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Old 28-10-2011, 11:30 AM   #1
Barrett Dorko
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Default Possibly wrong

Quote:
Pain is a conscious correlate of the implicit perception of threat to body tissue

Lorimer Mosely
This thread, begun by Diane, contains an amazing video. The quote above is currently used by Bas in his signature. I wasn't surprised to see that he understood its significance.

I have previously referred to the brain as contained in a cauldron of sorts. By that I meant that it was a cauldron surrounded by figures capable of enigmatic and, at times, frightening behavior. When the therapist begins care they become one of these figures whether they want to or not.

Late in his talk Moseley describes the mechanisms and consequences of descending facilitation and inhibition. By this he means, “Something enters the cauldron that calms the waters, or something enters it that excites them.” This “something” is either thrown in or emerges as the consequence of heat over time (read living).

The brain can be wrong, and the reasons for that may forever remain mysterious.

Understanding this would change everything about our care.

When are we going to learn it?
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Old 28-10-2011, 02:17 PM   #2
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Yep. That was an amazing video and very timely for me.

I had completed my presentation that I am giving today....when this video was posted.

It forced me to change almost half of my presentation....in a good way.

I'm hoping to embed some of that change among some primary access clinicians (Nurse practioners).

I wonder if they will be more receptive and willing to be guided by science than the PT community seems to be?

I'm guessing yes...
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Old 28-10-2011, 03:46 PM   #3
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Quote:
I wonder if they will be more receptive and willing to be guided by science than the PT community seems to be?
proud, You know I'm rooting for you. Don't underestimate the tendency of the caregiver to choose expediency over reason. This is why it's essential to point out how actual practice becomes simpler if we understand something. Getting them to understand it is the hard part.
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Old 28-10-2011, 04:07 PM   #4
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About change, it's slow, and it's hard for people. That I've noticed. I work at two different places. A woman at one of them, who attended a class I taught, told me a few days ago that she's been using my ideas to treat patients and that they've responded well.. it was just upper body though, a one-day. She wanted to know stuff she could try for lower body too. This is 4 months after the class. So, I showed her what I could in a half hour or so. I feel she is slowly converting herself from being an athletic strong exercise/muscle/joint manipulator kind of therapist into developing more interactive, nervous system-friendly hands-on skill. But it will take awhile more, I'm sure. We overhear each other at work all the time: curtained cubicles, right next door.

There is a lot that has to go on inside someone, emotionally, before they can change. But she's showing me that she's interested.

Anyway, congratulations on delivering your presentation today proud.
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Old 28-10-2011, 05:36 PM   #5
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Rooting for you proud.
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Old 28-10-2011, 05:46 PM   #6
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Just an idea, and I know it's Canada and all, but when that player in St. Louis hit the homer in the bottom of the 11th last night and his teamates jumped on his head - did that hurt?

Suppose it had been the other team?

Maybe there's a similar hockey example.
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Old 28-10-2011, 07:11 PM   #7
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Barrett,

I heard the player (Freese) in an interview shortly after the game state something to this effect.
http://espn.go.com/espnradio/play?id=7159108
I guess context matters to how something might feel.


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Old 28-10-2011, 07:52 PM   #8
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Thanks for this Gary.

One of the guys I work with says immediately, "It won't hurt because of the adrenalin." he won't listen to anything else, "Because that's what they taught me in school."

1996.

According to this interview, it not only didn't hurt, it made him "feel great." Talk about descending inhibition.
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Old 28-10-2011, 08:36 PM   #9
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Proud, knock their socks off.

I've talked to nurses and found they are interested and receptive, on the whole. Rather like patients, they aren't concreted into certain beliefs to the detriment of facts, which may be why they are receptive to alternative medicine practices as well.

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Old 28-10-2011, 09:40 PM   #10
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Well I just finished.

Amazingly, during the Q&A part at the end.....the questions immediately went to spinal manipulation....

You see....over 1/3rd of the room get their spine "adjusted" on a regular basis. They wanted to know how if the brain is the ultimate decision maker...then why is it that they feel so much better once they have their spine "re-aligned".

