Cervical traction (over the door, pneumatic, etc) is a modality and just like all modalities and other treatment interventions as a whole, work best if the patient is subgrouped into it for maximal effectiveness.
I normally teach my interns to use clinical prediction rules, not as a rule; but as a guide. I think they help the young practitioner make decisions. We use these to discuss what the variables are in the CPR (which ones show in a study to have more diagnostic value, etc) to review the study and critically appraise it, as well as help bring evidence into clinical practice.
The CPR I normally refer back to is from Raney 2009 The authors found that post-test probability of success from using cervical traction increased to 94% if 4 out of 5 criteria below are positive:
1. Positive shoulder abduction test
2. Positive cervical distraction test
3. Positive peripherlization with mobility testing of C4-7
4. Positive upper limb tension test
5. Age > 55 years old
Of course with CPRs, there are limitations and to my current knowledge, there is not a validation study available for these variables.
From my personal experience, I find these variables to be highly indicative of success for me (or at least thinking of using cervical traction). 4 out of the 5 tests above (obviously not age) demonstrate nerve root irritability that may not respond as usual to a facet joint dysfunction, etc.
I would like to add some other variables that would lead me to using cervical traction.
It would be more funny to read the following in Jeff Foxworthy’s voice, “you might be a redneck if…” (you may respond to cervical traction if…”).
1. Symptoms peripheralize to the entire hand and even circumferentially ‘around’ the arm.
2. Symptoms do not peripheralize peri-scapula.
3. The patient is able to centralize symptoms from a movement, mechanically based exercise program (such as cervico-thoracic extension, cervical retractions, etc) AND is adherent to HEP and posture (such as performing them every hour or as prescribed); but needs to every be consistent on the hour to abolish symptoms.
4. After treating the patient through a combination of manual therapy and directional preference exercises, we sit down to discuss patient education (pain science, biomechanical disc model, etc.) and symptoms start to creep back (so within a few minutes)
5. The patient believes that if their neck is “pulled” up, it will help with symptoms.
6. Arm > neck pain.
I know the above is quite broad and variables increased to 11!, but I find it incorporates all aspects of evidenced-based practice (patient expectations, clinician experience, and evidence).
Even though traction was not included in this recent study (hot off the press from JOSPT here!), the findings did show that expectation had a strong influence on patient outcomes.
What do you think? What other variables do you use that you find is successful in incorporating cervical traction? Would you change any of the ones I listed?