Clinical UM Guideline


Subject:Cervical Traction Devices for Home Use
Guideline #:  CG-DME-05Current Effective Date:  10/08/2013
Status:ReviewedLast Review Date:  08/08/2013

Description

Intermittent cervical traction is an accepted technology for treatment of a variety of musculoskeletal disorders of the neck, including but not limited to neck muscle spasm (such as whiplash), radiculopathy, discogenic pain and degenerative changes.  This document addresses the different devices used in the home for cervical traction, including "over-the-door" and pneumatic devices.

Clinical Indications

Medically Necessary:

An "over the door" home cervical traction device is considered medically necessary provided both of the criteria below are met: 

Not Medically Necessary:

Other designs of home cervical traction units, including but not limited to, pneumatic devices, frames attached to headboards, or freestanding units are considered not medically necessary.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
E0840Traction frame, attached to headboard, cervical traction
E0849Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible
E0850Traction stand, free-standing, cervical traction
E0855Cervical traction equipment not requiring additional stand or frame
E0856Cervical traction device, cervical collar with inflatable air bladder
E0860Traction equipment, over door, cervical
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses
Discussion/General Information

Neck pain is a common occurrence that affects many people during their lifetime.  The American College of Rheumatology (ACR, 2006) noted on an annual basis, approximately 10% of the population experiences an occurrence of neck pain.  Typically, neck pain is acute and improves within one to two weeks with conservative treatments, which may include heat, ice, massage, stretching and pain relievers.  Majority of the neck pain resolves within 8 to 12 weeks (ACR, 2006; van der Heijden, 1995).

Traction is a medical technique in which opposite forces is applied to separate parts of the body to stretch soft tissues, and/or separate bony structures.  Cervical traction focuses on stretching the head away from the rest of the body to release tension and pressure on neck structures.  It generally requires two minutes of sustained traction before the intervertebral spaces begin to widen.  Forces between 20 and 50 pounds are frequently used to achieve intervertebral separation.  Continuous or static traction can be applied in a steady amount for specific time periods. Intermittent or cyclical traction involves traction being applied and released multiple times during one treatment session.  Duration of cervical traction can range from a few minutes to 20 to 30 minutes, once or twice weekly to multiple times per day.  Proponents have reasoned that the benefits of cervical traction are explained by its ability to expand the space between vertebrae, increase joint mobility, and stretch muscles and ligaments adjacent to the vertebral bodies. 

A variety of cervical traction devices are available for use in the home.  The most commonly used device uses an "over the door" design, in which a patient wears a chin strap harness attached to a counterweight that is suspended over the door using a pulley system.  The weight pulls the chin harness upwards, relieving tension on the neck. Other variations of this device include frames which attach to a headboard or freestanding units.  "Over the door" units are designed to deliver no more than 20 pounds of tension.

Pneumatic devices are also available that push up the head while pushing down on the shoulders.  One such device is the Pronex® Pneumatic Traction device (Glacier Cross Inc., Kalispell, MT) which consists of a soft foam cushion that extends from the patient's shoulders to the back of the head (occiput) and is secured with a head strap.  A patient-controlled bellows then inflates the cushions, thus applying up to 20 pounds of tension.  The Saunders HomeTrac™ device (Empi, Shoreview, MN) is another patient-controlled pneumatic device in which the traction is also applied to the occiput and not the lower jaw (mandible).  This device is designed to deliver up to 50 pounds of tension.

Pneumatic devices are able to provide more pounds of tension, or force, versus the over the door traction devices.  However, there are no published clinical trials comparing the pneumatic traction devices to conventional "over-the -door" home cervical traction devices.  There is also a lack of consensus in the published literature regarding the specific amount, duration and frequency of traction force required to improve net health outcome.

In a controlled trial, Zylbergold (1985) studied 129 patients with varied disorders who received physical therapy, which included neck care instructions, heat, massage and range of motion and isometric exercise.  The patients were randomized to one of four groups to receive additional treatment modalities, which included static, intermittent or manual traction, versus no traction.  Prior to completion, 29 participants dropped out of the study for unclear reasons, which resulted in an equal distribution of 25 assessable patients per assigned group.  Participants in the control group and the treatment cohorts demonstrated significant improvements during the 6-week study period.  Individuals treated with intermittent, but not static traction performed better than those without traction in terms of perceived pain (p -0.030), forward flexion (p = 0.01), and right rotation (p = 0.004).  However, there was no statistically significant difference between the individual modalities.  The evidence suggested intermittent traction as a preferred treatment for improving mobility and pain when analyzing the data compared to the group who received no traction.  Because the follow-up period of the study was limited to six-weeks, the durability of the modest benefit from intermittent traction is unclear.  The results reported in this trial have not been reproduced by randomized control trials since 1985.

