The Mission of Hosenfeld Chiropractic is to:

1. Be able to generate a tissue-specific "working" diagnosis and appropriately treat it with time-limited passive modalities.
2. Be able to identify patients who exhibit psychosocial and/or physical risk factors which may predispose them to chronicity.
3. Aggressively transition patients into Active Care/Functional Restoration/Rehabilitation program and give them a thorough understanding of all aspects of Spinal Rehabilitation Principles and Protocols.
4. Develop an Outcomes Assessment Based Practice.
5. Follow accepted management guidelines.

"All episodes of symptoms that remain unchanged for 2-3 weeks should be evaluated for risk factors of pending chronicity. Patients at risk of becoming chronic should have treatment plans altered to de-emphasize passive care and re-focus on active care approaches." - Mercy Guidelines Following Accepted Treatment Guidelines:

There is increasing scientific evidence that most care administered for low back conditions is either inappropriate or less than optimal. This has resulted in the enormous increase in the rate of disabling low back pain and the costs associated with the management of it.

US Agency for Health Care Policy and Research Guidelines: Relief of discomfort with either analgesics and/or spinal manipulation.  Bed rest >4 days is not helpful and may further debilitate the patient.
Meta-analysis of the scientific literature has shown that manipulation speeds recovery of low back pain by 34% over other methods.
P. Shekelle, MD, Ph.D.
A. Adams, DC, Ph.D., et al. (50)

Adjustments improve the results of McKenzie exercises. Patients receiving manipulation and exercise outperformed those receiving exercises alone. Patients were classified by having a positive SI sign and an extension "bias." Erhard & Delitto, Physical Therapy 74:1093-1100, 1994

"The main theme of management must change from rest to rehabilitation and restoration of function." - Gordon Waddell, MD

FUNCTIONAL RESTORATION
The guiding philosophy of a functional restoration program is to restore joint mobility, muscular strength, endurance, and conditioning, as well as cardiovascular fitness leading to restoration of the ability to perform specific functional tasks such as lifting, bending, twisting, and tolerance to prolonged static positioning (i.e., sitting and standing).
Tom Mayer, MD

Tom Mayer's article: A Prospective Two-Year Study of Functional Restoration in Industrial Low Back Injury - An Objective Assessment Procedure.

FUNCTIONAL ASSESSMENT
Although muscle strength is important, quite often in the rehabilitation setting, that is the only factor which is assessed. Functional assessment includes assessing global joint function, coordinated movement patterns (motor control), muscle length and function as well as strength and endurance. A complete functional assessment of the locomotor system must occur prior to any institution of a progressive resistance exercise program. A set of non-dynamometric strength tests (trunk extension, trunk flexion, squatting) were shown to correlate better with disability than expensive dynamometric tests.

OUTCOME ASSESSMENT BASED PRACTITIONER
In the current health care environment, there is rapid push toward finding ways in which patients with neuromusculoskeletal (NMS) disorders can be treated in the most clinically efficient and cost effective way possible. The doctor who will be sought after by third party payers will be the one who is capable of getting a patient back on his or her feet a quickly as possible with the least amount of residual disability. Insurers and other third party payers are requiring the doctor to show objective evidence of continual improvement while under care or reimbursement will cease. There are numerous means to measure outcomes including Visual Analog Scales (VAS), Pain Diagrams, Oswestry Questionnaires, Headache Disability Index Questionnaires, etc. which are extremely reliable, valid and do not require great expense or time. They are reasonably simple means to measure outcomes and can be readily instituted in your practice.

SPINE UPDATE:
Exercise and Spinal Manipulation in the treatment of LBP
Lance Twomey, Ph.D.
James Taylor, MD Ph.D.
SPINE Vol. 20, #5, PGS 615-619

"Current research clearly indicated the importance of exercise and
mobility in the treatment of Low Back Pain."

"Manipulative procedures result in more rapid pain and functional relief compared with other conservative therapies." - SPINE Vol. 20, #5, PGS. 615-619

Four Factors Which May Predict a Longer Recovery (From the Mercy Guidelines):
1. Past history of greater than four episodes
2. Longer than one week of symptoms before presenting to doctor
3. Severe pain intensity
4. Pre-existing structural pathology or skeletal anomaly (i.e.,Spondylolisthesis) directly related to new injury or condition.

(Halderman S. Chapman-Smith, D. Petersen, DM. Frequency and Duration of Care. In Guidelines for Chiropractic Quality Assurance and Practice Parameters. Aspen 1125, 130, 1993, Gaithersburg)

Once the patient has reached the subacute stage, (normally between 1 and 4 weeks) you should start assessing and treating the functional pathologies involved with active care. This can begin with something as simple as pelvic tilt exercises and home isometric exercise programs. The Mercy guidelines state, "It is beneficial to proceed to rehabilitation phase as rapidly as possible, to minimize dependency on passive forms of treatment/care." In addition, "All episodes of symptoms that remain unchanged for 2-3 weeks should be evaluated for risk factors or pending chronicity. Patients at risk of becoming chronic should have treatment plans altered to de-emphasize passive care and re-focus on active care approaches."

"...there is a small window of time in low back pain care; we must act quickly within 4-6 weeks to bring patients into an active reconditioning program if we expect to return them to productive lives and prevent recurrence."

Margaret Nordin, Spine Letter, 1994; 2:5