The Case Report: An example of the possible, not the probable

The Case Report is an example of what is possible, not what is probable. Yet such reports provide an extremely important contribution to scholarship, both research, and practice. They are essentially anecdotes. Stories of events as unfolded in time and narratively recreated (even if punctuated by tables, images, and figures) for the reader to experience a bit of what the people involved had experienced. All while learning something about what is possible.

For a history of case reports in medical education, I refer the reader to the History of the MGH Case Reports, and briefly mention that Walter Cannon (yes, Dr. fight or flight himself) saw how valuable cases were for his college roommate’s legal education and started to do case studies in medical school education. Richard Cabot then formalized the process in the early 1900s and “Since 1924, the clinicopathological conferences (or “CPCs”) have been published regularly in the New England Journal of Medicine as Case Records of the Massachusetts General Hospital.”

Over the next few months, I will be posting considerations and thoughts about the case report for research, practice, professional development, and scholarship. Let’s start with the Cardiopulmonary PT Journal Instructions for Authors for submitting a Case Report:

Case Report: A case report focuses on a patient or group of patients and describes an element of cardiovascular and pulmonary physical therapy practice that has not been previously documented in the literature. (Emphasis added)

As currently written CPTJ is seeking Case Reports that describe novel and unique situations. Please do not consider this from only one perspective (or dimension or ICF component) of novelty and uniqueness. For example, it doesn’t need to be a unique or novel health condition, body structure, body function, activity or participation. A case report also does not need to describe a unique or novel approach to evaluation or intervention. However, all of those instances of uniqueness and novelty do count. But it may be a unique or novel combination of otherwise routinely experienced dimensions of clinical care. As physical rehabilitation professionals we are swimming in a sea of unique situations. This is particularly true when considering interactions between levels of complexity (cells, tissues, organs, systems, psychological, environmental, sociological, etc). When we evaluate patients seeking our care we attempt to identify the causes and consequences of problems both within and between levels. It is when we look at connections between the levels that there is an explosion of unique situations. The clear and explicit details of many cases have not been previously documented in the literature.

So while a patient with heart failure increasing 6 minute walk distance in response to aerobic or resistance training would not be considered unique or novel; if that patient started off unable to attain the workload of walking and targeted resistance training and electrical stimulation led to the ability to walk with anaerobic energy support, which allowed interval training, which then allowed endurance training that then led to a new participatory behavior that maintained a higher level of well being and quality of life; that would be novel since there are no published studies linking this trajectory together in a sample of patients. We suspect that this progression is possible, but not in clinical trials.

Such a case study may require many therapists to work together (!) in promoting continuity of care across settings. For example, starting in the ICU, to the acute hospital step down unit, to the rehab, then home care and then maybe outpatient rehab. Meaning, maybe this is a continuity of care case that is based on communication between 5 physical therapists!

In my next post, we will take a look at the CARE Guidelines: Consensus-based Clinical Case Reporting Guideline Development.

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