Psychological distress in a Department of Veterans Affairs spine patient population

Background contextThe veteran population presents a unique confluence of biopsychosocial factors in the treatment of spinal conditions. In addition to poorer health status and higher numbers of chronic medical conditions compared with the general population, previous reports have highlighted the high prevalence of psychological disorders within the Department of Veterans Affairs (VA) health system. To our knowledge, no study has specifically evaluated psychological distress in patients with a spinal disorder within the VA health system.PurposeTo determine the prevalence of psychological distress among spine patients in a VA hospital and if higher levels of distress correlated with patient demographics and self-reported patient outcome scores.Study design/settingCross-sectional evaluation of adult patients at a regional VA outpatient orthopedic spine surgery clinic.Patient sampleOne hundred forty-nine adult patients presenting for treatment of spine-related disorders.Outcome measuresPatients were evaluated using the Distress and Risk Assessment Method (DRAM), a validated survey consisting of the Zung Depression Scale and the Modified Somatic Perception Questionnaire. In addition, self-reported pain, disability, and quality of life were assessed using the visual analog scale (VAS) for neck or back pain and the Neck Disability Index or Oswestry Disability Index (ODI) depending on the patient's location of pain.MethodsThe DRAM survey was used to determine the prevalence of psychological distress by classifying patients into normal, at-risk, and severe distress groups. Visual analog scale scores for neck and back pain, and self-reported disability scores, and demographic data including age, gender, combat experience, and use of antidepressant, anxiolytic, or narcotic medications were obtained at the time of enrollment.ResultsThe DRAM survey identified 79.9% of patients as having some degree of psychological distress, whereas the remaining 20.1% were classified as normal. Among those with psychological distress, 43.6% of patients were categorized as severe distress. Compared with the normal group, a history of combat was more frequent in all distressed patient groups including the at-risk (p=.04) and severe distress (p=.009) groups. Those in the severe distress category more commonly reported the use of narcotics (p=.043) and antidepressant/anxiolytics medications (p=.0001). Those in the severe distress group had significantly higher ODI scores (p<.0001) and back pain VAS scores (p=.0360) compared with the normal group.ConclusionsWe identified a large number of patients (80%) with some level of psychological distress and 43% with severe distress. The percent of patients with severe psychological distress in the VA was double that previously reported in a non-VA patient setting. Patients with severe distress had higher ODI scores, back pain VAS scores, use of narcotics and antidepressants, and a reported history of combat when compared with those without distress.     

The distress and risk assessment method (DRAM)

Our aim was to judge the influence of preoperative psychological disturbance on the outcome of lumbar discectomy. We evaluated 66 patients, before and after operation, using a self-administered questionnaire. Disability was assessed using the Oswestry disability index and psychological disturbance the Distress and Risk Assessment Method (DRAM) score. Patients were classified as normal, at risk or distressed, and the outcome of surgery in the three groups was compared at a follow-up of six months. The mean self-reported preoperative disability was significantly higher in those with psychological disturbance. A total of 54 patients (82%) returned completed postoperative questionnaires. Postoperative disability scores at six months were not significantly different in the three risk groups. Psychological disturbance improved after surgery. Our study suggests that the early outcome of lumbar discectomy is not affected by preoperative psychological disturbance. We conclude that a patient with a symptomatic prolapsed intervertebral disc should not be denied surgery on the basis of preoperative psychological assessment.     

The Distress and Risk Assessment Method. A simple patient classification to identify distress and evaluate the risk of poor outcome.

The integration of physical and psychological assessment is frequently problematic. Psychological tests are often cumbersome and difficult to interpret. There would appear to be a need for a simple assessment method that would identify distress and help alert the clinician to the need for a more comprehensive assessment. The Distress and Risk Assessment Method is derived from a simple set of scales validated for use with patients with low-back pain. It offers a simple classification of patients into those showing no psychological distress, those at risk of developing major psychological overlay, and those clearly distressed. Four patient types can be identified on the basis of scores on two short questionnaires. The construction of the Distress and Risk Assessment Method is described and validity data (both clinical and psychological) are presented. The use of the Distress and Risk Assessment Method in the prediction of outcome of treatment is presented, and the paper concludes with general guidelines for its use.     

Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power.

