“pins: a method of finding and treating osteopathic key

“PINS: A Method of Finding and Treating Osteopathic Key Lesions”Dennis J. Dowling, DO

POFPS 44th Annual CME Symposium August 9-11, 2019 1

TM

August 9th, 2019

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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

Chair of POCKET Project

Former Professor & Chairman

Stanley Schiowitz, D.O., FAAO

Department of

Osteopathic Manipulative Medicine

New York College of Osteopathic Medicine

New York Institute of Technology

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I HAVE NOTHING to DECLARE

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No OFF-Label uses will be discussed

(and probably no ON-Label uses as well).

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Disclosure: I Have No Financial Interests

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PINSA Method of Finding

and

Treating Osteopathic Key Lesions

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TIGHTER

RESTRICTED

PART

LOOSER MORE

NOTICEABLE END

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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.

GLOSSARY OF OSTEOPATHIC TERMINOLOGY

osteopathic manipulative treatment (OMT):

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DOWLING’S

UNIVERSAL

METHOD of

BALANCING

DUMB

DOWLING’S

UNIVERSAL

METHOD of

BALANCING

TECHNIQUE#POFPS44



PROGRESSIVE

INHIBITION of

NEUROMUSCULAR

STRUCTURES

PINS

PROGRESSIVE

INHIBITION of

NEUROMUSCULAR

STRUCTURES

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MAY 2000 JAOA

http://www.aoa-net.org/Publications/JAOA/fulltext/500dowling.pdf

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PROGRESSIVE

INHIBITION of

NEUROMUSCULAR

STRUCTURES

PINS?

OSKELETAL FA

SC

IAL

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How does one apply

Osteopathic

Manipulative

Medicine?

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Use your

knowledge of

STRUCTURE

&

FUNCTION.

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Hey, Doc, I told you

the pain was on the

right!

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SS SYMPTOM

WHEN YOU GET STUCK…

… Don’t just look

at the symptom…

… LOOK FOR THE

CAUSE…

… and determine the

connection.

Ah,ha!

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HEADACHE#POFPS44

Method

1. ...EXAMINE the patient

2. Use the “S-T-A-R” determinants of SOMATICDYSFUNCTION which include:

a)Sensitivity changes [S] (or the more traditional [T] fortenderness) 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 notnecessarily 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.

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5. ANOTHER POINT is located distal or proximal to the pointthat is found in the region of the patient’s symptoms. Themore sensitive is designated as the initial “primary”. Theother point is considered as the “END POINT”. Theendpoint is most probably the “KEY LESION” initiatingand/or maintaining the dysfunction of the region.

6. A muscular, fascial, neurological and/or vascularCONNECTION between the primary sensitive point andthe end point.

7. A connection between the two points using knowledge ofANATOMY is drawn

8. INITIATE PRESSURE on the point with greater sensitivity(primary point) while simultaneously maintaining pressureon the end point. Pressure is maintained on the designatedEND POINT throughout.

Method

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9. The patient notes the initial amount of sensitivity (there willusually be a transient initial increase followed bysubsequent decreases).

10. After approximately 20-30 seconds, pressure issimultaneously placed on a NEW LOCATIONapproximately 2-3 centimeters from the primary point inthe direction of the end point. This can sometimes bedetermined by a subtle increase in subcutaneous tension, aslight twitch, or a pulsation.

11. EQUAL PRESSURE is exerted onto both the primary andsecondary points.

12. The patient is determines which of the two points(“PRIMARY” VS. “SECONDARY”) IS MORESENSITIVE.

Method

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13. If there is difficulty in determining a new secondary point:

– Sweep the area in an arc 30-45° 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.

Method

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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.

Method

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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.

Method

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PINSTreatment

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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.

• 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.

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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.

• 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. #POFPS44

Medications

• AllegraTM (fexofenadine hydrochloride)

• oral contraceptives

• Excedrin PM (APAP/ASA/caffeine)

• Motrin (ibuprofen)

• Imitrex

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Structural findingsCranial

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

OAESR RL; AA RR; C2 E SR RR; C3 E SL RL; C6 SR RR; C7SR RR; 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 SR RR; 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

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How do you make the

connection?

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HOW MUCH PRESSURE?

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PRIMARY POINT

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END POINT

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OUTCOME• IMMEDIATE RELIEF OF THE PATIENT’S

HEADACHE

• PATIENT INCORPORATED SELF TREATMENT

USING PINS• PATIENT REDUCED USE OF IMITREX FROM 21-30

PILLS PER MONTH TO 2-3 PER MONTH

• CONSIDER PROBLEMS OF MEDICATION AND

REBOUND EFFECT

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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)

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12

6

39

FPR & Still

Muscle Energy

HVLA

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00:00:0000:00:0500:00:1000:00:1500:00:2000:00:2500:00:3000:00:3500:00:4000:00:4500:00:5000:00:5500:01:0000:01:0500:01:1000:01:1500:01:2000:01:2500:01:30

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00:01:30

COUNTERSTRAIN

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00:00:0000:00:0000:01:0000:02:0000:03:0000:04:0000:05:0000:06:0000:07:0000:08:0000:09:0000:10:00

PINS

MINUTES

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00:10:00

PINS

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…HOW CAN YOU AFFORD

NOT TO WHEN IT IS

NECESSARY#POFPS44



When it’s necessary

Why do you use

PINS?

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PINS

TREATMENT

of

HEAD

&

NECK

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TRAPEZIUS

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STERNOCLEIDOMASTOID

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RHOMBOID MAJOR RHOMBOID MINOR

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LEVATOR SCAPULA

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SPLENIUS CERVICUS SPLENIUS CAPITUS

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C7

CERVICAL

PARASPINAL

DJ Dowling, DO

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STRAP MUSCLES

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SCALENE MUSCLES

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a PINS secret

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QUICKER PINS

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1 3

4

2

E

5

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6

7

8

9

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10

1112

13

Could reduce 10 to 3 minutes

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“pins: a method of finding and treating osteopathic key

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