Monday, September 22, 2014

Citation Software

The new issue of Online Cl@ssroom has a nice little article devoted to citation software (1). Most of us are already familiar with at least one program that collects and organizes citations, namely RefWorks. For those in research, they use Refman, which is a more powerful citation tracker. But there are a number of other venders for these programs. Included among them are:

Zotero: available at This is a  free program that works across platforms and links itself to your browser. From its home page, it notes that it will automatically sense the content in your browser and then let you add it to your personal library. All the content is then placed into a single searchable interface, which is organized in a fashion similar to an iTunes library. Youdo not need to look through folders inside folders. And you have the ability to tag your contents, making it easier to locate required content. Finally you can easily place citations tinot your word profcessing papers without having to leave the program you are working in.
CiteThisForMe: available at This also allows you to automatically grab bibliographic information right form whatever web page you are on. It easily lets you denote the kind of reference you are grabbing, creates a master list of all of your references, but lets you create individual bibliographic lists, download other lists, and share those lists with a defined group. It can format the reference lists in a wide range of styles.

EasyBib: available at This program works with Google Drive, which I have to admit I do not use for myself. In its free version, it allows you to only create reference lists in MLA style, which may not work as well in standard scientific writing, which generally requires Vancouver style references. However, it can be upgraded, for a small fee.
ProQuest Flow: available at This is a cloud-based product that “helps researchers better manage citations and full-text documents and gain control over the research workflow.” (As stated on its web-site). You can either automatically enter a citation with a one-click process, or you can manually enter information if necessary. This program has a huge database of reference styles.


1.       Require your students to use citation software. Online Cl@ssroom 2014;14(9),p4,8

Tuesday, September 16, 2014

CARE Guidelines

In my last blog post I discussed writing case reports. I noted at the end that there was new guideline for preparing case reports, known as CARE (, which my friend an colleague Dr. Karen Boulanger had written about in her most recent publication (1). Templates for CARE can be downloaded from the CARE website, at

The elements which should be included in writing a case report are as follows:

Title: The guidelines now recommend the words “Case Report” be in the title. This is actually counter to recommendations I have made in the past, where it was felt that since a paper would likely be put in a section of the journal devoted to case reports it was no longer necessary to list it as part of the title. This is a change, but it clarifies what the paper is about.
Abstract: Typically, this uses a structured format, but some journals have moved away from that. In the abstract, you should include the reason for the repot, presenting concerns of the patient, diagnosis, intervention and outcomes.

Key Words: These should be MeSH terms, so select carefully.
Introduction: Provide background for your case and why it is important.

Presenting Concerns: Why did the patient seek care? Provide historical information about the patient.
Clinical Findings: Provide only those findings which are relevant to the case. No need to provide ling lists of normal findings. Be sure to support your diagnosis with the findings.

Timeline: What was the course of care. A table or figure can help illustrate this quite well.
Diagnostic Focus and Assessment: Summarize your diagnostic finding and your clinical reasoning arising from those findings.

Therapeutic Focus and Assessment: Discuss your treatment plan and how it was administered.
Follow-up and Outcomes: Summarize the clinical course of the case. How did the patient respond to care? What was the final outcome?

Discussion: What does this all mean? What was learned as a result of publishing the report? What gap in the literature was filled? What other interpretations of the results might be considered? What limitations exist?
Patient Perspective: This is a new part of the paper. Where possible and appropriate, the patient should provide a brief narrative of their case to accompany the paper.

Informed Consent: The patient should provide consent and permission for the paper
This is all pretty much what traditionally has been seen in case reports, but this codifies the format, making it easier to know how to organize information and construct a logical flow from it. Please use!


1.       Munk N, Boulanger K. ASdaptation of the CARE guidelines for therapeutic massage and bodywork: efforts to improve the impact of case reports. Int J Ther Massage Bodywork 2014;7:32040

Monday, September 8, 2014

How to Prepare a Case Report

In the past couple of weeks I have had an opportunity to work with several faculty members who were interested in preparing case reports. It was my honor to do so. It led me to consider offering up a few thoughts on how to get them ready for publication.

The easiest way to prep a case report involves, really, just two issues: one is to have the case records at hand, and the second is to know the general template for putting that information into readable from. Assuming that you have the records available, I will focus on the second item here.
The general format or template for a case reports is: Structured Abstract, Introduction, Case Report, Discussion, Conclusion, References.

Structured Abstract: Really, this should be prepared last, after the paper is completed. But when you are ready, most journals require a structured abstract with specific subheadings: Objective (why are you writing the paper?); Clinical Features (what were the features the patient had when he or she came for care, leading you to your diagnosis?); Intervention and Outcome (what did you do and how did the patient respond?); Conclusion (what do you conclude for the above?). And you have to do all of this in 250 words or less.
Introduction: This usually will provide some background information on the condition of interest, as well as provide some context for the educational value of the case. Put it this way: what is unusual here, what gap in the literature will be filled by publishing the case?