BACKGROUND CONTEXT: The "centralization phenomenon" (CP) is the progressive retreat of referred pain towards the spinal midline in response to repeated movement testing (a McKenzie evaluation). A previous study suggested that it may have utility in the clinical diagnosis of discogenic pain and may assist patient selection for discography and specific treatments for disc pain. PURPOSE: Estimation of the diagnostic predictive power of centralization and the influence of disability and patient distress on diagnostic performance, using provocation discography as a criterion standard for diagnosis, in chronic low back pain patients. STUDY DESIGN/SETTING: This study was a prospective, blinded, concurrent, reference standard-related validity design carried out in a private radiology clinic specializing in diagnosis of chronic spinal pain. PATIENT SAMPLE: Consecutive patients with persistent low back pain were referred to the study clinic by orthopedists and other medical specialists for interventional radiological diagnostic procedures. Patients were typically disabled and displayed high levels of psychosocial distress. The sample included patients with previous lumbar surgery, and most had unsuccessful conservative therapies previously. OUTCOME MEASURES: Diagnosis: results of provocation discography. Index test: The CP. Psychometric evaluation: Roland-Morris, Zung, Modified Somatic Perception questionnaires, Distress Risk Assessment Method, and 100-mm visual analog scales for pain intensity. METHODS: Patients received a single physical therapy examination, followed by lumbar provocation discography. Sensitivity, specificity, and likelihood ratios of the CP were estimated in the group as a whole and in subgroups defined by psychometric measures. RESULTS: A total of 107 patients received the clinical examination and discography at two or more levels and post-discography computed tomography. Thirty-eight could not tolerate a full physical examination and were excluded from the main analysis. Disability and pain intensity ratings were high, and distress was common. Sensitivity, specificity, and positive likelihood ratios for centralization observed during repeated movement testing for pain distribution and intensity changes were 40%, 94%, and 6.9 respectively. In the presence of severe disability, sensitivity, specificity, and positive likelihood ratios were 46%, 80%, 3.2 and for distress, 45%, 89%, 4.1. In the subgroups with moderate, minimal, or no disability, sensitivity and specificity were 37%, 100% and for no or minimal distress 35%, 100%. CONCLUSIONS: Centralization is highly specific to positive discography but specificity is reduced in the presence of severe disability or psychosocial distress.     

Intradiscal methylene blue injection for the treatment of chronic discogenic low back pain

This article was a preliminary report of prospective clinical trial of a group of patients with chronic discogenic low back pain who met the criteria for lumbar interbody fusion surgery but were treated instead with an intradiscal injection of methylene blue (MB) for the pain relief. Twenty-four patients with chronic discogenic low back pain underwent diagnostic discography with intradiscal injection of MB. The principal criteria to judge the effectiveness included alleviation of pain, assessed by visual analog scale (VAS), and improvement in disability, as assessed with the Oswestry Disability Index (ODI) for functional recovery. The mean follow-up period was 18.2 months (range 12–23 months). Of the 24 patients, 21 (87%) reported a disappearance or marked alleviation of low back pain, and experienced a definite improvement in physical function. A statistically significant and clinically meaningful improvement in the changes in the ODI and the VAS scores were obtained in the patients with chronic discogenic low back pain (P=0.0001) after the treatment. The study suggests that the injection of MB into the painful disc may be a very effective alternative for the surgical treatment of chronic discogenic low back pain.     

Muscle energy technique in patients with acute low back pain: a pilot clinical trial

STUDY DESIGN: A prospective, pilot clinical trial. OBJECTIVE: Examining the outcomes of Muscle Energy Technique (MET) in patients with acute low back pain. BACKGROUND: MET is commonly used to treat patients with acute low back pain. No randomized controlled trials examining the outcomes of this treatment in symptomatic populations has been reported in the literature. METHODS AND MEASURES: Ten men and 9 women diagnosed with acute low back pain were randomly assigned with stratification to 1 of 2 treatment groups. Patients were matched according to age, gender, and initial Oswestry score. The control group received supervised neuromuscular re-education and resistance training while the experimental group received the same exercises coupled with MET. Both groups received the selected treatment 8 times over a 4-week period (2 times per week). Patients completed an Oswestry Disability Index on their first and eighth visits and change scores were calculated. RESULTS: A 2-tailed t test (P < .05) demonstrated a statistically significant difference with the experimental group showing greater improvement in the Oswestry Disability Index score than the control group. CONCLUSION: MET combined with supervised motor control and resistance exercises may be superior to neuromuscular re-education and resistance training for decreasing disability and improving function in patients with acute low back pain.     

Responsiveness of common outcome measures for patients with low back pain.

