Guiding Principle IV: The 7 day rule

In the beginning God created the heavens and the earth . . . and he rested on the 7th day!

Tim, are you going religious on us?

Okay. I’ll admit I have a faith and believe in God and all that.

But what I am about to share with you I did not discover as some form of religious superstition. This Guiding Principle is merely a clinical observation that I have observed consistently over decades and thousands of patients, such that I have come to appreciate it as one of the most helpful principles I use. This simple, practical and amazingly consistent principle has proven true hundreds of times over the years. I am confident that it will be useful to you in your practice.

What is the 7 day rule?

My personal ambition has always been to resolve my patient’s pain so that they ultimately do not need ongoing treatment.

I have found that in order to achieve lasting change, a symptom must be resolved for 7 or more consecutive days. In other words: on day eight following treatment the patient must have a full range of movement in the affected limb, no pain and no stiffness. I have found that when this can be achieved, then the body’s biomechanical function has definitely changed. Any compensations have actually resolved and the body has effectively re-learned/restored efficient, normal movement patterns. When this is achieved, the patient is unlikely to need any further treatment for that particular complaint.

 

When a patient has great results for only four or five or six days, you have not resolved their complaint. You have only eased it.

 

Example.

An example of chronic lower back pain caused by dynamic biomechanical compensations.

Week 1: A patient presents with persistent lower back overlying the right sacroiliac joint region. Their pain is eased with activity and increased with prolonged sitting. On assessment they have chronic myofascial restrictions in the right quadratus lumborum, left erector spinae, left gluteus medius and right adductor magnus. So you manipulate these areas.

Week 2: They return and state that the pain is in the same location but 60 per cent reduced in intensity. Great. A taste of success. But not resolution. Assessment reveals that some of these restrictions have resolved, others reduced. You manipulate again.

Week 3: They return once more and explain how wonderful you are! Shucks. It’s nice to be loved. They have had NO pain for five consecutive days for the first time in months. Their only complaint is some mild discomfort that has reoccured on day six.

What does this indicate?

They have not had relief for 7 or more days. Correct?

In my experience, with no further treatment, this is how this will play out: If you do not provide another treatment, this patient will gradually see their symptom reoccur, and in a few months will be in chronic pain again.

Why?

Don’t ask me the evidenced based research. This Guiding Principle is shamelessly anecdotal. I have observed consistently that if you provide the extra treatment, and ensure that the patient experiences 7 or MORE consecutive days completely symptom-free that they will NOT end up in chronic pain a few months later.

The moral of the story. 

When a patient has great results for four or five or six days, you have not resolved their complaint. You have only eased it.

Treat to RESOLVE the complaint!

If I have not said it already, be sure to see your patients for a course of treatment, not a single treatment. When a patient comes to you they are visiting you in order to resolve a complaint. In order for you to serve them professionally you need to assess, treat and evaluate. If you only see them once, how can you evaluate? A single, standalone treatment for a new patient is poor service and unprofessional.

I am not suggesting that you get them to return in order to make more money and keep them coming back. I am suggesting that you get them to return because you are serious about resolving their complaint so they don’t need to keep coming back. In short, if they do not have a follow up treatment, the first treatment was probably a waste of their time and money. Especially if they have to start the process again with a different therapist.

Treat to resolve the complaint.

Complete enough consecutive treatments (three or four is usually enough) to be confident that you have correctly assessed what they are suffering from, and either resolved their complaint or placed yourself in a position where you can confidently refer them to someone who can, or refer them for imaging or whatever else may be needed.  This is good professional service.

Only when you treat to resolve the complaint will you persevere with treatment until your patient is completely symptom-free for 7 or more consecutive days. Only when you treat to resolve the complaint will you really provide a valuable and professional service. In most cases where patients get relief for more than 7 days they will not need to return to you to treat the same complaint again. Ultimately you have saved them time and money and more importantly empowered them to engage in the quality of life they desire without being dependent on you for ongoing health.

Exceptions.

Exception 1. Permanently damaged structure.

Severe structural injury or advanced degeneration in joint or disc is irreversible. In this scenario you may only be able to alleviate the symptoms caused by the compensatory myofascial restrictions for six days or less. Don’t be too quick to write off poor results though. Do everything you can to get them to 7 consecutive days of relief before conceding that the structural injury or degeneration is too significant. You may be surprised.

Exception 2. Perpetuating factors. 

The 7 day rule helps in this respect: If you have successfully resolved the pain for more than 7 days, you know that you have restored healthy movement patterns. If you know you have achieved this and the pain does reoccur after three weeks or three months, you know that there is a perpetuating factor. Something the patient is doing: exercise, posture, sleep, gait, dietary inadequacy or something else that has contributed a reoccurrence. If you can figure out what their perpetuating factor is, then you can achieve permanent relief. The Big 3 article is a good starting point.

How do I apply it?

Treatments one week apart is a good rule of thumb. Often relief will be great but symptoms reoccur on day five or six. The symptoms that occur in the first three or four days following treatment do not usually indicate the primary dysfunction. The symptoms that present later in the week usually indicate the true primary dysfunction.

If you have read any evidence based research that may support this clinical observation I would love to know about it. Please send me a comment.