Start with the Activity: Understanding Severity

SINSS stands for severity, irritability, nature, stage, and stability. James introduces it as a way to organize information about the patient's problem and its behavior. Begin with what the patient is finding difficult. Walking, climbing stairs, and standing on one foot to dress are separate activities; they need not have the same degree of limitation.

In this framework, severity describes the effect on function. James also uses "subject reactivity" for this concept. The key question is what happens when the person tries to perform the activity. A general report that the ankle hurts does not tell you whether the person can walk normally, must modify walking, or cannot walk because of the symptoms.

James describes three levels:

The useful record includes both the activity and the reason for your classification. "High severity for stair ascent: unable to reach the upstairs office" communicates more than "high severity." It also gives you a meaningful activity to revisit when assessing progress or discussing a functional goal.

In the recording, a sales representative cannot climb the stairs to the second-floor office; James classifies this as high severity. He also describes a soccer player who has resumed running without pain and classifies that activity as low severity. These are examples of function being used to organize the report, rather than assigning the entire person a single global severity label.