STUDY DESIGN: A prospective cohort study assessing the responsiveness of two disease-specific questionnaires and a generic health questionnaire for patients with low back pain and sciatica. OBJECTIVES: To compare the responsiveness of the eight scales and two summery scales of the SF-36 questionnaire with that of the Oswestry Disability Index and Low Back Outcome Score questionnaires. SUMMARY OF BACKGROUND DATA: Evaluation of treatment outcome is being determined more frequently from a patient's perspective, particularly the impact treatment has on current health status. METHODS: Patients were recruited from two orthopedic back pain clinics in a tertiary hospital. Patients completed the pretreatment questionnaire 1 month before treatment and follow-up questionnaires a minimum of 2-6 months after treatment. Patients undergoing surgery were also observed for a minimum of 2 years. RESULTS: Overall, the Oswestry Disability Index was most responsive; however, individual scales from the SF-36 questionnaire showed equal or greater sensitivity to change than the Oswestry Disability Index in each of the patient subgroups. The SF-36 Role Physical scale was prone to floor effects (a high percentage of respondents score zero), and the change scores from the SF-36 Role Emotional scale varied by 100 points in either direction in each of the patient subgroups. CONCLUSION: Responsiveness varied according to which method was used in its calculation. The responsiveness of the SF-36 questionnaire shows that it can be a useful adjunct in the assessment of patients with low back pain when combined with disease-specific questionnaires.     

Psychological and functional profiles in select subjects with low back pain.

BACKGROUND CONTEXT: Some researchers have found a correlation of poor treatment outcomes in patients with low back pain and abnormal psychological profiles, whereas others have failed to confirm this correlation. A critical feature of this debate has been whether abnormal psychological profiles seen in patients with back pain are the result of the ongoing back pain or whether pre-existing psychological features predispose to a poor clinical outcome. PURPOSE: To determine the relationship of psychometric testing scores to the presence and duration of back pain of differing causes. STUDY DESIGN/SETTING: This was a prospective observational study of the psychological profiles of groups of patients with low back pain and controls. PATIENT SAMPLE: Subjects having a variety of painful back conditions (n=310) were compared with a control group of subjects without low back complaints who had undergone cervical spine surgery (n=73). OUTCOMES MEASURES: Psychometric testing (Modified Zung and Modified Somatic Pain Questionnaire) was performed along with pain scores (visual analog scale [VAS]), a standardized Low Back Pain Questionnaire, and the Oswestry Low Back Pain Disability Questionnaire in the evaluation of back pain and control subjects. METHODS: The subjects with painful back conditions included patients with presumed discogenic pain undergoing discography (n=95); patients with symptomatic isthmic spondylolisthesis coming to fusion (n=61); patients with chronic vertebral osteomyelitis before diagnosis and treatment (n=39). There was also a nonpatient group of soldiers with chronic low back pain not seeking medical care (n=115). The control subjects without low back pain consisted of a group who had undergone cervical spine surgery (n=73). Psychometric testing was performed and compared in the evaluation of subjects having these different painful back conditions. Analysis was done comparing pain scores, function scores, and psychological testing scores between the symptomatic and asymptomatic groups. RESULTS: The VAS maximum in last week score for the entire group was 7.1, and scores were not significantly different in all low back pain groups. The Oswestry scores were poorest in the discography group compared to spondylolisthesis and osteomyelitis. Functional scores were similar in the soldiers with low back pain and controls without low back pain. Both Depression and Somatic Pain scores were most abnormal in the discogenic low back pain group. Only 21% of this group had normal scores, compared with 71% of the spondylolisthesis group, 79% of osteomyelitis group, and 88% of the group with chronic low back pain not seeking treatment (p<.001 in all groups). The asymptomatic control group had 85% normal scores. CONCLUSIONS: Despite similar pain levels and pain duration, patients with the discographic diagnosis of discogenic back pain have poorer functional scores and very abnormal psychological scores compared with other subjects with chronic low back pain resulting from spondylolisthesis requiring surgery or chronic pyogenic osteomyelitis. Chronic moderately severe mechanical low back pain in healthy subjects was not associated with abnormal psychological scores or functional disability.     

