The PINS Technique. American Academy of Osteopathy Annual Convocation March 22 nd, :00-9:30 AM & 10:00 11:30 AM

Transcription

1 The PINS Technique American Academy of Osteopathy Annual Convocation March 22 nd, :00-9:30 AM & 10:00 11:30 AM Dennis J. Dowling, D.O., M.A., F.A.A.O. Nothing to declare

2 TM

3 Dennis J. Dowling, D.O., FAAO Director of Manipulative Medicine Services Department of Physical Medicine & Rehabilitation Family Medicine Department Nassau University Medical Center East Meadow, New York Director of OMM Assessment COMLEX-Level 2 PE National Board of Osteopathic Medical Examiners Former Professor & Chairman Stanley Schiowitz, D.O., FAAO Department of Osteopathic Manipulative Medicine New York College of Osteopathic Medicine New York Institute of Technology

4

5 TIGHTER RESTRICTED PART LOOSER MORE NOTICEABLE END

6 GLOSSARY OF OSTEOPATHIC TERMINOLOGY osteopathic manipulative treatment (OMT): progressive inhibition of neuromuscular structures (PINS), a system of diagnosis and treatment in which the osteopath locates two related points and sequentially applies inhibitory pressure along a series of related points between the two points. 2.Developed by Dennis Dowling,DO.

7 DOWLING S UNIVERSAL METHOD of BALANCING DUMB TECHNIQUE

8 PROGRESSIVE INHIBITION of NEUROMUSCULAR STRUCTURES PINS

9 MAY 2000 JAOA

10

11

12

13 PROGRESSIVE INHIBITION of NEUROMUSCULAR STRUCTURES PINS OSKELETALFASCIAL?

14 How does one apply Osteopathic Manipulative Medicine?

15 Use your knowledge of STRUCTURE & FUNCTION.

16

17

18 Hey, Doc, I told you the pain was on the right!

19

20 WHEN YOU GET STUCK Don t just look at the symptom Ah,ha! SS SYMPTOM and determine the connection. LOOK FOR THE CAUSE

21 HEADACHE

22 Method 1....EXAMINE the patient 2. Use the S-T-A-R determinants of SOMATIC DYSFUNCTION which include: a)sensitivity changes [S] (or the more traditional [T] for tenderness) on palpation b)tissue texture changes [T] c) Asymmetry [A] d)restriction of Motion [R] 3. Pain is an indication that there is a problem, it does not necessarily localize the level or even the side of dysfunction. 4. A SENSITIVE POINT is determined in the immediate region of the patient s dysfunction and/or complaints by palpation. The pressure is relatively light and only enough to elicit the sensitivity reaction. Utilize 2-4 pounds of pressure.

23 Method 5. ANOTHER POINT is located distal or proximal to the point that is found in the region of the patient s symptoms. The more sensitive is designated as the initial primary. The other point is considered as the END POINT. The endpoint is most probably the KEY LESION initiating and/or maintaining the dysfunction of the region. 6. A muscular, fascial, neurological and/or vascular CONNECTION between the primary sensitive point and the end point. 7. A connection between the two points using knowledge of ANATOMY is drawn 8. INITIATE 2-4 pounds of PRESSURE on the point with greater sensitivity (primary point) while simultaneously maintaining pressure on the end point. Pressure is maintained on the designated END POINT throughout.

24 Method 9. The patient notes the initial amount of sensitivity (there will usually be a transient initial increase followed by subsequent decreases). 10. After approximately seconds, pressure is simultaneously placed on a NEW LOCATION approximately 2-3 centimeters from the primary point in the direction of the end point. This can sometimes be determined by a subtle increase in subcutaneous tension, a slight twitch, or a pulsation. 11. EQUAL PRESSURE is exerted onto both the primary and secondary points. 12. The patient is determines which of the two points ( PRIMARY VS. SECONDARY ) IS MORE SENSITIVE.

25 Method 13. If there is difficulty in determining a new secondary point: Sweep the area in an arc at a distance 2-3 cms from the primary point to determine a secondary point; When the patient can not determine that there are two points being pressed,; When the two points elicit the same sensitivity, release the primary and maintain pressure on the secondary point 14.The process is continued until the last secondary point is two centimeters from the end point. THE ENDPOINT HAS RECEIVED INHIBITION THROUGHOUT. 15. Frequently, a point may be located approximately halfway between the initial primary point and the endpoint that is exquisitely sensitive and may appear to reinitiate the chief complaint symptoms or radiate to the primary point. This actually is an indicator that there was dysfunction of all of the involved tissues and not just the area of chief complaint. It also indicates excellent prognosis for success with the treatment.

26 Method 16. Once the final two points are being inhibited, the physician can determine the amount of tension that persists at the end point location. The end point may not have greatly decreased in intensity, or it may have discontinued in sensitivity altogether. 17. If the endpoint remains persistent, the physician can choose to treat the residual component in whatever manner he wishes. PINS technique can be the sole approach to the dysfunctions that were found or can be used in conjunction with any modality of osteopathic manipulative treatment 18. The somatic dysfunction is REASSESSED. 19. The patient is advised that, despite the relative comfort of the treatment, there may be a post-treatment reaction. These can include transient soreness, aches, and fatigue. Bruising can occur in patients who are prone to this or if excessive pressure has been used. Generally, all of these will resolve in 24 to 48 hours.

