriage of the head. Cervical ac-tive ranges of motion were full and painless except forsome slight restriction of left lateral bending and rota-tion of the head to the left. These motions were ac-companied by discomfort in the right side of the neck.Cervical compression of the neck in the neutral posi-tion did not create discomfort. However, compressionof the neck in right rotation and extension producedsome right suboccipital pain. Cranial nerve examina-tion was normal. Upper limb motor, sensory and reflexfunctions were normal. With the patient in the supineposition, static palpation revealed tender trigger pointsbilaterally in the cervical musculature and right trape-zius. Motion palpation revealed restrictions of rightand left rotation in the upper cervical spine, and re-striction of left lateral bending in the mid to lower cer-vical spine. Blood pressure was 110/70. Houles test(holding the neck in extension and rotation for 30 sec-onds) did not produce nystagmus or dizziness. Therewere no carotid bruits.

h) The patient was diagnosed with cervicogenic head-ache due to chronic postural strain.

Management and Outcome:a) Describe as specifically as possible the treatment pro-

vided, including the nature of the treatment, and thefrequency and duration of care: e.g. The patient under-took a course of treatment consisting of cervical and

Template

Commentary


upper thoracic spinal manipulation three times perweek for two weeks. Manipulation was accompaniedby trigger point therapy to the paraspinal muscles andstretching of the upper trapezius. Additionally, advicewas provided concerning maintenance of proper pos-ture at work. The patient was also instructed in the useof a cervical pillow.

b) If possible, refer to objective measures of the patientsprogress: e.g. The patient maintained a headache diaryindicating that she had two headaches during the firstweek of care, and one headache the following week.Furthermore the intensity of her headaches declinedthroughout the course of treatment.

c) Describe the resolution of care: e.g. Based on the pa-tients reported progress during the first two weeks ofcare, she received an additional two treatments in eachof the subsequent two weeks. During the last week ofcare she experienced no headaches and reported feel-ing generally more energetic than before commencingcare. Following a total of four weeks of care (10 treat-ments) she was discharged.

Discussion:Synthesize foregoing sections: e.g. The distinction be-tween migraine and cervicogenic headache is not alwaysclear. However, this case demonstrates several features ...

Summarize the case and any lessons learned: e.g. Thiscase demonstrates a classical presentation of cervicogenicheadache which resolved quickly with a course of spinalmanipulation, supportive soft-tissue therapy and posturaladvice.

References: (using Vancouver style) e.g.1 Terret AGJ. Vertebrogenic hearing deficit, the spine

and spinal manipulation therapy: a search to validate the DD Palmer/Harvey Lillard experience. Chiropr J Aust 2002; 32:1426.

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Legends: (tables, figures or images are numbered accord-ing to the order in which they appear in the text.) e.g.

Figure 1: Intensity of headaches as recorded on a visualanalogue scale (vertical axis) versus time (horizontal ax-is) during the four weeks that the patient was under care.Treatment was given on days 1, 3, 5, 8, 10, 12, 15, 18, 22and 25. Headache frequency and intensity is seen to fallover time.

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