Clinical Reasoning in Physical Therapy

Clinical Reasoning: Definition and Importance

• Clinical reasoning is a complex cognitive process crucial for evaluating and managing patient medical problems.
• It goes beyond knowledge application; it includes diagnosing, making therapeutic decisions, and estimating prognosis.
• Clinical reasoning is the most important skill for physical therapists, distinguishing them from personal trainers.
• It involves more than just prescribing exercises; a deeper understanding of the patient's condition is needed.

SINSS Model: A Systematic Approach

• SINSS is a framework for systematic information gathering for diagnosis, treatment decisions, intervention planning, and patient education on prognosis.
• Its components include Severity, Irritability, Nature, Stage, and Stability.

Severity

• Severity assesses the impact of pain on daily activities using a 0-10 Numeric Pain Rating Scale.
• Categories are high, moderate, and low, focusing on the impact on daily living, work, recreation, etc.

Irritability

• Irritability is defined as the ratio of aggravating to easing factors.
• It evaluates how easily pain is provoked and how quickly it subsides.
• Consider the extent of aggravation causing increased pain and the time taken for pain relief after removing the aggravating factor.
• Irritability is important in deciding intervention aggressiveness; don't over-treat high irritability or under-treat low irritability.

Nature

• Nature involves the specific diagnosis, condition and the pain characteristics.
• Types include nociceptive (mechanical or inflammatory), neuropathic, central, viscerogenic, and autonomic pain.
• Mechanical pain: variable onset, may worsen with movement, improves with rest, little or no morning stiffness.
• Inflammatory pain: age of onset < 45, insidious onset, improves with movement, does not improve with rest, morning stiffness > 30 minutes.
• Different pain types have different associated descriptions and structures (e.g., muscle pain is cramping and dull, nerve pain is sharp and bright).

Stage

• Stage refers to the duration of symptoms:
• Acute: less than 3 weeks
• Subacute: more than 3 weeks but less than 6 weeks
• Chronic: more than 6 weeks.
• This impacts the expected timeframe for tissue healing.

Stability

• Stability examines symptom progression over time:
• Improving: decreased intensity, frequency, or location of symptoms
• Worsening: increased intensity, frequency, or location of symptoms
• No change: neither better nor worse
• Inconsistent: sometimes better, sometimes worse

Symptom Behavior Model: Testing Hypotheses

• This model uses a test-treat-retest approach to test hypotheses derived from the SINSS assessment.
• Patients should not be the judge of their improvement; clinicians should demonstrate it.
• It considers both subjective (patient reported) and objective (examination data) information.
• Interventions are based on SINSS and asterisk signs (activities reproducing symptoms).
• Asterisk signs should be defined with values (objective), tracked, and retested after intervention to assess its effect.
• Demonstrating tangible results to patients is crucial (Be Like Costco).

Patient Case Example (37-year-old male with acute low back pain)

• The patient experienced acute low back pain after squatting.
• Initial pain was 7/10, decreased to 5/10.
• Pain described as a deep ache with sharp stabs.
• Limited forward bending and rotation ROM.
• Unable to sit for more than 10 minutes without pain.

Learning Objectives

• Define and understand the importance of clinical reasoning.
• Understand and apply the SINSS model.
• Understand the Symptom Behavior Model.
• Apply SINSS to patient cases.

Key Takeaways

• SINSS and the Symptom Behavior Model provide structured approaches for information gathering, hypothesis generation, and intervention evaluation.
• Patient-centered care is essential, emphasizing understanding how the condition affects daily life and demonstrating progress to patients.
• Data-driven decisions are crucial using quantifiable data (e.g., pain scales, ROM) for progress tracking.
• Regular retesting of asterisk signs is important for measuring intervention effectiveness.

Explore the essential components of clinical reasoning, particularly the SINSS model. Understand how this systematic approach aids in patient evaluation, diagnosis, and treatment decisions. This quiz emphasizes the distinction between physical therapists and personal trainers in their clinical practice.