A blinded review of randomized clinical trial (RCT) methods by van der Heijden and colleagues (1995) was conducted to evaluate traction and the effects on neck and lumbar pain.  Out of 21 eligible trials, only one randomized control trial on cervical traction by Goldie (1970) scored more than 50 points on a 100 point scale.  In the meta-analysis, the authors concluded "There has been no clear-cut information about the mechanism nor evidence for any specific effect of cervical and lumbar traction."  However, the authors also noted there was "no conclusive evidence that traction is ineffective therapy."

In a meta-analysis by Graham and colleagues (2006), literature dating back to 1970 was reviewed, and a single study of high quality (Klaber-Moffett 1990) was identified.  This study failed to show evidence of benefit from static cervical traction over placebo.  The low-quality trials showed moderate evidence "favoring intermittent traction for pain reduction" in patients with mechanical neck disorders.  There was conflicting evidence for global perceived effect.  The authors summarized because of the methodology and quality of the trials, the evidence is inconclusive.

In July 2008, Graham and colleagues published a Cochrane Review of seven randomized controlled trials (total participants = 958), which utilized continuous or intermittent traction for the treatment of chronic neck pain.  This evidence review included published studies through March 2008.  Two review experts independently assessed each selected study for risk of bias using the Back Review Group's 11 criteria (van Tulder, 2003) and the validated 5-point Jadad 1996 evidence quality criteria.  The investigators in this updated evidence review again found only a single study of adequate quality (Klaber-Moffett 1990), and this study did not show evidence of benefit of cervical traction.  The authors concluded, "Current literature does not support or refute the efficacy or effectiveness of continuous or intermittent traction for pain reduction, improved function or global perceived effect over placebo traction, tablet or heat or other conservative treatments in patients with chronic neck disorders."

In a trial of 81 participants with cervical radiculopathy (CR), Young and colleagues (2009) randomized individuals to multi-modal manual therapy (manual therapy and exercise) with intermittent supine cervical traction (MTEXT group) versus multi-modal therapy with sham traction (MTEX group).  The Numeric Pain Rating Scale (NPRS), the Neck Disability Index (NDI), and the Patient- Specific Functional Scale (PSFS) were the primary outcome measures.  At the 4-week follow-up, there were significant improvements in pain, function, disability, and symptom distribution regardless of treatment with or without intermittent supine cervical traction.

Chiu and colleagues (2011) reported results from a RCT involving 40 adults randomized to intermittent supine cervical traction (ICT) under supervision by a physiotherapist.  Thirty-nine participants were randomized to the control group which received placebo heat treatment with infrared irradiation.  All participants were evaluated at baseline, 6-weeks (immediately after the intervention period was completed) and at 12-weeks by an independent assessor who was blinded to the group assignment.  Assessment tools included the Chinese version of the Northwick Park Neck Pain Questionnaire (NPQ), Verbal Numerical Pain Scale (VNPS), and the cervical active range of motion (AROM) was measured using the Multi-Cervical Rehabilitation Unit (MCRU).  There was no statistically significant difference between the ICT treatment group compared to the control group in NPQ (P > 0.05, 95% confidence interval [CI], 29.66-37.50) and VNPS (P > 0.05, 95% CI, 3.29 – 4.50).  Additionally, there was no significant difference in any range of motion noted.  The authors concluded "Six weeks intermittent cervical traction is not superior to the infrared irradiation in the management of patients with chronic neck pain in terms of pain intensity, disability score and cervical active range of motion in the six-week and 12-week followup."

Although traction has been used as a treatment for neck pain for decades, its effectiveness is unproven.  In addition, there is no evidence of high quality, demonstrating an outcome benefit of pneumatic cervical traction over standard home "over-the-door" cervical traction devices.  Large, well designed, randomized controlled trials are needed that evaluate the effect of cervical traction as an adjunct treatment in both chronic and acute neck pain syndromes.  Currently there is an open phase III randomized controlled trial recruiting participants to be treated for cervical radiculopathy.  However, the results have not been published.

