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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