Total hip arthroplasty outcomes correlate with spine disability

Functional deficits persist in a significant percentage of total hip arthroplasties (THA), leading to patient dissatisfaction. Spinal stenosis is a leading cause of chronic disability and lower extremity weakness. Although previous studies have evaluated the potential benefit of THA on back pain, none have reported the effects of spine disability on functional outcomes and patient satisfaction with THA. A total of 244 primary THAs (233 patients) with minimum 2-year follow-up rated their satisfaction, return to activity, and standard hip outcomes using the Oxford Hip Score (OHS). History of lumbar spine pain, lumbar surgery, and daily activity limitations was documented and an Oswestry Disability Index (ODI) score was calculated. Out of 244, 151 (62%) patients reported a history of back problems: 35 patients (14%)—history of lumbar surgery, 91 (37%)—daily low back pain, and 97 (40%)—back pain that limited activity. Patients with a history of back problems had lower OHS scores than those without back pain, p = 0.0001. Patients with daily low back pain or low back pain that limited activity had lower OHS scores, p < 0.0001. Increasing spine disability, as determined by ODI, correlated with poor OHS, p < 0.0001. Spine disability (ODI) was directly associated with patient dissatisfaction for pain relief (R = 0.41, p < 0.0001), return to activity (R = 0.34, p < 0.0001), and overall surgical results (ODI, R = 0.38, p < 0.0001) at 2 years after THA. ODI correlated strongly with poor THA outcomes. In conclusion, lumbar spine disability correlated directly with poor Oxford Hip Scores. Spine disability was directly associated with THA patient dissatisfaction with pain relief, return to activity, and overall outcome of surgery. This study demonstrates that poor functional results in THA patients correlate directly with spine disability.     

Greek versions of the Oswestry and Roland-Morris Disability Questionnaires

Disability questionnaires are increasingly used for clinical assessment, outcome measurement of treatment and research methodology of low back pain. Their use in different countries and cultural groups must follow certain guidelines for translation and cross-cultural adaptation. The translation of such an instrument must be tested for its reliability and validity to be applied and to allow comparability of data. The Oswestry Disability Index and the Roland-Morris Disability Questionnaire are two disability questionnaires most commonly used as outcome measures in patients with low back pain. The two questionnaires were translated for use with the Greek population, were back translated and tested, and became available in a final version. The Greek versions of the Oswestry Disability Index and the Roland-Morris Disability Questionnaire were tested in 697 patients with low back pain. Internal consistency reliability for the Greek translation of the Oswestry Disability Index and the Roland-Morris Disability Questionnaire reached a Cronbach's alpha coefficient of 0.833 and 0.885 respectively. Face validity and content validity were ensured. Concurrent validity was assessed using a six-point pain scale as a criterion. The correlation of both scales was significant. The Greek translation of these disability questionnaires provided reliable and valid instruments for the evaluation of Greek-speaking patients with low back pain.     

亚甲兰注射治疗椎间盘源性腰痛的临床观察

目的选择一组符合行腰椎融合手术标准的慢性失能性椎间盘源性腰痛患者,给予腰椎椎间盘内注射亚甲蓝,观察其临床效果。方法回顾性分析2010年8月～2011年12月行亚甲蓝椎间盘内注射治疗的90例椎间盘源性腰痛病例。用疼痛视觉模拟量表(visual analog scale,VAS)评分和Oswestry功能障碍指数(Oswestry disability index,ODI)评估每个患者手术前后的腰痛情况和腰椎功能,以评价亚甲蓝注射疗效。结果患者术后随访时间为3～6个月。所有患者中,83例(92.2%)腰痛症状有明显改善或完全消失,80例(88.9%)腰椎功能明显改善。手术前后的VAS评分和ODI比较,差异具有统计学意义(P<0.01)。结论椎间盘内注射亚甲蓝是一种非常有效的治疗椎间盘源性腰痛的方法。     

Transforaminal lumbar interbody fusion: a retrospective study of long-term pain relief and fusion outcomes

No long-term studies exist on the effectiveness of transforaminal lumbar interbody fusion. This study sought to determine postoperative pain, disability, and fusion status of transforaminal lumbar interbody fusion patients after > or = 4 years to establish long-term outcomes. A retrospective analysis of 42 patients with minimum 4-year follow-up was conducted. Patients completed visual analog pain scale (VAS) and Oswestry functional capacity evaluation pre- and postoperatively. Statistically significant improvement was noted in VAS and Oswestry functional capacity evaluation scores. Transforaminal lumbar interbody fusion is effective in alleviating intractable back pain over an extended time period. Solid radiographic fusion is unnecessary for clinically successful outcomes.     

