Clinical UM Guideline
|Subject:||Cervical Traction Devices for Home Use|
|Guideline #:||CG-DME-05||Current Effective Date:||10/06/2015|
|Status:||Reviewed||Last Review Date:||08/06/2015|
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.
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. 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, with inflatable air bladder(s)|
|E0860||Traction equipment, over door, cervical|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
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 1 to 2 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). However, almost half of individuals with neck pain will have residual pain or experience frequent reoccurrences (Cohen, 2015).
Traction is a medical technique 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 joint mobility, and a stretching muscles and ligaments adjacent to the vertebral bodies, which will improve 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. Traction can be provided in a variety of settings, including the office setting, as a physical therapy modality or in the home.
Although traction has been used as a treatment for neck pain for decades, its effectiveness is unproven. 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. Nevertheless, cervical traction remains a common treatment modality in the treatment of neck pain and radiculopathy.
In a controlled trial, Zylbergold (1985) studied 129 individuals with varied disorders who received physical therapy consisting of neck care instructions, heat, massage and range of motion and isometric exercise. The participants 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 individuals 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=0.03), 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 is 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 6 weeks, the durability of the modest benefit from intermittent traction is unclear.
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 1 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 individuals 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 (n=958 participants), 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 6 week and 12 week followup.
Bryans and colleagues (2014) evaluated the available evidence on chiropractic treatment of neck pain and developed recommendations regarding the use of various chiropractic treatment modalities. A total of 41 RCTs with a low risk of bias were used to develop the treatment recommendations. Based upon the reviewed evidence, the authors noted:
There is insufficient evidence to support a recommendation for intermittent mechanical traction for the treatment of chronic neck pain. This conclusion is based on 1 low-risk-of-bias study that found no additional improvement in pain or disability after 10 to 12 treatment sessions when combined with nontherapeutic infrared irradiation.
In addition, the authors noted that based upon the limitations within the studies, such as the inclusion of participants without regards to the chronicity of the pain, no recommendations regarding traction could be made for neck pain of variable duration.
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.
In a RCT, Fritz and colleagues (2014) evaluated the effectiveness of cervical traction in the treatment of cervical radiculopathy. A total of 86 adults aged 18 to 70 with a primary complaint of neck pain with pain or numbness extending distally to the acromioclavicular joint or caudal to the superior border of the scapula and a NDI of 10 or greater on a 100 point scale were randomized to 1 of 3 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 presence of symptoms 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 (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 six months, arm pain scores were lower for the over the door group compared to the exercise only group (mean difference 2.2; 95% CI: .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. The authors noted 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. This was a small study with a high drop-out rate (32 individuals, 37.2%) during the follow-up period. Several participants moved between groups: 2 crossed over from exercise only to mechanical traction due to lack of progress, 1 crossed from mechanical to over door traction due to difficulty lying supine, 1 crossed from over door traction to exercise only at physician request, 3 crossed from over door to mechanical traction due to individual preferences. In addition, there were baseline differences between the groups, such as duration of symptoms. Finally, the authors note that due to the inability to recruit the original target sample size of 192 participants, the study was likely underpowered. The authors suggest that further research is needed to identify the most effective nonsurgical treatments in those with cervical radiculopathy.
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. In addition, there are no studies identified of high quality evidence comparing the efficacy and safety of the various home cervical traction devices.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
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||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Rationale, References and Website sections.|
|01/01/2015||Updated Coding section with 01/01/2015 HCPCS change to descriptor for E0856.|
|Reviewed||08/14/2014||MPTAC review. Updated References and Website sections.|
|Reviewed||08/08/2013||MPTAC review. Updated References, Discussion and Website sections.|
|Reviewed||08/09/2012||MPTAC review. Updated References, Discussion and Website sections.|
|Reviewed||08/18/2011||MPTAC review. Updated References, Coding, Discussion and Website sections.|
|Reviewed||08/19/2010||MPTAC review. Updated References, Discussion and Website 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. Description and References updated.|
|Reviewed||09/14/2006||MPTAC review. 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|