Clinical UM Guideline

This document addresses the different devices used in the home for cervical traction, including “over-the-door” and pneumatic devices.

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.

Medically Necessary:

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

• The individual has a musculoskeletal or neurologic impairment requiring traction equipment; and
• The appropriate use of a home cervical traction device has been demonstrated to the individual and that individual is able to tolerate the selected device.

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. 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.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure code listed above when criteria are not met.

When services are also Not Medically Necessary:
For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Neck pain is a common occurrence that affects many people during their lifetime. The American College of Rheumatology (ACR, 2015) noted that on an annual basis, approximately 30% of the population experiences an occurrence of neck pain. Typically, neck pain is acute and improves within 1 to 2 weeks with conservative treatments, which may include heat, ice, massage, stretching and pain relievers. The majority of neck pain resolves within 8 to 12 weeks (ACR, 2015; van der Heijden, 1995). However, almost half of individuals with neck pain will have residual pain or experience frequent reoccurrences (Cohen, 2015).

Traction is a treatment modality in which opposite forces are applied to separate parts of the body to stretch soft tissues, and/or separate bony structures. It has been proposed that cervical traction results in an expansion of the intervertebral spaces, an increase in joint mobility, and stretching of muscles and ligaments adjacent to the vertebral bodies, potentially improving the clinical outcomes in those with neck pain. After 2 minutes of sustained traction, 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. In addition to office-based traction, individuals with long-standing pain may benefit from home-based traction.

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

Pneumatic devices are designed to be used in the supine position with the device beneath the head and shoulders and a strap or straps holding the head in place. User controlled pumps or bellows allow the individual to increase the tension, pulling the head away from the body. This extends the neck, stretches the affected muscles and increases the intervertebral spaces. Pneumatic devices typically can deliver up to 50 pounds of tension.

When used with other standard modalities, traction may result in greater improvements in mobility and pain compared to standard therapy alone (van der Heijden, 1995; Zylbergold, 1985). While the quality of existing evidence is low, involving small studies with limited follow-up and generally inconclusive results, the totality of data is generally supportive (Graham, 2006; Graham; 2008; Young, 2009). The use of “over the door” home cervical traction devices is a generally accepted modality for the treatment of musculoskeletal or neurologic impairment requiring traction equipment.

In a meta-analysis of seven randomized controlled trials (RCTs), Yang and associates (2017) evaluated the effectiveness of intermittent cervical traction (ICT) in relieving neck pain. A total of seven RCTs (n=402) were included in the analysis. The ICT groups reported lower pain scores immediately following the treatment course, there was no difference at the final follow-up (standard mean differences [SMD]=-0.57; 95% confidence interval [CI], -1.46 to 0.32; I²=83%). The authors concluded that ICT might result in short-term neck pain.

In an RCT, Fritz and colleagues (2014) evaluated the effectiveness of cervical traction in the treatment of cervical radiculopathy. A total of 86 adults with a primary complaint of neck pain with pain or numbness were randomized to one of three treatment groups: exercise, exercise and mechanical traction in the clinical setting or exercise with a home over-door traction device. Median symptom duration was 53 days with 33 (38.4%) individuals reporting presence of symptoms greater than 6 weeks and 11 (12.8%) reporting the presence of symptoms for greater than 1 year. Participants received 10 physical therapy sessions over 4 weeks, with follow-up assessments completed at 4 weeks, 6 months and 12 months by a researcher blinded to the individual treatment groups. All participants were given the same exercise regimen. Intention-to-treat analyses for the primary outcome (neck disability index [NDI] score) at 6 months showed lower scores in mechanical traction compared to exercise group only (mean difference 13.3; 95% CI: 5.6, 21.0; p=0.001) and over-door traction group (mean difference 8.1; 95% CI: 0.8, 15.3; p=0.031). At 12 months, lower NDI scores persisted in the mechanical traction verses exercise group (mean difference 9.8; 95% CI: 0.2, 19.4; p=0.046). Mechanical traction showed lower neck pain intensity scores compared to the exercise only group at 6 months (mean difference 1.9; 95% CI: 0.7, 3.2; p=0.003) and the over-the-door traction group (mean difference 1.2; 95% CI: 2.4, 0.03; p=0.045). At 6 months, arm pain scores were lower for the over-the-door group compared to the exercise only group (mean difference 2.2; 95% CI: 0.8, 3.7; p=0.004). There were no differences in arm pain between groups at 12 months. Individuals reporting a successful outcome based on a global rating score were 53 (61.6%) at 4 weeks, 32 (37.2%) at 6 months and 35 (40.7%) at 12 months. These results generally favored the traction groups as compared to exercise only group; however, they were not statistically significant at any of the follow-up. The authors noted that the addition of cervical traction to a standard exercise program resulted in lower NDI and pain intensity scores in individuals with cervical radiculopathy, particularly in those individuals who received mechanical traction in the office setting. However, results showed additional benefit in the over-door traction group over the exercise only group as well, especially in those who were comfortable with the device.