27 Method 20. Patterns that are followed may indicate the actual structures inhibited: - Straight paths may indicate involved muscles or specialized fascial components - Zig-zag patterns may indicate nerves or blood vessels 21. More central patterns may actually cross midline (i.e. a frontal/trigeminal primary point on the right may have an endpoint located in the sub-occipital triangle on the left). 22. Some apparent endpoints may actually be mid-point components either within a structure or at the end of a structure (i.e. an apparent endpoint located near the fibular head may represent the halway point from a primary point at the greater trochanter of the femur and the fifth metatarsal head) representing an overlap of contiguous structures (i.e. iliotibial band peroneal brevis). This may not be determined until a subsequent visit. 23. When multiple counterstrain tenderpoints are located within a region, look for a PINS pattern.

28 HOW MUCH PRESSURE?

29 PINS Treatment

30 Chief Complaint 25 year old married female osteopathic medical student chief complaint of migraine headache. nausea, blurring of vision, increased lacrimation, and neck stiffness. The pain had begun a few days ago and was unrelieved by the use of non-steroidal anti-inflammatory medications, sleep, or frequent doses of Imitrex (sumatriptan succinate), which she took orally. She stated that she takes between 21 and 30 Imitrex pills per month. Loud sounds, light and certain food smells appear to worsen the chief complaint. There were no other visual, auditory, or olfactory complaints or associations with the presence of headache. The current episode appeared to be unrelated to her menses since her last menstrual period two weeks prior.

31 Past Medical History paresthesias to the upper extremities secondary MVA two months earlier. She was the driver of a vehicle, which was stopped at a traffic light, when she was struck from behind. She did see the other vehicle and braced herself for impact. Also a history of transient hematochezia, occasional vaginitis, coccigodynia, and allergic rhinitis. She had neck pain, shoulder pain, low back pain, and abdominal pain. She had a fall in which she struck the top of her head at age twelve and has had migraines since that time. Family history is significant in that other members of the family have had migraines, a brother has allergies, and her mother has colon problems. The patient has two glasses of wine once per week, during religious observations, and denies use of recreational drugs or tobacco. She has had a tonsillectomy, rhinoplasty, and sinus cauterization.

32 Medications Allegra TM (fexofenadine hydrochloride) oral contraceptives Excedrin PM (APAP/ASA/caffeine) Motrin (ibuprofen) Imitrex

33 Structural findings Cranial OA compression; Right condylar compression; restriction of frontal, right parietal, and right temporal bone motion during flexion; occipitomastoid suture restriction on the right; cranial rhythmic impulse of 4; Left sidebending-rotation pattern; facial asymmetry (right narrow orbit; flattened nasolabial fold left; deviation of nose; etc.); sensitive point at the supraorbital ridge; restriction of the right TMJ Cervical OAES R R L ; AA R R ; C2 E S R R R ; C3 E S L R L ; C6 S R R R ; C7S R R R ; spasm of the right trapezius; spasm of the right sternocleidomastoid Thoracic and Rib spasm of the right levator scapula; spasm of the left scalene muscles; Right first rib elevation; myofascial restriction of the hyoid and anterior strap muscles; multiple thoracic Type II somatic dysfunctions Lumbar L5 F S R R R ; thoracolumbar paravertebral muscle spasms Sacrum and Pelvis Unilateral sacral shear on the right; right anteriorly rotated ilium; right piriformis tender point; Chapman points along the iliotibial band on the right; restriction of the coccyx and pelvic diaphragmatic restriction on inhalation

34

35 How do you make the connection?

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55 PRIMARY POINT

56

57 END POINT

58 OUTCOME IMMEDIATE RELIEF OF THE PATIENT S HEADACHE PATIENT INCORPORATED SELF TREATMENT USING PINS PATIENT REDUCED USE OF IMITREX FROM PILLS PER MONTH TO 2-3 PER MONTH CONSIDER PROBLEMS OF MEDICATION AND REBOUND EFFECT

59

60 When do you use PINS? Typical approach to treatment is: Not working at all Not working well limited effectiveness Not being maintained When you have the time (experiment)

61 12 HVLA FPR & Still Muscle Energy

62 00:00:00 00:00:05 00:00:10 00:00:15 00:00:20 00:00:25 00:00:30 00:00:35 00:00:40 00:00:45 00:00:50 00:00:55 00:01:00 00:01:05 00:01:10 00:01:15 00:01:20 00:01:25 00:01:30

63 00:01:30 COUNTERSTRAIN

64 00:00:00 00:01:00 00:02:00 00:03:00 00:04:00 00:05:00 00:06:00 00:07:00 00:08:00 00:09:00 00:10:00 MINUTES PINS

65 00:10:00 PINS

66 HOW CAN YOU AFFORD NOT TO WHEN IT IS NECESSARY

67 Why do you use PINS? When it s necessary

68

69 PINS TREATMENT of HEAD & NECK

70

71 TRAPEZIUS

72 STERNOCLEIDOMASTOID

73 RHOMBOID MAJOR RHOMBOID MINOR

74 LEVATOR SCAPULA

75 SPLENIUS CERVICUS SPLENIUS CAPITUS

76 C7 CERVICAL PARASPINAL DJ Dowling, DO

77 STRAP MUSCLES

78 SCALENE MUSCLES

79

80 a PINS secret

81 QUICKER PINS

82 E

83

84 Could reduce 10 to 3 minutes