Case Report: Well, this is the report of the case, of course. It needs to provide the reader only the essential information: on diagnosis and tests run, on treatment and on outcome. The reader should be able to confirm that you made a correct diagnosis, and they should be able to understand the intricacies of your treatment, and they should be able to assess the outcome instruments you used for monitoring progress.
Discussion: This explains the educational value of the paper. What did we learn here? How does what we learned here fit into the larger body of information available about this condition or topic? The primary function of a case report is to educate the reader, to help them learn something. That should be the focus of the paper- so, you may focus on teaching about the condition, or perhaps its management or perhaps something else.

Conclusion: This is really just a recapitulation of what came before. It should not offer any speculation, but may suggest directions for future research based on what you found.
References: Of course, references are important since they provide the foundation for the importance of your case.

I recommend that you pick up a case report or two from a chiropractic journal and look to see how well they fit into this template. Knowing these components can ease the fear you might feel in considering writing something for publication.
As I prepared to post this, I received a note from Dr. Karen Boulanger, about a new paper she co-wrote related to preparing case reports. It is excellent and can be accessed at


Tuesday, September 2, 2014


We are just a few days away from the deadline for submission to ACC-RAC. And I have had an opportunity to assist a number of faculty in developing their submissions. Each year, one of the things I see are projects that involve survey methodology. This got me thinking about what it means to use a sample. What methods exist for selecting a sample from a population? Peter Jarvis, is his text “The Practitioner-Researcher: Developing Theory from Practice” (pages 122-123) provides a full list of samples. Among them are:

  • Random Sample: Here, all we do is select a sample for the population in a way that gives everybody in the population an equal chance of being selected.
  • Systematic Random Sample: Here, we find our population and then use some system to select our sample. If we did this in a class, it might mean that we use every 3rd student’s data or something similar.
  • Stratified Random Sample: We divide our population into groups somehow, and then we select an equal number of people per group. For example, we could stratify by age range.
  • Cluster Sample: Jarvis uses the example of doing research about teaching medicine and selecting a number of medical schools in a particular area and then study the teachers in just those schools.
  • Stage Sample: This builds on a cluster sample, but then uses a second random sample in the population drawn from the cluster group.
  • Convenience Sample: We select our sample from a convenient population. This is what we do with most of our clinical trials- the community is invited, some people respond, and then we get our sample from those that do.
  • Quota Sample: We select a specific number of individuals from each category we seek to study.
  • Purposive Sample: We hand pick the sample. Perhaps we invite our colleagues to participate in our research.
  • Dimensional Sample: This is a modified quota sample where we also ensure that we capture all the dimensions of the practice to be studied.
  • Snowball Sample: We ask, for example some experts to be in our study, and then ask them to suggest additional experts. The sample then “snowballs” in size.

Thus, there are many ways to find a sample, and as always, we just need to use the best one to answer out question.

Monday, August 25, 2014

Three New From Biomed Central

Archibald D, Macdonald CJ, Plante J, houge RJ, Fiallos J. Residents' and preceptors' perceptions of the use of the iPad for clinical teaching in a family medicine residency program. BMC Medical Education 2014, 14:174  doi:10.1186/1472-6920-14-174


Background: As Family Medicine programs across Canada are transitioning into a competency-based curriculum, medical students and clinical teachers are increasingly incorporating tablet computers in their work and educational activities. The purpose of this pilot study was to identify how preceptors and residents use tablet computers to implement and adopt a new family medicine curriculum and to evaluate how they access applications (apps) through their tablet in an effort to support and enhance effective teaching and learning.
Methods: Residents and preceptors (n = 25) from the Family Medicine program working at the Pembroke Regional Hospital in Ontario, Canada, were given iPads and training on how to use the device in clinical teaching and learning activities and how to access the online curriculum. Data regarding the use and perceived contribution of the iPads were collected through surveys and focus groups. This mixed methods research used analysis of survey responses to support the selection of questions for focus groups.

Results: Reported results were categorized into: curriculum and assessment; ease of use; portability; apps and resources; and perceptions about the use of the iPad in teaching/learning setting. Most participants agreed on the importance of accessing curriculum resources through the iPad but recognized that these required enhancements to facilitate use. The iPad was considered to be more useful for activities involving output of information than for input. Participants' responses regarding the ease of use of mobile technology were heterogeneous due to the diversity of computer proficiency across users. Residents had a slightly more favorable opinion regarding the iPad's contribution to teaching/learning compared to preceptors.
Conclusions: iPad's interface should be fully enhanced to allow easy access to online curriculum and its built-in resources. The differences in computer proficiency level among users should be reduced by sharing knowledge through workshops led by more skillful iPad users. To facilitate collection of information through the iPad, the design of electronic data-input forms should consider the participants' reported negative perceptions towards typing data through mobile devices. Technology deployment projects should gather sufficient evidence from pilot studies in order to guide efforts to adapt resources and infrastructure to relevant needs of Family Medicine teachers and learners.