References

Peer Reviewed Publications:

  1. Borman P, Keskin D, Ekici B, Bodur H. The efficacy of intermittent cervical traction in patients with chronic neck pain. Clin Rheumatol. 2008; 27(10):1249-1253.
  2. Chiu TT, Ng JK, Walther-Zhang B, et al. A randomized controlled trial on the efficacy of intermittent cervical traction for patients with chronic neck pain. Clin Rehabil. 2011; 25(9):814-822.
  3. Goldie I, Landquist A. Evaluation of the effects of different forms of physiotherapy in cervical pain. Scand J Rehab Med. 1970; 2(2):117-121.
  4. Jadad A, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996; 17(1):1-12.
  5. Joghataei MT, Arab AM, Khaksar H. The effect of cervical traction combined with conventional therapy on grip strength on patients with cervical radiculopathy. Clin Rehabil. 2004; 18(8):879-887.
  6. Klaber-Moffett JA, Hughes GI, Griffiths P. An investigation of the effects of cervical traction. Part 1: Clinical effectiveness. Clin Rehabil. 1990; 4(3):205-211.
  7. Salt E, Wright C, Kelly S, Dean A. A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain. Man Ther. 2011; 16(1):53-65.
  8. Swezey RL, Swezey AM, Warner K.  Efficacy of home cervical traction therapy. Am J Phys Med Rehab. 1999; 78(1):30-32.
  9. Thoomes EJ, Scholten-Peeters W, Koes B, et al. The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review. Clin J Pain. 2013 Feb 26. [Epub ahead of print].
  10. van der Heijden GJ, Beurskens AJ, Koes BW, et al. The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods. Phys Ther. 1995; 75(2):93-104.
  11. van Tulder M, Furlan A, Bombardier C, Bouter L; Editorial Board of the Cochrane Collaboration Back Review Group. Updated method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group. Spine (Phila Pa, 1976). 2003; 28(12):1290-1299.
  12. Waylonis GW, Tootle D, Denhart C, et al.  Home cervical traction: evaluation of alternate equipment. Arch Phys Med Rehabil. 1982; 63(8):388-391.
  13. Young IA, Michener LA, Cleland JA, et al. Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized clinical trial. Phys Ther. 2009; 89(7):632-642.
  14. Zylbergold RS, Piper MC. Cervical spine disorders. A comparison of three types of traction. Spine. 1985; 10(10):867-871.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=280.1&ncd_version=2&basket=ncd%3A280%2E1%3A2%3ADurable+Medical+Equipment+Reference+List. Accessed on July 9, 2013.
  2. Childs JD, Cleland JA, Elliott JM, et al. Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthapaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008; 38(9):A1-A34.
  3. Graham N, Gross A, Goldsmith CH, et al. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database of Systematic Reviews. 2008; Issue 3. Art. No.:CD006408.
  4. Graham N, Gross AR, Goldsmith C; the Cervical Overview Group. Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med. 2006; 38(3):145-152.
  5. Gross A, Forget M, St George K, et al. Patient education for neck pain. Cochrane Database Syst Rev. 2012 Mar 14;3:CD005106.
  6. Washington State Department of Labor and Industries Technology Assessment. Pronex and HomeTrac Cervical Traction. Available at: http://www.lni.wa.gov/ClaimsIns/Files/OMD/PronexAndSaundersTA.pdf.  Accessed on June 9, 2013.
Web Sites for Additional Information
  1. National Institutes of Health. Neck Pain. Updated March 22, 2013. Available at:  http://www.nlm.nih.gov/medlineplus/ency/article/003025.htm. Accessed on July 9, 2013.
Index

Cervical Traction Devices for Home Use
Home Traction Devices (Cervical)
HomeTrac
Pronex
Traction Devices (Cervical) for Home Use

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History
StatusDateAction
Reviewed08/08/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References, Discussion and Web Site sections.
Reviewed08/09/2012MPTAC review. Updated References, Discussion and Web Site sections.
Reviewed08/18/2011MPTAC review. Updated References, Coding, Discussion and Web Site sections.
Reviewed08/19/2010MPTAC review. Updated References, Discussion and Web Site sections.
Reviewed08/27/2009MPTAC review. Updated References and Discussion. Removed Place of Service Section.
Reviewed08/28/2008MPTAC review. Updated References and Discussion.
Reviewed01/01/2008Updated coding section with 01/01/2008 HCPCS changes.
Reviewed08/23/2007MPTAC review. No change to position. Description and References updated.
Reviewed09/14/2006MPTAC review.  No change to Clinical Indication; References updated.  Coding updated; removed HCPCS K0627 deleted 12/31/04.
 11/17/2005Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised09/22/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem BCBS West Region

09/22/2004

DME.215Cervical Traction Devices
WellPoint Health Networks, Inc.

12/02/2004

9.07.04Cervical Traction Devices for Home Use