Clinical UM Guideline
|Subject:||Cervical Traction Devices for Home Use|
|Guideline #:||CG-DME-05||Current Effective Date:||10/08/2013|
|Status:||Reviewed||Last Review Date:||08/08/2013|
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.
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.
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.
|E0840||Traction frame, attached to headboard, cervical traction|
|E0849||Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible|
|E0850||Traction stand, free-standing, cervical traction|
|E0855||Cervical traction equipment not requiring additional stand or frame|
|E0856||Cervical traction device, cervical collar with inflatable air bladder|
|E0860||Traction equipment, over door, cervical|
|ICD-10 Diagnosis||ICD-10-CM draft codes; effective 10/01/2014:|
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.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Web Sites for Additional Information|
Cervical Traction Devices for Home Use
Home Traction Devices (Cervical)
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.
|Reviewed||08/08/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References, Discussion and Web Site sections.|
|Reviewed||08/09/2012||MPTAC review. Updated References, Discussion and Web Site sections.|
|Reviewed||08/18/2011||MPTAC review. Updated References, Coding, Discussion and Web Site sections.|
|Reviewed||08/19/2010||MPTAC review. Updated References, Discussion and Web Site sections.|
|Reviewed||08/27/2009||MPTAC review. Updated References and Discussion. Removed Place of Service Section.|
|Reviewed||08/28/2008||MPTAC review. Updated References and Discussion.|
|Reviewed||01/01/2008||Updated coding section with 01/01/2008 HCPCS changes.|
|Reviewed||08/23/2007||MPTAC review. No change to position. Description and References updated.|
|Reviewed||09/14/2006||MPTAC review. No change to Clinical Indication; References updated. Coding updated; removed HCPCS K0627 deleted 12/31/04.|
|11/17/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||09/22/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
Last Review Date
|Anthem BCBS West Region|
|DME.215||Cervical Traction Devices|
|WellPoint Health Networks, Inc.|
|9.07.04||Cervical Traction Devices for Home Use|