Willison DJ, Ondrusek N, Dawson A, Emerson C, Ferris LE, Saginur RI, Sampson H, Upshur R. What makes public health studies ethical? Dissolving the boundary between research and practice. BMC Medical Ethics 2014, 15:61  doi:10.1186/1472-6939-15-61

Background: The generation of evidence is integral to the work of public health and health service providers. Traditionally, ethics has been addressed differently in research projects, compared with other forms of evidence generation, such as quality improvement, program evaluation, and surveillance, with review of non-research activities falling outside the purview of the research ethics board. However, the boundaries between research and these other evaluative activities are not distinct. Efforts to delineate a boundary – whether on grounds of primary purpose, temporality, underlying legal authority, departure from usual practice, or direct benefits to participants – have been unsatisfactory.
Public Health Ontario has eschewed this distinction between research and other evaluative activities, choosing to adopt a common framework and process to guide ethical reflection on all public health evaluative projects throughout their lifecycle – from initial planning through to knowledge exchange.

Discussion: The Public Health Ontario framework was developed by a working group of public health and ethics professionals and scholars, in consultation with individuals representing a wide range of public health roles. The first part of the framework interprets the existing Canadian research ethics policy statement (commonly known as the TCPS 2) through a public health lens. The second part consists of ten questions that guide the investigator in the application of the core ethical principles to public health initiatives.
The framework is intended for use by those designing and executing public health evaluations, as well as those charged with ethics review of projects. The goal is to move toward a culture of ethical integrity among investigators, reviewers and decision-makers, rather than mere compliance with rules. The framework is consonant with the perspective of the learning organization and is generalizable to other public health organizations, to health services organizations, and beyond.

Summary: Public Health Ontario has developed an ethics framework that is applicable to any evidence-generating activity, regardless of whether it is labelled research. While developed in a public health context, it is readily adaptable to other health services organizations and beyond.

Van der Worp MP, de Wijer A, Staal JB, MWG Nijhuis- van der Sanden.  Reproducibility of and sex differences in common orthopaedic ankle and foot tests in runners. BMC Musculoskeletal Disorders 2014, 15:171  doi:10.1186/1471-2474-15-171

Background: For future etiologic cohort studies in runners it is important to identify whether (hyper)pronation of the foot, decreased ankle joint dorsiflexion (AJD) and the degree of the extension of the first Metatarsophalangeal joint (MTP1) are risk factors for running injuries and to determine possible sex differences.
These parameters are frequently determined with the navicular drop test (NDT) Stance and Single Limb-Stance, the Ankle Joint Dorsiflexion-test, and the extension MTP1-test in a healthy population. The aim of this clinimetric study was to determine the reproducibility of these three orthopaedic tests in runners, using minimal equipment in order to make them applicable in large cohort studies. Furthermore, we aimed to determine possible sex differences of these tests.

Methods: The three orthopaedic tests were administered by two sports physiotherapists in a group of 42 (22 male and 20 female) recreational runners. The intra-class correlation (ICC) for interrater and intrarater reliability and the standard error of measurement (SEM) were calculated. Bland and Altman plots were used to determine the 95% limits of agreements (LOAs). Furthermore, the difference between female and male runners was determined.
Results: The ICC’s of the NDT were in the range of 0.37 to 0.45, with a SEM in the range of 2.5 to 5 mm. The AJD-test had an ICC of 0.88 and 0.86 (SEM 2.4° and 8.7°), with a 95% LOA of -6.0° to 6.3° and -5.3° to 7.9°, and the MTP1-test had an ICC of 0.42 and 0.62 (SEM 34.4° and 9.9°), with a 95% LOA of -30.9° to 20.7° and -20° to 17.8° for the interrater and intrarater reproducibility, respectively.

Females had a significantly (p < 0.05) lower navicular drop score and higher range of motion in extension of the MTP1, but no sex differences were found for ankle dorsiflexion (p ≥ 0.05).
Conclusion: The reproducibility for the AJD test in runners is good, whereas that of the NDT and extension MTP1 was moderate or low. We found a difference in NDT and MTP1 mobility between female and male runners, however this needs to be established in a larger study with more reliable test procedures.


Monday, August 18, 2014

IRB Application Materials Checklist

When you are considering conducting research, you have to complete and submit an application to the IRB. We use a check list to ensure that we have all the require elements needed to properly assess each application. Often, initial applications are incomplete so I thought I would list here all the required components of an application.