I'm quite certain a few had close relationships with chiropractors who had convinced them otherwise. A few in the crowd even seemed hostile to the notion that their brains were involved at all!

I think on a fundemental level most "got it".....but I left there thinking I offended a number of folks in the audience.

I didn't like that. And I didn't anticipate it either since I made no mention of chiropractic care in my presentation.

I did mention the limited role of spinal manipulation and how it's effects are primarily neuro-modulatory rather than "adjusted vertebral position". But that represented less than 2 minutes of the entire one hour presentation.

yet the entire Q&A was about spinal manipulation.

It's an uphill battle that I just don't think we will ever win...I'm afraid.

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Old 28-10-2011, 09:45 PM   #11
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proud, welcome to the world of truly dead people.

Manipulation has been so synonymous with "the only thing that keeps me going" that any, ANY criticism will sound as if you are telling them they are crazy. They have been indoctrinated for so long.
Seriously: a patient once told me I said he was a liar, because I said that manipulation "wasn't necessarily doing what we think it is doing". He heard it as: "You are lying about your relief."

It WILL always happen, but hopefully enough sticks to others to make a difference.
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Old 28-10-2011, 10:22 PM   #12
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I worked darn hard on that presentation. I even had the image of the nail going through a boot...this case example:

http://www.bmj.com/content/310/6971/70.full

To help explain that the pain experience can be present in abscence of noceceptive input.

I used Moseley's grey cubes optical illusion (Thanks Steven Hill) to help illustrate the comlexity of the human brain etc etc.

I really do think it went over well. It just seems there were a number in the audience who seemed stuck on that two minute section regarding the role of spinal manipulation.

I wished there were more questions...OTHER than spinal manipulation.

Should have left it out...but a part of me knew I guess that if I'm going to drive the point home....Spinal manipulation would be an avenue to go.

I just didn't anticipate some of the reaction. One in particular was staring at me with her eyebrows in that position that very clearly says...."you are clearly an idiot".

I recognize the look...because a great number of patients give me the same look when I tell them that vertebrea do not get "put back in place" with a spinal manipulation.

I simply don't see a way out of our current healthcare culture.

Snake oil is for sale and there are plenty of buyers....even buyers who should really know better.

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Old 28-10-2011, 10:35 PM   #13
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Sounds like you did a great job proud.

The cognitive dissonance for some is to overwhelming for them to consider a different model that helped with their relief other then they are now adjusted properly. Not much one can do for them except maybe plant a seed and hope that somewhere at sometime, something can help it grow (just don't hold your breath waiting for that to happen). Move on and continue to help those that you can.
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Old 28-10-2011, 10:42 PM   #14
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Keep banging away proud.
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Old 28-10-2011, 10:55 PM   #15
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I think you did the best you could, proud.

Put it all down to the 'joy' of facing cognitive dissonance which most of us have endured for quite a while. The idea of putting something solid back into its place is a powerful and very satisfying image that displaces everything else, regardless of the science. Especially with the sound of clunks and clicks....

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Old 28-10-2011, 11:08 PM   #16
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proud,



Seriously, the first reaction is always surprise that you seem un-"ortho"-dox. That you don't want to adhere religiously to an operator model. That you are not maintaining that careful (comfortable) separation of body and brain. The one where "other" professions deal with the brain but we are some sort of experts about the body. I.e., the mesoderm.

They'll get over it; Miss or Ms. Raised Eyebrows will get over herself. She might even email you with more questions after she recovers from her shock.
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Old 28-10-2011, 11:32 PM   #17
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Quote:
The market for something to believe in is infinite.
Hugh MacLeod
This was in an email I got today and I feel it fits here.

Proud, welcome to my world.

Well, at least it used to be my world to this extent. I learned a while ago to acknowledge the feelings others are bound to have given their personal experience. Simply and briefly I anticipate how what I say will be at odds with what they think but suggest that new explanations may enhance the effect of their care.

This works a little, I think.
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Old 29-10-2011, 12:06 AM   #18
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I think Seth Godin's post today fits here as well.

