How You Can Do Research in Your Practice: Case Studies

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1 How You Can Do Research in Your Practice: Case Studies SCCA Convention 2014 Luke Henry, D.C. 1

2 Introduction Why you should be interested in research Enhance chiropractic education Increases recognition of chiropractic outside the profession (e.g. Department of Veterans Affairs, NFL, Olympics) Used by third party payors to determine benefits Evidence-based practice 2

3 Benefits of doing research Help colleagues with difficult and unusual cases Professional recognition of being published Increase referrals from the medical community Increased credibility with patients Have a voice in evidence-based care. 3

published Increase referrals from the medical community

4 Overview: chiropractic journals and other relevant publications Trade journals and magazines 1. Dynamic Chiropractic, Chiro Economics, The American Chiropractor, etc. College magazines Association journals (e.g. Journal of the ACA and ICA) Technique journals Peer-reviewed journals Journal of Chiropractic Humanities, chiropractic history, philosophy, education journals Non-chiropractic journals: Spine, alternative medicine, nutrition, public health, pain, etc. 4

magazines Association journals (e.g. Journal of the ACA and ICA) Technique journals Peer-reviewed journals Journal

5 Peer reviewed journals Indexed on PubMed ( 1. JMPT, JCCA, JCM, Chiropractic and Manual Therapies Index to Chiropractic Literature ( McCoy (JUCCR, etc.) Journal of the Academy of Chiropractic Orthopedists Journal of Vertebral Subluxation Research (no longer active) Internet Journal of Chiropractic 5

6 6

7 U.S. National Library of Medicine, NIH, 7

8 Types of research papers Case studies Case series Retrospective and prospective studies Clinical trials Blinded or double blinded randomized controlled trials 8

9 Most relevant to private practice Case studies Case series 9

10 Case studies and series Present difficult or unusual cases May lead to larger clinical trials 10

11 Using statistics Epidemiological studies Cohort studies 11

12 Randomized controlled trials RCTs have strongest statistical power Inherent difficulty of blinding in chiropractic / physical procedures vs. a sugar pill in medicine - It is difficult to do a sham adjustment or sham therapy May not be practical in private practice 12

13 Parts of a case study Abstract Introduction Intervention and Outcome Discussion Conclusion 13

14 Patient consent / privacy Get the patient s written consent HIPAA - You may do this through your Notice of Privacy Practices Most journals require a separate form Remove personally identifiable information 14

of Privacy Practices Most journals require a

15 Abstract Writing the abstract Contains a summary of each part Usually 250 words or less 15

16 Choosing keywords that are relevant MeSH 16

17 Introduction Include a review of relevant literature You can use an index to search for relevant publications PubMed, CINAHL, chiroindex.org (Index to Chiropractic Literature), Google Scholar, etc. Provide background for the reader 17

18 Intervention and outcome Describe the patient s care in your office Include enough detail to answer the reader s questions Describe the specific examination, imaging findings, technique, exercises, etc. that were done Don t assume that the reader is another chiropractor Other medical providers or allied health professionals may read your paper 18

19 Discussion You discuss the results You may want to use something measurable Pre and Post Visual Analog Scale, SF-36, functional outcomes assessment (Oswestry, Roland-Morris, or Vernon-Mior pain and disability indexes for the back or neck) A number of standardized outcomes assessment tools are available that have already been validated Statistical analysis strengthens your paper 19

pain and disability indexes for the back or neck) A number of standardized outcomes assessment

20 Tables, graphs and figures in your paper Label images, Figure 1, Figure 2, etc. Table 1, Table 2, etc. 20

21 Conclusion Don t speculate: Be conservative with your conclusion Don t draw any broad generalizations from a case study You may want to encourage future researchers to do a larger trial This could be accomplished at a research institution more easily that at a private practice 21

22 Conclusion Don t speculate: Be conservative with your conclusion Don t draw any broad generalizations from a case study You may want to encourage future researchers to do a larger trial This could be accomplished at a research institution more easily that at a private practice 22

23 Acknowledgements Don t forget to thank those that helped with preparing the manuscript. 23

24 Your advantage The practicing clinician has the advantage of treating a real patient population, which may differ from the patients presenting at an academic or research institute 24

25 Writing style Try to make your paper interesting to the reader Include details that are clinically relevant 25

26 Peer review Papers must be reviewed by other experts in the field of study before being considered for publication Before submitting your paper, be sure to comply with the guidelines on the journal s website 26

