Clinical Reasoning and SINSS Model

Clinical Reasoning Overview

• Clinical reasoning is a complex cognitive process for evaluating and managing a patient's medical issue
• Involves diagnosing, making therapeutic decisions, and estimating prognosis

Importance of Clinical Reasoning

• Clinical reasoning is an important skill
• Differentiates medical professionals from personal trainers

SINSS Model

• SINSS is a useful model for systematic clinical reasoning
• The components are Severity, Irritability, Nature, Stage, Stability

Severity

• Severity can be categorized as high, moderate, or low
• Severity impacts daily activities, work, recreation
• Measured using a 0-10 verbal scale (Numeric Pain Rating Scale)

Irritability

• Irritability is the ratio of the magnitude of aggravating factors to easing factors
• Consider how much aggravation increases pain and how long it takes to calm down
• It is key in determining the aggressiveness of exam or intervention techniques.
• High, moderate and low

Nature

• Nature includes the specific diagnosis or condition and the nature of the pain itself
• Types of pain include:
  • Nociceptive (mechanical or inflammatory)
  • Neuropathic
  • Central
  • Viscerogenic
  • Autonomic

Nature: Mechanical vs. Inflammatory Back Pain

• Mechanical back pain may occur at any age with acute onset, variable onset caused by a specific event, worsening with movement/exercise, improving with rest and little to no morning stiffness
• Inflammatory back pain onset is before age 45 years, pain duration is over 3 months, insidious onset, improving with movement or exercise, not improving with rest, has early morning stiffness lasting over 30 minutes and pain at night

Nature: Pain Descriptions and Structures

• Cramping, dull, aching indicates Muscle issue
• Dull, aching indicates Ligament, joint capsule issue
• Sharp, shooting indicats Nerve root issue
• Sharp, bright, lightning-like indicates Nerve issue
• Burning, pressure-like, stinging, aching indicates Sympathetic nerve issue
• Deep, nagging, dull indicates Bone issue
• Sharp, severe, intolerable indicates Fracture issue
• Throbbing, diffuse indicates Vasculature issue

Stage

• Stage refers to the time duration symptoms have been present
• Acute: Less than 3 weeks
• Subacute: More than 3 weeks but less than 6 weeks
• Chronic: Greater than 6 weeks
• Stage affects interventions based on tissue healing timeframes

Stability

• Stability refers to progression of symptoms over time
• Improving: Symptoms decrease in intensity, frequency, or location, and may involve less pain medication
• Worsening: Symptoms increase in intensity, frequency, or location
• No change: Neither better nor worse intensity, frequency, or location
• Inconsistent: Sometimes better, sometimes worse

Symptom Behavior Model

• This is a framework for testing hypothesis list developed through SINSS clinical reasoning
• Test-Treat-Retest is the hallmark

Asterisk Signs

• Activities or movements that reproduce the patient's symptoms
• Comparable signs with defined values that can be tracked
• E.g. Walking for 5 minutes vs Walking
• E.g. Cervical rotation: 46 degrees vs limited

Subjective and Objective Data

• Subjective data is information reported by the patient
• Objective data is collected during examination (ROM, strength and outcomes measures)

Symptom Behavior Model Application

• Perform an intervention based on hypothesis list (SINSS and asterisk signs)
• Retest asterisk sign (usually objective in-session and ask about subjective at next session)
• Show the patient how much improvement and why it is important

Explore clinical reasoning, a cognitive process for managing patient issues. Learn the SINSS model: Severity, Irritability, Nature, Stage, and Stability. Understand how these components guide medical decisions and treatment approaches.