Quote:
Arguing with success

"You can't argue with success."
Of course you can.
Conventional wisdom says you shouldn't bother. But arguing with failure is dumb. Failure doesn't need to be argued with, it's already failed.
It takes guts to argue with success, guts and insight. And it's the best way to make things better.
"But I feel better after I get my spine aligned", "My patients get better"

Many here have been arguing against this success for some time. And it's the best way to make things better.
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Old 29-10-2011, 12:30 AM   #19
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proud, I think what's most important is that you figured out what you wanted to say, thought it through, make a presentation, then presented it, exposed your more-organized, more actively cultivated, more comprehending and composted PT mind to others. It might seem futile, but everything people hear registers somewhere, and will work on them whether they are aware of it or not. Which is why it's important to be careful beforehand. So you don't just get out there and propagate false memes. I.e., add to the problem instead of subtract from it. Plus, you have emerged from the experience knowing a lot more about what's in your own head than you would have if you hadn't bothered to try.
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Old 29-10-2011, 12:47 AM   #20
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Maybe this is relevant? It could at least be useful for SS related discussions. Better Disagreement is an essay at Less Wrong.

Proud,

Did you invite people here to continue the conversation? For the few who follow-up on the suggestion, it allows for clarification and improved understanding.
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Old 29-10-2011, 01:30 AM   #21
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Since I now work in a medical university setting, I frequently treat some really highly educated, scientifically-trained people- people with a lot more formal education than myself.

So far, except for one extraordinary PhD in pharmacology, who seemed to grasp pain as a physiological process rather than a static state in the peripheral tissues, these individuals are remarkably more difficult to educate about pain than my patients with average or even below average education.

Today, I saw a PhD in microbiology who trains medical students in the highly complex biological cycles of cells. She's seen a chiropractor for years to treat chronic neck and low back pain that she attributes to an injury when she was 14 years old. She's now well into her 40s. She made it a point to tell me that he was a "good one". Of course, I'm wondering to myself if he's so good, then why does she still have neck and low back pain?

In my experience, biomedically-trained audiences are the worst, the most confused, the most ill-informed and the least likely group to alter their attitudes and ideas about pain. The level of their training doesn't seem to matter; what seems to matter is their indoctrination and firm conviction that biomedicine has the best answer to the pain experience, which persists despite reams of data indicating just how woefully inadequate it is.

So, proud, I'm not sure what I'd recommend to you. I guess it's ok to "bang away", as Rod suggests above, as long as you don't sustain a concussion or, worse, skull fracture in the process.

Maybe be more selective with your audiences?
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Old 29-10-2011, 03:38 AM   #22
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Thanks everyone for the support. Although I was a bit suprised at the few in the audience that appeared perplexed( Angry?)...for the most part the majority in the audience were very receptive and seemed to be enjoying the presentation.

I should make that clear.

The slide that seemed to create all the negative reaction was my slide which indicated that the literature regarding spinal manipulation is strongly suggesting that things are not "re-aligned" or "adjusted" in terms of vertebral position...but rather is neuro-modulatory event.

Prior to putting this slide up...I simply asked how many in the audience had their spine manipulated at some point in their lives. At least 1/3rd of the audience of 150 raised their hands. I then asked if they had given any thought about was was actually happening with this "manipulation"

I set them up a bit. Then threw up my slide.

Epic fail and I sensed it right away. One third of the audience went from listening and enjoying to....annoyed. Ms eyebrows was particularily thorny.

Who could have guessed that 1/3rd of the people had come to believe that spinal segments "go out of place" and some magical clinician was putting this back in it's rightful place?

It's a nice fairy tale and I learned today that people rather like fairy tales.

There were 20 presenters at this two day conference. All participants will be filling out evaluations of each presentation so that they can plan next years event.

Apparerently I will be finding out on Monday how I rated ( scale of 0-5). Should be interesting.

I wonder if next year they'll invite a nice "Part B" Physiotherapist to replace me?

