Second Edition T his is the second in a series of articles that will attempt to share various concepts of research with doctors in clinical practice and focus on the value and limitations of case reports. The case report is a very special way doctors in clinical practice can attempt to communicate with our research communities by sharing what happens in the clinical "trenches." Robert W. Ward. DC. past editor of the Journal of Chiropractic Education, described the importance of a case report in the following way: "The pointy-headed ivory tower population doesn't get to see the interesting things that happen in clinical practice. They often rely on case reports from the field in deciding what sorts of pilot studies to nm. and those often lead to real full-scale clinical trials (the sort of research that field clinicians generally don't have the lime, resource, or interest to undertake)'." Before we tout the wonder of the case report, though, there arc many kinds of limitations with this type of study that need to be understood so that the results described by these studies arc not ovcrintcrprctcd. For instance, one reason case reports arc considered anecdotal is that there arc no control groups or comparative treatments to help mitigate the placebo or ideomolor effect. Control Groups Ideally, a control group is a group within a comparative study that lias liad cither no intervention or a sham procedure, or some studies have both. A sham procedure is supposedly an intervention that has no therapeutic effect. This was a particular issue with chiropractic when a study by Balon et al. found no benefit of chiropractic care for asthma, since both the sham (massage) and chiropractic intervention had the same benefit'. However, just a few months later, a study by Fields ct al. found that parental massage for asthmatic children had a therapeutic effect'. This called into question the sham procedure used in the Balon study and the conclusions drawn by those authors. Generally, a study with a control and sham procedure is more effective when both the examiner and subject arc unaware (blinded) of a manual healthcare intervention: however, in most clinical studies, this is very difficult or virtually impossible. While sham interventions and blinding is relatively easy with inert red and blue pills, it represents a challenge to adequately study chiropractic clinical interventions4. Placebo Effect The placebo effect suggests that a subject's response to an inert intervention can be dependent upon the subject's perception and expectation, dc Cracn ct al. found that the color and size of the placebo pill makes a difference, with "hot-colored" pills working better as stimulants while "cool-colored" pills work belter as depressants5. The challenge for manual healthcare interventions and ruling out a placebo effect is that most hands-on interventions have some kind of an effect, and this makes using placebos in manual healthcare studies problematic. Bialosky et al. even look this concept a bit further by suggesting "that manual therapists conceptualize placebo not only as a comparative intervention, but also as a potential active mechanism to partially account for treatment effects associated with manual therapy'." While positive suggestions and attitudes may help stimulate a patient's "placebo effect." critics then find it difficult to isolate a patient's therapeutic response to just a specific manual healthcare inters ention. Ideomotor Effect The terms "ideomotor effect, response, and phenomena" were introduced by William Benjamin Carpenter in 1852 as a means to explain his theory of how muscular movement can be independent of conscious desires or emotions". Hy man described how the ideomotor effect demonstrates tliat "honest, intelligent people can unconsciously engage in muscular activity that is consistent with their expectations*." Ultimately, this effect suggests that research using human subjects, where the examiner and subject are not blinded, can often lead to findings unconsciously directed by the examiner and unconsciously performed by the subject. This is a common critique of case reports and of doctors in clinical practice claiming successes for their interventions. How can a doctor in practice run a full-scale study incorporating control groups to help rule out the placebo and ideomotor effects? Without research experience and developing a prospective research design for a case report, a doctor in practice often is left with retrospective case reports that discuss an interesting intervention or response to treatment. Sometimes, though, there arc novel case studies tliat on some level attempt to find ways to address controls or comparative interventions and placebo or ideomotor effects. Case Report One9: Case History: A 37-ycar-old female was seen forbenign paroxysmal positional vertigo (BPPV) referred by her allopathic physician for chiropractic care. The patient had two to three months of constant vertigo, which was unresponsive to medications and prohibited her from driving or walking without difficulty. Interventions/Results: She presented with sacroiliac joint hypcr-mobilily syndrome (category two), right temporal bone restricted in external rotation, and significant malocclusion with clenching. Sacro occipital technique category two protocols for the pelvis were applied along with cranial and TMJ therapies. Dental cotrcatment was necessary to sustain the cranial and TMJ corrections. By the seventh office visit (three to four weeks of care), the patient's vertigo liad resolved, her category two stabilized, and TMJ translation had improved without pain. Implications: In this case, the interesting aspect was that the patient had consistent symptoms for two to three months and was unresponsive to medication. In a way. the medication became a comparative intervention and the length of symptomatology suggested that the treatments rendered might have been related to the patient "s improvement. Case Report Two"1: Case History: A 42-year-old female presented with an unsteady Par-kinsonian type of gait diagnosed as psychogcnically driven. She also was diagnosed with an atypical version of a complex regional pain syndrome (CRPS) called complex pain syndrome (CPS) due to its whole body generalization, as well as having a history of migraines. Methods/Results: The patient was co-lrcaled with dental night- and daytime appliances, and a trochantcr belt. She also was treated with category two protocols for sacroiliac joint hypcrmobility. sutural cranial tcmporomandibular joint (TMJ) interventions. T8 chiropractic manipulative reflex technique (CMRT). and nutritional modifications to support liver function and reduce inflammation. At the first office visit with the dental appliance, trochantcr belt, and category treatment, all of her shaking stopped when standing and her pain was profoundly reduced. Implications: What is compelling with this patient is that she had symptoms that had lasted for years and was on multiple medications for various symptoms with no change. It is significant that at the first office visit with the dental and chiropractic treatment, as well as the sacrotrochantcr support, her chronic tremor stopped. Furthermore, the tremors were controlled with care, and when she was unable to receive care, her symptoms would return. A confoundcr is that her condition was presumed to have a psychogenic component which suggests her response to treatment may be due to a placebo or idcomotor effect. Case Report Three": Case History: A 10-year-old female cattle dog with known chronic symptoms of bloating, mood changes, joint pain, and chronic psoas tension, all of which were unresponsive to prior interventions, presented for chiropractic care. Methods/Results: Occipital fiber analysis (OFT), a part of sacro occipital technique, was used to assess the canine and treatment consisted of chiropractic manipulative reflex technique (CMRT). Following the occipital analysis and treatment procedure, the reflex pain areas were diminished significantly. The dog also was relaxed, with decreased joint pain, and the psoas tension was notably reduced, as determined by both the canine's owner and treating physicians. Implications: One reason why researchers use animals for studies is presumably because animals don't understand (arc blinded to) the types of interventions being performed on them. For that reason, the canine's response to chiropractic care, when she was unresponsive to veterinary care, suggests tlial the intervention was the cause for improved function and symptoms. Even so. some research suggests that animals may still be susceptible to the placebo effect12. Ideally, the goal of the case report is a way of developing modes of communication between doctors in clinical practice and those in research who arc not commonly treating patients. Like all research studies, some case reports may yield greater applicability for further study, and the hope is that as more information is shared in the cvidcncc-bascd arena, the outcome will be improved delivery of health care. The Sacro Occipital Technique Research Conference offers doctors the ability to share various ideas that can improve assessment and treatment applications assisting patient response to care. The welcoming of new ideas and sharing of interdisciplinary relationships makes contributing to and attending this conference a valuable opportunity for the doctor in clinical practice. This year's conference will be held in Rcdondo Beach. California on May 15. 2014. Please visit: www.SOTO-USA.org for more information. References: Ward RW. Why it is Important to Write a Case Report. |http://www. sotousa.coin/\vp/?pagc_id=716| Last accessed Janaury 5. 2014. Balon J. Akcr PD. Crowthcr ER. Daniclson C. Cox PG. O'Shaughnessy D. Walker C. Goldsmith CH. Duku E. Scars MR. A comparison of active and simulated chiropractic manipulation as adjunc-tivc treatment for childhood asthma. N EnglJMcd. 1998 Oct 8:339(15): 1013-20. Field T. Hcntclcff T. Hcrnandcz-Rcif M. Martinez E. Mavunda K. Kuhn C. Schanbcrg S. Children with asthma have improved pulmonary functions after massage therapy. J Pcdiatr. 1998 May;132(5):854-8. ' Hawk C. Long CR. Rowcll RM. Gudavalli MR. Jcdlicka J. A randomized trial investigating a chiropractic manual placebo: a novel design using standardized forces in the delivery of active and control treatments. J Altcrn Complement Mcd. 2005 Feb:ll(l):109-17. dc Cracn AJ. Roos PJ. dc Vrics LA. Klcijncn J. Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness. BMJ. 19% December 21 -.313(7072): 1624-1626. Bialosky JE. Bishop MD. George SZ. Robinson ME. Placebo response to manual therapy: something out of nothing? J Man Manip Thcr. 2011 Stock A. Stock C. A short history of idco-motor action. Psychol Res. 2004 Apr:68(2-3): 176-88. Hyman R. The Mischief-Making of Idcomotor Action. The Scientific Review of Alternative Medicine. 1999:3(2):34-43. Bloink T. Blum CL. SOT Cranial and TMJ therapy for unresolved BPPV: A case report. 1 st Annual Sacro Occipital Technique Research Conference Proceedings: Las Vegas. NV. 2009:12-4. Gcrardo RC. Patient with severe tremors, complex pain syndrome, and migraines co-treated with dental and SOT chiropractic care: A case report. 1st Annual Sacro Occipital Technique Research Conference Proceedings: Las Vegas. NV. 2009:34-6. Thompson JE. Bockhold H. Blum C L. Sacro Occipital Technique: Occipital fiber technique on canine. 1st Annual Sacro Occipital Technique Research Conference Proceedings: Las Vegas. NV. 2009:85-7. McMillan. Frankin D. The Placebo Effect in Animals. JAVMA. Oct. 1999:215(7). Charles L. Blum, DC is in private practice Santa Monica, California, director of research for Sacro Occipital Technique Organization - USA, adjunct research faculty at Cleveland Chiropractic College and leaches the Sacro Occipital Technique (SOT) eleclh'e class at Palmer College of C liiropractic - West ami Southern C ^alifomia University of Health Sciences.
