Clinical Reasoning and SINSS Model in Physical Therapy

• Clinical reasoning is being presented by Adam Squires PT, DPT, Cert SMT, Cert DN, who is a Board Certified Specialist in Orthopedic Physical Therapy

• Objectives include defining clinical reasoning, understanding its importance, applying the Symptom Behavior Model, and understanding and applying the SINSS model to patient cases.

Clinical Reasoning Definition

• Clinical reasoning is a complex cognitive process essential for evaluating and managing a patient's medical problem
• It includes diagnosis, making therapeutic decisions, and estimating prognosis
• It separates trained professionals from personal trainers

SINSS Model

• It is a useful model for systematic clinical reasoning
• Applies to determining diagnosis
• Applies to assist in treatment/referral decisions
• Applies to making intervention decisions
• Applies to educating patients on prognosis
• SINSS stands for Severity, Irritability, Nature, Stage, and Stability

Severity

• Is classified as high, moderate, or low
• Includes impact on daily activities like work and recreation
• Can be measured using a 0-10 verbal scale (Numeric Pain Rating Scale)

Irritability

• The ratio of the magnitude of aggravating factors to easing factors
• Includes how much of an aggravating factor is needed to increase pain
• Includes how long it takes to calm back down when an aggravating factor is removed or a relieving factor is applied
• It determines the aggressiveness of exam or intervention techniques
• Avoid over-examining/treating high irritability
• Avoid under-examining/treating low irritability
• Graded as high, moderate, or low

Nature

• Includes the specific diagnosis or condition the patient is experiencing and the nature of the pain itself
• Types of pain are nociceptive (mechanical or inflammatory), neuropathic, central, viscerogenic, and autonomic

Nature

• Mechanical back pain occurs at any age, has a more acute onset, variable onset (may be caused by specific event), worsens with movement/exercise, improves with rest, and has little to no morning stiffness
• Inflammatory back pain occurs at less than 45 years of age, has a pain duration of greater than 3 months, has an insidious onset, improves with movement/exercise, does not improve with rest, and has early morning stiffness, which lasts greater than 30 minutes. Pain at night may wake the patient

Nature - Pain Descriptors

• Cramping, dull, aching pain relates to muscle
• Dull, aching pain relates to ligament and joint capsule
• Sharp, shooting pain relates to nerve root
• Sharp, bright, lightning-like pain relates to nerve
• Burning, pressure-like, stinging, aching pain relates to sympathetic nerve
• Deep, nagging, dull pain relates to bone
• Sharp, severe, intolerable pain relates to fracture
• Throbbing, diffuse pain relates to vasculature

Stage

• Refers to the time the symptoms have been present
• Acute is less than 3 weeks
• Subacute is more than 3 weeks, but less than 6 weeks
• Chronic is greater than 6 weeks
• Affects interventions based on tissue-healing timeframes

Stability

• Refers to the progression of symptoms over time
• Improving signs include symptoms that decrease in intensity, frequency, or location, and using less pain medication
• Worsening signs include symptoms that increase in intensity, frequency, or location
• No change refers to when there is neither better nor worse intensity, frequency, or location
• Inconsistent signs mean sometimes better, sometimes worse

Symptom Behavior Model

• Defined as the framework for testing hypothesis lists developed through SINSS clinical reasoning
• Test-Treat-Retest is the hallmark
• Emphasize that it is the provider's job to demonstrate to the patient that they are improving.

Asterisk Signs

• Include activities or movements that reproduce patient’s symptoms
• Are "comparable signs" with defined values that can be tracked
• Examples are walking for 5 minutes, and cervical rotation: 46 degrees vs limited
• Subjective information is what the patient reports
• Objective information is data collected during examination, such as ROM and strength

Implementing Symptom Behavior Model

• Based on your hypothesis list (SINSS and asterisk signs), perform an intervention
• Retest asterisk sign, usually objective asterisk in-session
• Ask about subjective asterisks at the next session
• Show the patient how much improvement and why it is important to them

Patient Case

• 37-year-old male with acute low back pain after squatting at the gym 2 days prior.
• Pain was 7/10 right after, lessened in the last 24 hours to 5/10 at its worst, and is described as a deep ache with sharp stabs intermittently
• Not able to sit for more than 10 minutes before pain is 5/10, and has to stand and walk around for 15 minutes or more before it calms down
• When bending, the patient can reach to his knees before pain stops him and rotation is extremely limited bilaterally

Adam Squires PT, DPT presents an overview of clinical reasoning, its importance in healthcare, and application of the Symptom Behavior Model. The lecture also details the SINSS model (Severity, Irritability, Nature, Stage, Stability) for diagnosis, treatment, and patient education.