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Old 29-10-2011, 03:46 AM   #23
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If that happens, join Pain Science Division, contribute to our newsletter, propose a course you want to teach, let us sponsor you.
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Old 29-10-2011, 03:52 AM   #24
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Quote:
Originally Posted by proud View Post
Who could have guessed that 1/3rd of the people had come to believe that spinal segments "go out of place" and some magical clinician was putting this back in it's rightful place?
If I were a betting man I'd bet that more than a third of the people would think that proposition is true. The number that actually had their spine manipulated is only a subset of the population of people who accept this notion. That said, not all people who enjoy manipulation subscribe to the bone out of place concept.
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Old 29-10-2011, 04:03 AM   #25
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proud,

This is a good lesson for all of us teaching. Now I'll say (gently), "Many who are regularly manipulated with good effect think that something is being put back in place but the research doesn't support that mechanism. Instead...

In this way no one's experience is threatened and a rational explanation is offered. This will cut back on the number of tomatoes thrown, I think. Maybe.
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Old 29-10-2011, 04:53 AM   #26
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Quote:
Originally Posted by zimney3pt View Post
I think Seth Godin's post today fits here as well.



"But I feel better after I get my spine aligned", "My patients get better"

Many here have been arguing against this success for some time. And it's the best way to make things better.
The discussion became circular around this theme Kory.

Person #1: "But I feel better after I get my spine re-aligned"

Me: "Yes, and I haven't suggested otherwise. I simply am indicating what the literature suggests...that things are not "re-aligned".

Person #1: So if bones don't move than what is the cracking sound.

Me: " Likley just air...similiar to when you crack your knuckles"

Person #1: "but something must be moving"

Me: "Yes, many things will "move"

Person #1: "Ah...so it is possible that my spine was slightly out of place and it was very subtly put back in place"

Me: "That's not the mechanism that the literature is supporting right now"

Person #1: "All I know is that I feel much better after my spine is adjusted"

You get the idea....

I'm going to have nightmares over those eyebrows tonight....
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Old 29-10-2011, 05:02 AM   #27
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I'm going to have nightmares over those eyebrows tonight....
Scientists Measure Dream Content for the First Time: Dreams Activate the Brain in a Similar Way to Real Actions


Sweet dreams..
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Old 29-10-2011, 05:30 AM   #28
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Here and here.
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Old 29-10-2011, 06:04 AM   #29
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I'll be enduring yet another health fair next week in support of a work site that is very supportive of me. I know that they've got a couple of chiros coming in as well, bringing in their bells in whistles from the mall to show everyone their interrupted nerve flows and mis-alignments. I figure I'm doing good if I get through the day without getting something thrown at me. Although, maybe I should figure I'm doing good if the opposite occurs.

My plan is to bring these 3 questions out when people go down the alignment path in the future.
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Old 29-10-2011, 08:13 AM   #30
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I suggest you start with this part:

"I’m not saying that mechanics are not important or useful (as you’ll see in the other article). "

People respond better if they believe you are on their side and are willing to agree with them rather than feel you are out to get them and prove them or their beliefs wrong. I've had my back manipulated. It feels good. Acknowledge that. You can't explain why joints often feel painful or why "popping" them relieves that pain, so it isn't the best approach to discount other theories but rather simply discuss that why it "feels" good is all neurological.

My interest has been more in athletic training and performance than it has been in pain but I came to realize the importance neurology played in all aspects of human movement and that is how I ended up here. The single most influential thing for me was simply a modified slump test self performed. When I stretched, my hamstrings felt "tight". It felt muscular, yet when I released the cervical flexion the tightness went away. So I had to ask myself how that happened. No other joint angle changed and there is no muscle directly connecting my neck to my lower leg. So I realized that it was neurological, and that my own perceptions of what I was feeling were incorrect. This opened up a whole new way of looking at things which I had previously thought I understood.

I'm telling you this because I think this is something that can be done in an educational type setting like you are going to be at and used as a tool to get people thinking and understanding things from a neurological perspective without directly challenging any other belief system.
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Old 29-10-2011, 08:40 AM   #31
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Cory's questions are valid and useful to ask, but I agree with Randy's post also.
Perhaps the road to take is not to challenge people's beliefs but to present an 'open mind' attitude and then Cory's questions, with the aim of making them think for a bit. Even if they walk off in a huff, some may return for further information, having thought for a bit.

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Old 29-10-2011, 12:33 PM   #32
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Didn't Mosely said, regarding pain education: "stay under their radar"
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Old 29-10-2011, 01:25 PM   #33
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Didn't Mosely said, regarding pain education: "stay under their radar"
My experience with this is that if you stay under their radar, you don't get their attention.

