Development of Case Study's in Massage Therapy Research

Massage Research Matters

What is a Case Report

A classic case report is a systematic, in-depth discussion of a single clinical case that the practitioner found to be of interest and believes others in the profession will benefit from learning about. The report can describe a single treatment session, or multiple sessions with the same client addressing the initial clinical situation and its evolution throughout treatment. The value of these reports lies in careful and systematic observation, followed by treatment, continued observation and objective reporting. That is what makes this research.

After all, we tell one another about interesting cases all the time—but without disciplined observation and objective reporting we are simply sharing anecdotes. Some case reports involve more than a single subject, describing multiple similar cases, these are know as a case series.

The Evidence Pyramid

An evidence pyramid is used by many medical libraries, including the National Library of Medicine, to sort their holdings, and by policy-makers to decide how much weight to give information in their decision-making processes. In these pyramids case reports always appear as the lowest form of research involving human subjects—just a notch above opinions, which are not research at all.

On the one hand, case reports are at the bottom of the evidence pyramid because they are least reliable in terms of predicting outcomes for anyone other than the subjects discussed. Because they are based on samples of a single person or a few people; the subjects are not randomly selected; and there are no control groups to help evaluate the extent to which the outcomes seen are actually attributable to the treatment, case reports cannot offer us statistically valid data from which to predict what will happen to others. But that is not their role.

One can view the position of case reports at the bottom of the pyramid as indicating their foundational role in research development: Everything else rests on them. Case reports provide the initial evidence upon which other forms of research can be built. The core hypotheses tested in higher-ranking, more reliable (and considerably more expensive) forms of research, often begin with the clinical experience of an observant practitioner with the altruism and discipline to report her or his observations to others, so that our thinking can be informed by their experience.

Case Reports' Purpose

Case reports are written by practitioners who want to communicate to other practitioners something important they have experienced. This may be a client presenting with something surprising and anomalous; or it may be that the surprising aspect was the outcome, or lack of out-come, from the treatment.

Ground Breaking Case Studies

The Identification of AIDS
Toxic Shock Syndrome,
The Ebola virus as the cause of hemorrhagic fever
Fetal Malformation Caused by use of thalidomide during pregnancy

For example, awareness of AIDS began with the surprising appearance of a young white man with Kaposi's sarcoma. At the time, Kaposi's sarcoma was known as a very rare disease of elderly men of Mediterranean or Jewish heritage, young African men, or transplant patients. It was totally unexpected in a young white American man. Once one case was brought to awareness via a published case report, it served to alert other physicians to the possibility. As more cases were reported, public-health officials could see that something serious was afoot; that Kaposi's sarcoma was showing up at previously unheard-of rates.

So the first reported served as an alert and launched the purposeful search for other cases of Kaposi's sarcoma. As numbers of cases were reported it became possible to look for patterns in the populations or locations in which they were being found. Thus we could begin to identify more vulnerable populations and begin to formulate hypotheses about causes, vectors of transmission and possible treatment. The initial case report was pivotal in launching the process. You can see how the accuracy of such reports, and the lack of jumping to conclusions, would be vitally important for the work that follows it.

The role of case reports as alerts is ongoing. For example, in June 2005 the Mayo Clinic issued a press release indicating that "A Mayo Clinic case series analysis has pinpointed for the first time syndromes associated with toxic damage to the brain and nervous system from manganese fumes generated during welding. The analysis also revealed that all affected patients shared a risk factor: welding with inadequate ventilation."

Education value

For a profession such as therapeutic massage, which has health professionals newly interested in it, case reports can serve another function: A dearly written case report describing massage for a common type of client complaint can have great value in introducing massage to health-care practitioners who are still unfamiliar with exactly what we do. There are many physicians, for instance, who would not easily imagine what a massage treatment for carpal tunnel syndrome would entail. At this stage of our emergence as a health-care profession, well-written case reports about typical clients may serve to educate the broader health-care community, because for them our typical treatment will be novel.