In 2016, Chumbley and associates evaluated whether regular use of a home cervical traction device (Saunders device) could decrease the reported cervical pain levels of active pilots. Participants who completed the program (n=12) used the device three times weekly for 6 weeks. While the participants reported a modest improvement in pain in the arm using traction comparted to the control group, the decrease in daily pain reports reported in the traction group did not reach statistical significance. There were no comparisons to over-the-door traction devices.

Pneumatic devices are able to provide more pounds of tension, or force, versus the over-the-door traction devices. However, there is also a lack of consensus in the published literature regarding optimum and safe tension amounts, duration and frequency of traction. Currently there is a paucity of evidence to show that pneumatic devices provide additional clinical benefit over the standard over-door traction devices.

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. Bryans R, Decina P, Descarreaux M, et al. Evidence-based guidelines for the chiropractic treatment of adults with neck pain. J Manipulative Physiol Ther. 2014; 37(1):42-63.
3. 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.
4. Chumbley EM, O'Hair N, Stolfi A, et al. Home cervical traction to reduce neck pain in fighter pilots. Aerosp Med Hum Perform. 2016; 87(12):1010-1015.
5. Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015; 90(2):284-299.
6. Colombo C, Salvioli S, Gianola S, et al. Traction therapy for cervical radicular syndrome is statistically significant but not clinically relevant for pain relief. A systematic literature review with meta-analysis and trial sequential analysis. J Clin Med. 2020; 9(11):3389.
7. Fritz JM, Thackeray A, Brennan GP, Childs JD. Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial. J Orthop Sports Phys Ther. 2014; 44(2):45-57.
8. 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.
9. 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.
10. 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.
11. Swezey RL, Swezey AM, Warner K. Efficacy of home cervical traction therapy. Am J Phys Med Rehab. 1999; 78(1):30-32.
12. 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; 29(12):1073-1086.
13. 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.
14. 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.
15. Waylonis GW, Tootle D, Denhart C, et al. Home cervical traction: evaluation of alternate equipment. Arch Phys Med Rehabil. 1982; 63(8):388-391.
16. Yang JD, Tam KW, Huang TW, et al. Intermittent cervical traction for treating neck pain: a meta-analysis of randomized controlled trials. Spine (Phila Pa 1976). 2017; 42(13):959-965.
17. 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.
18. 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 16, 2023. Available at: https://www.cms.gov/medicare-coverage-database/new-search/search.aspx. Accessed on April 2, 2024.
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 Syst Rev. 2008; (3):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; (3):CD005106.
6. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Noninvasive nonpharmacological treatment for chronic pain: A systematic review update. Comparative Effectiveness Review No. 227. April 2020. Available at: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/noninvasive-nonpharm-pain-update.pdf. Accessed on April 2, 2024.
7. Washington State Department of Labor and Industries Technology Assessment. Pronex and HomeTrac Cervical Traction. August 5, 2002. Available at: https://www.lni.wa.gov/patient-care/treating-patients/treatment-guidelines-and-resources/_docs/PronexAndSaundersTA.pdf. Accessed on April 2, 2024.

1. American College of Rheumatology (ACR). Neck Pain. Updated April 2023. Available at: http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Living-Well-with-Rheumatic-Disease/Neck-Pain. Accessed on April 2, 2024.
2. National Institutes of Health (NIH). MedlinePlus.
   • Neck Pain. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003025.htm. Accessed on April 2, 2024.
   • Traction. Available at: https://www.nlm.nih.gov/medlineplus/ency/article/002336.htm. Accessed on April 2, 2024.

Cervico2000
ComforTrac
HomeTrac
Pratos
Pronex
Saunders

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.

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