SINSS in Physical Therapy

• SINSS: Severity, Irritability, Nature, Stage, Stability.

Objectives

• Understand the significance of systematic approaches in physical therapy examinations.
• Define and apply the terms: severity, irritability, nature, stage, and stability.
• Describe using findings from SINSS to guide further examination.
• Connect SINSS findings to the vigor and extent of physical therapy examination.
• Identify methods to reduce clinical reasoning errors.

Systematic Examination Approaches

• Systematic approaches to examinations lead to effective/efficient clinical reasoning.
• Errors in clinical reasoning are reduced using systematic examination approaches.
• Hypothesis testing is allowed, to rule in/out potential diagnoses.
• Guidance to intervention is provided.
• Novice practitioners are allowed advancement more rapidly.
• Pattern recognition and organization are key factors.

Clinical Reasoning

• Clinical reasoning in physical therapy should be adaptive, iterative, and collaborative.
• The goal is a biopsychosocial approach to patient management.

Common Clinical Reasoning Errors

• Ineffective gathering of information can lead to clinical reasoning errors via poor subjective/history taking.
• Failure to filter/group signs and symptoms can lead to errors via pattern recognition during tests/measures.
• Deficits in knowledge and personal biases can lead to errors.

SINSS Construct Overview

• SINSS encompasses subjective and objective components.
• SINSS helps understand detailed and nuanced aspects of a patient's presentation.
• Appropriate vigor/extent of examination and intervention is allowed.
• SINSS reduction of clinical reasoning errors and connection back to STT can occur.

Severity

• Severity is the intensity of symptoms which allows for understanding the impact of pain/symptoms.
• Severity includes pain level, interference with ADLs, pain medication use, and night pain.

Assessing Severity

• Severity is assessed via pain scale, Functional Outcome Measures (FOMs), medication use, and asking how bad it is for the patient.

Severity: Clinical Relevance

• Patients with moderate to high levels of severity may not tolerate a "normal" physical therapy examination.
• Severity is influenced by patient's perception of their problem.
• Severity increases with pain catastrophizing and fear of movement.
• Prognosis and patient outcomes can be assisted by severity.

Irritability

• Irritability indicates how easily the patient's symptoms are provoked AND alleviated.
• Key components of irritability include vigor of activity required to reproduce symptoms.
• Severity of symptoms once provoked is an indicator.
• The amount of time and interventions to return to baseline is an indicator.

Assessing Irritability

• It helps to understand severity first.
• Duration of symptom provocation, and ratio of easing/aggravating factors determine irritability.

Irritability: Clinical Relevance

• Avoidance of painful positions, postures, activities is a factor.
• Irritability levels that decrease can gradually be re-introduced.
• Symptoms can be reduced using irritability information.
• Integrates tissue type and healing times which connects to STT + normal healing.
• Examination and interventions are guided by irritability.

Nature

• Nature is a broad, conceptual term including the patient's diagnosis and the type of pain experienced.
• Includes individual characteristics of the patient and how they manage the condition.
• This can be the type of pain, associated body system, specific diagnosis, other factors.

Nature: Clinical Relevance

• Interventions can be matched to a diagnosis.
• Provides understanding of associated problems.
• Allows for "triage" of the condition, including red/yellow flags
• Being appropriate for PT can be determined.
• Two patients with the same diagnosis may have very different experiences of pain/disability.

Stage

• Stage is the timeframe in which a condition is presenting.
• Tissue healing and progression through stages are variable.
• Prognosis and intervention selection are assisted.

Assessing Stage

• Acute is days to weeks (<3).
• Subacute is weeks (3-6).
• Chronic is weeks to months (>6 weeks – till...).
• Acute on Chronic: acute exacerbation of a chronic condition.
• Subacute on Chronic: later stage exacerbation of chronic condition.

Stage: Clinical Relevance

• Acute Stage: Dominated by inflammatory response with pain more severe and easily provoked.
• General goal in the acute stage is to control inflammation and offset negative effects of rest.
• Subacute Stage: Tissue repair and growth and decreased severity/irritability (compared to acute).
• Promotion of healing and mobile scar tissue is a general goal in the subacute stage.

Stage: Clinical Relevance - Chronic

• Chronic: Tissue maturation with general goals to improve strength and return to normal function.
• More aggressive/vigorous steps can be taken during the chronic stage.

Stability

• Stability: Process of determining how the condition is changing over time.
• Requires an understanding of baseline symptoms, severity, and stage.

Stability Assessment

• Improving indicates decreased symptom severity, location, frequency, and improvement in ADLs/function.
• Worsening is the opposite of improving.
• Unchanging means symptoms are not worsening/improving over time or with intervention.
• Fluctuating means symptoms are improving at times, worsening at others.

Stability: Clinical Relevance

• Valuable insight on how the patient is progressing is provided via prior to and during therapy.
• Requires constant re-evaluation, comparing results to baseline.
• Many (msk) conditions improve over time without interventions
• Unchanging = most difficult.

Summary

• SINSS is a systematic clinical reasoning approach that guides both examination and intervention.
• Repetition/exposure enables one to become efficient with the system.
• Implementing may accelerate students from beginning to advanced stages of learning.