Clinical Reasoning in Physical Therapy

Clinical Reasoning

• Clinical reasoning is a complex cognitive process crucial for evaluating and managing patient medical problems.
• It involves diagnosing, making treatment decisions, and estimating prognosis.
• Clinical reasoning differentiates physical therapists from personal trainers, emphasizing the necessity of going beyond simple exercise prescription.

SINSS Model

• SINSS (Severity, Irritability, Nature, Stage, Stability) is a systematic framework for gathering diagnostic, treatment, referral, intervention, and patient education information.

Severity

• Evaluates pain impact on daily activities (e.g., daily living, work, recreation).
• Uses a 0-10 Numeric Pain Rating Scale, categorizing severity as high, moderate, or low.
• Focuses on the impact on daily activities.

Irritability

• Defined as the ratio of aggravating factors to easing factors.
• Assesses how easily pain is provoked and how quickly it subsides.
• Important to consider the aggressiveness of exams/interventions (avoid over- or under-treating).
  • Consider how much pain is increased by aggravation and how long it takes to subside.

Nature

• Includes specific diagnosis, condition, and nature of pain.
• Types of pain: nociceptive (mechanical/inflammatory), neuropathic, central, viscerogenic, autonomic.
• Distinguishes between mechanical (variable onset, improves with rest, no morning stiffness) and inflammatory (onset < 45, insidious, improves with movement, no rest improvement, >30 min morning stiffness) back pain.
• Provides examples of types of pain and associated structures (muscle = cramping, nerve = sharp, bone = deep, etc.)

Stage

• Duration of symptoms:
  • Acute (< 3 weeks)
  • Subacute (3-6 weeks)
  • Chronic (> 6 weeks)
• Impacts expected tissue healing time.

Stability

• Examines symptom progression:
  • Improving
  • Worsening
  • No change
  • Inconsistent

Symptom Behavior Model

• A framework for testing hypotheses from the SINSS assessment, using a test-treat-retest approach.
• Patient's role is not to determine improvement; the therapist's role is to demonstrate it.
• "Be like Costco" - emphasizes tangible results for patients.

Asterisk Signs

• Activities/movements that reproduce symptoms (objective, measurable).
• Example: walking for 5 minutes vs. walking, cervical rotation: 46 degrees vs limited.
• Importance of objective measurement and tracking.

Subjective vs. Objective Data

• Considers both patient-reported subjective information and objectively measured data (e.g., ROM, strength) during examination.

Intervention and Retest

• An intervention is performed based on SINSS and asterisk signs.
• Asterisk signs are retested (objective during session and subjective next session) to see the treatment's effect.
• Importance of showing improvement to the patient and explaining the significance.

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

• Acute pain (2 days after squatting); initial pain 7/10, reduced to 5/10.
• Deep ache with sharp pain.
• Unable to sit for >10 minutes without pain.
• Limited ROM in forward bending and rotation.
• Instructions to apply SINSS and identify appropriate asterisk signs, noting subjective and objective measurements.

Learning Objectives

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

Key Takeaways

• SINSS and Symptom Behavior Model provide structured approaches for gathering data and evaluating intervention effectiveness.
• Models emphasize patient-centered care, focusing on the impact of symptoms on patients' daily life and demonstrating improvements (and the reasons why they matter).
• Data-driven decision-making is encouraged using quantifiable data.
• Retesting is critical to measure intervention effects.

Explore the intricacies of clinical reasoning, a vital cognitive process for evaluating and managing medical problems. This quiz delves into the SINSS model, focusing on severity and irritability in patient assessments and treatment decisions.