A cross-sectional study correlating lumbar spine degeneration with disability and pain

STUDY DESIGN: Cross-sectional design. OBJECTIVES: To investigate the correlation between degeneration in the lumbar spine and self-reported disability and pain levels in patients with and without a history of trauma. SUMMARY OF BACKGROUND DATA: The link between lumbar spine degeneration and low back pain remains controversial, as does the correlation between trauma and spinal degeneration. METHODS: Radiographic and questionnaire data were collected from 172 consecutive patients with low back pain. Back pain severity was measured using two scales: one for pain over the entire episode and one for pain during the previous week. All patients also completed the Revised Oswestry Disability Questionnaire before radiography was performed. Further questions concerning the chronicity of symptoms and trauma were included. RESULTS: Controlling for age, patients with low back pain with a history of trauma had a statistically significant increase in the severity of facet degeneration (P < 0.02) compared with nontrauma patients with low back pain. However, there was no difference in disability and pain scores between the trauma and nontrauma patients or between the genders. A weak correlation between pain severity ratings and the number of levels of degeneration and the severity of the degeneration at the disc and facets was noted. CONCLUSIONS: Patients with low back pain with a history of trauma had more severe facet arthrosis than do nontrauma patients with low back pain, but there were no differences in pain and disability. There was a weak correlation between the quantity and severity of lumbar degeneration with pain levels, but not with disability scores. These findings are discussed in the light of recent reports regarding the cervical spine.     

前路和经椎间孔入路腰椎椎体间融合术治疗腰椎术后综合征的比较

目的:比较前路腰椎椎体间融合术(anterior lumbar interbody fusion,ALIF)和经椎间孔入路腰椎椎体间融合术(transfomminal lumbar interbody fusion,TLIF)治疗腰椎术后综合征的效果.方法:2005年3月～2007年3月收治31例腰椎术后综合征患者.其中14例行ALIF,17例行TLIF,观察两组患者手术前后Oswestry功能障碍指数(ODI)、模拟疼痛评分(VAS)、椎体间高度、椎体间角度,比较两组患者疗效、融合情况和并发症.结果:AUF组手术时间平均为110min,术中出血量平均为210ml,TLIF组分别为160min、620ml,两组比较有显著性差异(P<0.05).AUF组出现2例腹膜撕裂,予缝合后愈合:3例发生腹膜后血肿、麻痹性肠梗阻,经保守治疗完全恢复正常.TLIF组出现2例硬膜撕裂,予缝合后愈合;2例神经根牵托伤,经脱水、非甾体类消炎止痛药物治疗完全恢复正常.随访12～24个月,平均18个月,每组术后1年时ODI和VAS均较术前明显减少(P<0.01),椎间高度、角度均明显增加(P<0.05);两组间术前及术后1年ODI、VAS、椎间高度、椎间角度无明显差异(p>0.05);ALIF组疗效优良率为85.7%,TLIF组为82.4%.两组之间无显著性差异(P>0.05);两组椎间融合率均为100%.结论:AUF和TLIF治疗腰椎术后综合征均可达到满意的椎间融合率和临床效果,ALIF手术时间相对较短、出血量相对较少.     

慢性腰痛对脊旁多裂肌萎缩影响的临床研究

目的：明确慢性腰痛对脊旁多裂肌净横截面积大小及脂肪化程度的影响。方法：2010年3月至2013年8月对门诊治疗的腰痛患者进行回顾性分析,最终筛选出31例符合非特异性慢性腰痛患者,其中男19例,女12例;年龄23～55岁,平均36.4岁。主要症状是反复腰痛,病程大于1年,X线、CT、MRI均未见明显异常。采用MRI成像测量同一病例先后不同时间点多裂肌净横截面积及T2信号比率的变化,再获取2次MRI检查时VAS和Oswestry功能障碍评分,分析先后2次测量多裂肌净面积及T2信号比率的变化与腰痛的病程、VAS、Oswestry功能障碍评分的相关性,从而得出腰痛对脊旁多裂肌的影响。结果：同一病例第2次MRI检查多裂肌净横截面积明显小于第1次MRI检查,T2信号比率则明显高于第1次MRI检查（P<0.05）.多裂肌净横截面积减小率与VAS评分、病程和Oswestry功能障碍评分均呈正相关（P<0.001）,而T2信号比率增加率与VAS评分、病程和Oswestry功能障碍评分均无相关性（P>0.05）.结论：慢性腰痛是脊旁多裂肌萎缩和脂肪化的重要原因,腰痛时间、程度和功能障碍程度均与多裂肌萎缩呈正相关。     

