Clinical Reasoning in Physical Therapy

Clinical Reasoning

• Clinical reasoning is a complex cognitive process crucial for evaluating and managing patient medical problems.
• It includes diagnosing patient problems, making therapeutic decisions, and estimating patient prognosis.
• It sets physical therapists apart from personal trainers.

Objectives

• Define clinical reasoning and understand its importance in clinical practice.
• Understand and utilize the SINSS model of clinical reasoning.
• Understand the Symptom Behavior Model of clinical reasoning.
• Apply SINSS to analyze patient cases.

SINSS Model

• A useful model for systematic clinical reasoning.
• Used to determine diagnosis.
• Used to aid in treatment/referral decisions.
• Used to create intervention decisions.
• Used to teach patients about prognosis.
• Components include Severity, Irritability, Nature, Stage, and Stability.

Severity

• Measured on a 0-10 verbal scale (Numeric Pain Rating Scale).
• Evaluates the impact of pain on daily activities like work, recreation, and daily living tasks.
• Categorized as high, moderate, or low.

Irritability

• The ratio of aggravating factors to easing factors.
• Examines how much and how quickly aggravating factors increase pain and how long it takes for easing factors to reduce pain.
• Categorized as high, moderate, or low.

Nature

• Describes the specific diagnosis or condition and the essential nature of the pain.
• Includes categories like Nociceptive (mechanical or inflammatory), Neuropathic, Central, Viscerogenic, and Autonomic pain types.
• Examples of types of pain are mechanical back pain and inflammatory back pain

Stage

• Categorizes the duration of symptoms as acute (less than 3 weeks), subacute (more than 3 weeks but less than 6 weeks), or chronic (greater than 6 weeks).
• Stage is evaluated to correlate with tissue healing timeframes. This is important in developing intervention strategies.

Stability

• Tracks symptom progression over time.
• Categories include improving (symptoms decrease), worsening (symptoms increase), no change, and inconsistent (sometimes better, sometimes worse).

Symptom Behavior Model

• A framework for testing hypotheses about patient problems using the SINSS model.
• The hallmark of this model is Test-Treat-Retest.
• Suggests the role of the practitioner as showing patient improvement, not just expecting the patient to acknowledge improvement.
• Relies on asterisk signs (activities or movements that re-create symptoms) and subjective and objective data.

Patient Case

• A 37-year-old male presented with acute low back pain after squatting.
• Pain was initially 7/10, but lessened to 5/10.
• Pain was described as a deep ache with intermittent sharp stabs.
• Pain worsened when sitting for more than 10 minutes.
• Pain resolved after 15 minutes of walking or standing.
• Rotation was severely limited bilaterally.

Application

• Applying SINSS to the patient case for justification.
• Identifying subjective and objective asterisks.
• Discussing considerations in a group setting or with supervisors.