27 Format Requirements differ slightly from one journal to another. Each journal or periodicals guidelines for authors are available on website. 27

28 Format Length of the paper (e.g words or less for a case study) Style Format for citations Format for files Format for images, tables, graphs, etc. Electronic or paper submission (most journals prefer electronic) A cover letter may be required You may wish to include a brief biography 28

29 Format (continued) Generally, it is best to double-space the lines in the paragraphs Patient consent for publication Copyright assignment to the journal 29

30 Open Access Journals Once frowned upon by academics but today this is increasingly common and accepted. E.g. Internet Journal of Chiropractic, Biomed Central You have to pay a fee for publication but the article is free for readers 30

31 Navigating the peer review process After a period of time your paper will come back to you with comments / suggestions from reviewers. Resubmit the paper after making changes and adding author s reply. Notate the page and line of each change made. If your paper is rejected then you are free to try another publication. 31

32 Navigating the peer review process (continued) It may take several revisions before your paper is accepted by the reviewers. Stay positive, the criticism will ultimately make your paper stronger. Peer review helps ensure that only quality papers make it to publication. 32

33 Need help? Your college s library likely subscribes to research journals and may help you retrieve articles at less cost. Contact your chiropractic college s research department. They may be able to help with statistics or formatting your paper. Sherman, for example, wants to help graduates get published. 33

34 Congratulations! Once your paper is published, you may wish to provide copies to patients or other professionals. Update your CV to reflect your publications. Your published papers / books will likely come up during deposition or court. 34

35 Congratulations! Getting published has numerous professional benefits. Best of all, you are sharing your years of knowledge and experience with the rest of the profession. 35

36 Example Abstract 1 Resolution of Hemifacial Spasm Following Specific Upper Cervical Chiropractic Care, Lucian Henry DC Journal of Upper Cervical Chiropractic Research ~ August 15, 2011 ~ Pages Objective: To describe resolution of symptoms in a patient with chronic hemifacial spasm, neck pain, and low back pain following specific chiropractic adjustments to correct vertebral subluxations. Clinical Features: A 48-year-old male patient with hemifacial spasm, accompanied by neck pain and low back pain was evaluated using palpation, posture analysis and chiropractic radiographic analysis. He was diagnosed with subluxation of the atlas, L4, L5, sacrum, and sacroiliac joints. Intervention and Outcome: Treatment consisted of specific upper cervical adjustments using Palmer Toggle Recoil technique and Thompson drop technique on the lumbar, sacral, and pelvic areas. The patient s symptoms resolved following three chiropractic adjustments and he was still free of symptoms at a 3 month follow up. Conclusion: Further investigation is warranted on the relationship between subluxation at the upper cervical spine and cranial nerve dysfunction. Upper cervical chiropractic care may benefit patients with hemifacial spasm. Keywords: Chiropractic, chiropractor, spinal manipulation, hemifacial spasm, facial spasm, vertebral subluxation, adjustment 36

37 Example Abstract 2 CASE SERIES: Chiropractic Management in Diffuse Idiopathic Skeletal Hyperostosis: A Case Series, Lucian Henry, DC Annals of Vertebral Subluxation Research ~ February 28, 2013 ~ Pages Objective: The objective of this report is to describe the chiropractic management of patients with spinal pain complicated by diffuse idiopathic skeletal hyperostosis. Methods: Four patients with neck and / or back pain were examined and radiographs revealed DISH. The patients were diagnosed with vertebral subluxation, complicated by DISH at the cervical spine. All patients were treated with chiropractic manipulation using Diversified and / or Gonstead technique. Group Pre VAS scores were compared to group Post VAS scores using the paired t test. A statistically significant difference was considered to be present if the two-tailed p-value was < an alpha of Results: Follow-up VAS scores (mean = 0.875, standard deviation +/- 1.8) were significantly less (statistically speaking) compared to the initial VAS scores (mean = 8.5, standard deviation +/- 1.1) (p = ). Conclusion: There is ample literature on the benefits of chiropractic care for neck and back pain but there is little literature on chiropractic care for patients with DISH. Chiropractic is likely beneficial for patients with DISH and further investigation is warranted. Keywords: Chiropractic, adjustment, manipulation, Diffuse Idiopathic Skeletal Hyperostosis, DISH, subluxation 37

38 Example Case Study Henry L. Chiropractic Care Of A Patient With Crouzon Syndrome And Multiple Congenital Anomalies At The Cervical Spine: A Case Report. The Internet Journal of Chiropractic Volume 3 Number 1 Available at: 38

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