As a developing profession it is important for therapeutic massage to also consider the educational value of teaching case-report methods. The case report is a time-honored tool of medical education, from daily ward presentations to grand rounds to published clinical case reports. All residents must report, at the end of each shift, the findings and current status of each case admitted to the hospital during their shift. Through having to report on these cases each day, new residents learn to observe carefully and report accurately—and do both efficiently.

Teaching these skills of careful observation, of recognizing what is essential and what is irrelevant to report, also imparts practice and skill in clinical decision-making. Doing this under the tutelage of senior physicians is an apprentice-like aspect of medical education. One can learn much from books, but you must learn clinical reasoning from other reasoning humans. We will grow as a profession and our descriptions of tissue states will grow more sophisticated and refined if we push ourselves and our students to write more case reports, first for class and later for publication..

Writing for Publication

It is important to remember that a case report is a form of professional and scientific communication. You will find that some journals provide very specific instructions for authors of case reports, while other journals do not. If the journal in which you would like to publish does pro-vide such instructions, you must adhere to them carefully.

A case report is a concise but detailed description of a clinical case of interest that also includes a brief review of the relevant literature so the reader can see where this case sits within what is already known about the issue at hand. A case report may be retrospective, covering a client with whom you have completed treatment, or prospective. One might choose to do a retrospective case report because the outcomes of treatment were surprising to you, whether surprisingly beneficial or surprisingly unhelpful. To do a retrospective case report requires that your treatment notes, beginning with the first observations, are complete and accurate enough to use in reporting.

The standard sections of a case report are the title, the summary or abstract, the introduction, the case history, the literature review and the discussion. Each is important.

Title

A title can be straightforward, such as, "Successful treatment of carpal tunnel syndrome with massage," or can lean toward the poetic or catchy, such as "Sometimes what seems to be a heart attack is actually a pain in the neck." The catchy ones may be more memorable as titles, but the straightforward ones quickly tell a reader scanning titles whether the piece will be of interest to her.

Abstract

While some case reports do not include abstracts, it is becoming more common to include one as doing so aids in case reports' retrieval from electronic databases. An abstract should: state the clinical issue being addressed and why it matters to readers; identify the objective, design, setting, subject and treatment; and include a one-sentence summary of the results of the case.

Introduction

The introduction serves at least two purposes. It draws readers into the report, piquing their interest, and it provides the context for the case. Thus you must include a definition of the problem or condition, a summary of what is already known about it, and what sort of challenges in its management remain. You must also identify the contribution which this report will make to the literature. Thus, the introduction is where you would include a review of the relevant literature.

Case Presentation

The heart of the case report is the presentation of the case. It gives the readers the raw information they need to understand what is happening with the client. It helps them consider whether there is another course of treatment the client might have considered, and why. It is critical to begin by simply giving information and not your own reactions. The information should include a description of the client and the information you gather during intake, including the history of the presenting condition, results of your assessment, and any tests you conducted or the results of tests brought to you (such as X-rays).

A good case report will provide as much "hard" data as possible, including trying to harden "soft" data, such as having clients complete a visual analogue scale of their pain rather than just asking how much pain they are experiencing. When you have presented the information completely, accurately and concisely, then it is appropriate to share your initial impressions of the client and what is happening with him or her. The case presentation would also include a description of the session, the outcome(s) you expected from it, and the actual outcomes.

Discussion and Conclusion

The case report ends with a discussion and conclusion. This section gives the author the greatest freedom. Here is where you make sense of what you have just presented, tying your client's experience into the literature. Here also is where you discuss any remaining questions and make recommendations or suggestions for future clinical practice. Cases are reported because they have something to offer the profession. They may provide information that would refute existing theory and practice, offer information to generate new theories, describe novel treatment, or inform the audience of unusual presenting conditions or adverse responses to treatment. Whatever your motivation for reporting a case, it must be reiterated in the discussion and supported by the information you have presented.

In his book, Clinical Case Reporting in Evidence-Based Medicine, Milos Jenicek says of case reporting, "It is an integral part of medical culture, relied upon ... to enrich professional experience, lead to better clinical reasoning, and prompt further research."

Janet Kahn, Ph.D