Practically the entire presentation building up to the whole "bone out of place" thingy was illustrations ( Nail in boot, congenital phantom limb, Pain is like vision illusions, pain is like thirst).

I took Barrett's advice and provided "stories". I relayed an experience I had with a patient who had come to understand that his spine would randomly pop out of place. His movements were incredibly antalgic and he reported to me that he lived in fear of his back "going out". He was thankful for the clinician who was able to "pop" it back in place for him but wanted me( a Physical therapist) to help him strengthen his "core" in hopes to make it less "unstable"

I educated this patient, worked with him for a month, three years latter he still comes to visit me to thank me. He's never had an incident of his "back going out" since.

I used Moseley's "exploding disc" example.

People were laughing. Nodding. Loved the illusions. Loved the stories. By all accounts, they were "getting it".

Then...the slide. The deathly slide.

I'm pretty sure I put it up there knowing what was going to happen. But it must have been unconsious on my part because I didn't anticipate the reaction.

So, for the most part, I remained under the radar. But it wasn't until I came into focus when people "paid attention".

I'm pretty sure that without that slide....people would have left with the general thought that I was an interesting, dynamic presenter with some "neat ideas"....

With the deathly slide...they at least left wondering......what the heck I was talking about.

Time will tell how that went over....
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Old 29-10-2011, 02:10 PM   #34
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I've met Cory a couple of times. He's huge.

No one in their right mind would throw something at him but, if I were him, I would have someone else taste my food for a while.

proud, The neuromatrix model? Is that the slide?

Glad the story went well. It helps if it's true, but it doesn't have to be - just well-told.
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Old 29-10-2011, 02:17 PM   #35
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One thing to consider is that your audience probably hasn't agreed to interact under Crocker's rules. The lack of such agreement has been referred to as a "tea party" (not the currently fashionable one) around here. As noted in my link

Quote:
Crocker's rules encourage being tactful with anyone who hasn't specifically accepted them.
But also noted in a link in the above link

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Note that Crocker's Rules does not mean you can insult people; it means that other people don't have to worry about whether they are insulting you.
Anyway, maybe a course brochure should include an agreement to interact via Crocker's Rules in the registration form.
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Old 29-10-2011, 05:42 PM   #36
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Jon,

That was an awesome post. These rules need their own thread.
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Old 30-10-2011, 12:07 AM   #37
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Barrett,

Quote:
proud, The neuromatrix model? Is that the slide?
No, it was a slide were I indicated that the literature strongly suggests that when the spine is manipulated...the bones are not "re-aligned" or "adjusted" in terms of vertebral position.

This one caught a few people off guard. Presumably because some clinician somewhere had convinced them otherwise.

The neuromatrix slide went over well.

Jon,

Quote:
Did you invite people here to continue the conversation? For the few who follow-up on the suggestion, it allows for clarification and improved understanding.
This was a group of 150 Nurse practioners with a real passing interest in MSK issues. I am more than certain that an invite here would have been ignored.

What's hilarious is that the first 10 minutes of my one hour presentation was very mesodermal in nature....that was done to the satiate the appetite for the "Ortho god" persona that I was billed as.

Unexpectedly, they cleared a table for me to demonstrate on a model a few "special tests" that I had compiled. They loved this part. Took notes I noticed.

Then I moved on, and they seemed interested.

Until the manipulation slide. That seemed to confuse/anger some in the audience.

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Old 30-10-2011, 12:16 AM   #38
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Ah... they wanted you to represent their preconceived ideas, the way everyone else usually does. Then you didn't. Instead of representing the wizard of Oz you were Toto, pulled aside the curtain. Made their crests fall. Good for you.
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Old 30-10-2011, 10:55 PM   #39
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Quote:
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My plan is to bring these 3 questions out when people go down the alignment path in the future.
While not directly related to alignment, the following factoid would be an interesting addition to your second question.

Quote:
Approximately 60-70% of patients with systemic cancer will have spinal metastasis; fortunately, only 10% of these patients are symptomatic.--source
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