Circumferential and posterolateral fusion for lumbar disc disease

Clinical outcome of low back fusion is unpredictable. There are various reports discussing the merits and clinical outcome of these two procedures. The patients were selected from a population of patients who had chronic low back pain unresponsive to conservative treatment. Thirty-six instrumented posterolateral fusions and 35 instrumented circumferential fusions with posterior lumbar interbody fusions were done simultaneously. Preoperative radiographic assessment included plain radiographs, magnetic resonance imaging scans, and provocative discography in all the patients. Posterolateral fusion or anterior lumbar interbody fusion was done for internal disc disruption. The Oswestry disability index, subjective scoring, and assessment of fusion were done at a minimum followup of 2 years. On subjective scoring assessment there was a satisfactory outcome of 63.9% (23 patients) in the posterolateral fusion group and 82.8% (29 patients) in the posterior lumbar interbody fusion group. On assessment by the Oswestry index no difference was found in outcome between the two groups. The posterolateral fusion group had a 63.9% satisfactory outcome and the posterior lumbar interbody fusion group had an 80% satisfactory outcome using the Oswestry disability index for postoperative assessment. There was 61.1% improvement in working ability in the posterolateral fusion group and 77.1% improvement in the posterior lumbar interbody fusion group which was not statistically significant. The authors consider instrumented circumferential fusion with posterior lumbar interbody fusion better than instrumented posterolateral fusion for managing chronic disabling low back pain.     

Development of the Neck Pain and Disability Scale. Item analysis, face, and criterion-related validity.

STUDY DESIGN: The development and testing of a new comprehensive measure of neck pain and disability, the Neck Pain and Disability Scale. OBJECTIVES: To provide an initial evaluation of the Neck Pain and Disability Scale's reliability and validity. SUMMARY OF BACKGROUND DATA: Although several measures exist for generalized pain and disability, none is specific for neck pain. More specific measurements should improve assessment of treatments and clinical research aimed at cervical pain syndromes. METHODS: The Neck Pain and Disability Scale was designed using the Million Visual Analogue Scale as a template and consists of 20 items that assess neck pain. In this study, 100 patients with neck pain, 52 patients with lower back and leg pain, and 27 pain-free volunteers were rated by the Neck Pain and Disability Scale. In addition, a subset of the 47 patients with neck pain were rated by several other established psychometric instruments. RESULTS: An item analysis showed a high degree of internal consistency among the 20 items on the Neck Pain and Disability Scale (r = 0.93), and face validity was established by comparing patients who had neck pain as well as lower back and leg pain with a pain-free group. The Neck Pain and Disability Scale scores correlated with the Oswestry Disability Questionnaire, the Pain Disability Index, and psychological measures of depression and neuroticism. CONCLUSIONS: The results suggest a highly reliable instrument for evaluating neck pain with at least four underlying dimensions. Further work to address the predictive validity of this new tool are under way.     

Randomized trial comparing interferential therapy with motorized lumbar traction and massage in the management of low back pain in a primary care setting.

STUDY DESIGN: A randomized trial designed to compare interferential therapy with motorized lumbar traction and massage management for low back pain in a primary care setting. OBJECTIVE: To measure and compare the outcome of interferential therapy and management by motorized lumbar traction and massage. SUMMARY OF BACKGROUND DATA: Management of low back pain by interferential therapy and motorized lumbar traction and massage is common in Germany. No reports of previous randomized trials for the outcome from interferential therapy were found. METHODS: Consenting patients were randomly assigned into one of two groups. A pretreatment interview was performed by the patient using a computer-based questionnaire. It also incorporated the Oswestry Disability Index and a pain visual analog scale. Management consisted of six sessions over a 2- to 3-week period. Oswestry Disability Indexes and pain visual analog scale scores also were obtained immediately after and at 3 months after treatment. RESULTS: A total of 152 patients were recruited. The two treatment groups had similar demographic and clinical baseline characteristics. The mean Oswestry Disability Index before treatment was 30 for both groups (n = 147). After treatment, this had dropped to 25, and, at 3 months, were 21 (interferential therapy) and 22 (motorized lumbar traction and massage). The mean pain visual analog scale score before treatment was 50 (interferential therapy) and 51 (motorized lumbar traction and massage). This had dropped, respectively, to 46 and 44 after treatment and to 42 and 39 at 3 months. CONCLUSIONS: This study shows a progressive fall in Oswestry Disability Index and pain visual analog scale scores in patients with low back pain treated with either-interferential therapy or motorized lumbar traction and massage. There was no difference in the improvement between the two groups at the end of treatment. Although there is evidence from several trials that traction alone is ineffective in the management of low back pain, this study could not exclude some effect from the concomitant massage.