Certificate from the Human Protections Administrator: when you submit your application I will review it and decide whether it is exempt or whether it requires submission to the full IRB. When I do, I generate a form that is sent back to you informing you of that decision.
IRB application: clearly, this is required. But I would say that 9 times out of 10, there are missing elements in the application. Please go through the entire application and complete every section, even the ones that don’t appear necessary to you (such as a question about the use of radiology when you are conducting a survey). There are also pull-down menus that you need to complete.
IRB application signature page: the final page of the IRB application is a signature page. It requires not just your signature, but that of your supervisor. Make ure that both of you have singed this prior to submission.

Personnel roster: This can be downloaded off the IRB website or from the portal. It requires you to list all the people involved in the project, and it asks you to define their role. All involved must have completed the NIH Protections of Human Research Participants training program and have an up-to-date certificate on file.
CV/biosketch: we are required to have a copy of your most recent curriculum vitae of NIH biosketch on file. This will the case for all the personnel involved in the study. For many of you, we already hold the information, but for anyone new, we will need it, and for those that are old, they should regularly updated.

PHRP certificate: this is the NIH required training. It can be accessed at When you are done, it will allow you to print a certificate. We track these in a database. They must be updated annually.
IRB approvals from other institutions: where applicable, we will need copies of IRB approvals from any other institution involved in the research.

Recruitment material: If you are recruiting participants for your study, the IRB needs to see your recruiting material, even copies of emails you intend to send.
Study materials: we need copies of the survey you intend to give, or the script you will use for recruitment or for conducting qualitative research (such as focus group).

Educational material: we need copies of any material provided to the patient or participant.
Informed consent document: this is critically important, and must be included with an application where applicable.

With the deadline  2015 ACC-RAC coming up, we usually see an increasing number of applications in August. This list here will help ensure you are able to have your application processed in timely fashion.




Monday, August 11, 2014

Palmer Homecoming 2014

Another Homecoming has come and gone, but I feel that this one was an exceptionally strong event. For those of you who were unable to attend here is a partial list of some of the great speakers and topics we presented.

Plenary Sessions
Dennis Marchiori: Strengthening Palmer’s Core

Christopher Colloca: Validating our Traditional Chiropractic Philosophy with Contemporary Science
Christine Goertz: Chiropractic Quality, Cost and risks: What the Evidence Says and Why You Should Care

Deed Harrison: Chiropractic BioPhysics: Research Evidence
Bharon Hoag: A Vision of Chiropractic in Today’s Healthcare

Gerry Clum: Black and White in a World of Gray!

Breakout Sessions
Todd Hubbard: The Upper Cervical Complex: Anatomical and Biomechanical

Ron Boesch, Chris Roecker and Mike Tunning: Using EvidenceBased Orthopedic Exams in Practice
Charles Blum: Introduction to Sacro Occipital TechniqueIncorporating an EvidenceBased Chiropractic System ofAnalysis and Treatment

Roger Hynes, Alana Callendar: 100 Years of Fellowship and Education,

James Cox: Cox Flexion Distraction Spinal Manipulation: Biomechanics and Clinical Outcomes
Michelle Barber: Meditations on Philosophy

Brett Winchester: The Current Concepts in Motion Palpation
Lora Tanis: Tiny TuneUps, Evaluation and Adjusting Strategies for the Neonate

Lou Freedman, Dan Weinert: Neuroimmunomodulation,
Michelle Barber, Virginia Barber: Two Barbers, No Waiting: Bringing Customer Service to the Forefront of the DoctorPatient Interaction

Deed Harrison: The Spine as the Foundation for Health and Disease: A Contemporary Chiropractic BioPhysics® (CBP®) Technique Presentation

Brian Justice: Primary Spine Care: A RealWorld Approach to Chiropractic Practice in the Evolving Health Care System

Mary Frost: Digital Marketing Basics
Tracy Littrell: Radiographic Positioning and View Selection
M. Deborah Sesker, Cheryl Child: The Third Era of Healthcare,
Nate Hinkeldey, Michael Olsen, Mike Petrie, Mike Tunning: Interdisciplinary Care Models: Working Together to Benefit the Patient

Anna Allen: Professional Boundaries
Lia Nightingale: Recognizing Food Allergies: Challenges and Opportunities

Ron Boesch, Dave Juehring, Mike Petrie, Mike Tunning: An Overview of Movement Development, Injury, and Recovery
Ian McLean: Radiography for Chiropractors

Ron Boesch: What, When, Where of Testing…Patient Management
Jeff Sklar: Chiropractors in Cancer HospitalsUsing Evidence-Based Orthopedic Exams in PracticeUsing Evidence-Based Orthopedic Exams in PracticeUsing Evidence-Based Orthopedic Exams in Practice