Obviously, we don’t have a crystal ball to know exactly how many visits a patient will require to get better.  Each person is unique and there are many variables. So how do we approach treatment?

What is the Rule of 50%?

Cox practitioners are taught to treat patients using the rule of 50%.  For every 50% a patient improves, I cut the treatment frequency in half.  For example, if I am treating a patient 3 days per week, I cut back to 2x per week.  If I am treating them 1x per week, I let them go 2 weeks before follow-up. 

How do we determine 50% improvement?

I typically use a combination of pain scales and exam findings to determine if a patient is 50% improved.  On a 10-point pain scale, if a patient’s pain has dropped from a 6 to a 3, then they are 50% improved. Maybe their ability to bend forward has doubled or ability to sit has increased.  It is not an exact science.  Sometimes I just ask the patient to estimate how much improvement they feel from when we started. 

How long before I can expect 50% improvement?

In most cases I would like to see at least 50% improvement within 1 month of care.  If the patient has not achieved this, then I re-evaluate them. I must ask myself several questions. Has the patient been compliant?  Are they keeping their appointments?  Are they doing their exercise?  If so, do I need to change the treatment?  Should I do some imaging, or should I possibly refer them out? 

Can I expect 50% improvement if I have chronic pain?

With chronic pain patients, we hope to achieve 50% improvement within 90 days.  Medicine teaches that if a procedure can provide 30% relief, then it is a good outcome and worth doing.  Most chronic pain sufferers realize that they are dealing with management of their pain vs curing their pain. 


Treating by the rule of 50% gives us structure. It helps keep me on track and it helps the patient understand where they are in the course of treatment. 

I talk with patients a lot about managing their conditions vs curing them.  They may be pain free for periods of time but statistically it is a matter of when their pain will return, not if it will return.  It is just the nature of back pain.

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