Cervical Range of Motion Exercises with Over the Door Traction

By:  Tim Conley, PT, ATL

Introduction

Cervical traction is a non-invasive procedure used to provide symptomatic relief for a variety of cervical pathologies. While it has been shown to provide at least temporary symptomatic relief, there is still limited high quality data on its long-term therapeutic efficacy, and the best way to provide it.  Some recommend manual traction vs mechanical traction, intermittent or static, and the best position to provide it in, Supine vs Sitting.  There is also the cost of providing cervical traction, and how the patient can achieve the benefits, in the clinic and at home.  This white paper reviews the indications, contraindications, and techniques involved in performing cervical traction, and highlights the protocol adopted by RangeMaster Physical Therapy of “Cervical Range of Motion Exercises with Over the Door Traction” and the RangeMaster C-Trax Over the Door Cervical Traction Unit.

The purpose of this procedure is to help those with limitations in cervical range of motion as the result of pain and stiffness, as well as those with pain that radiates into the shoulder or arm with neck motion, known as Radiculopathy. It is designed to allow the individual to move their cervical spine, while unweighting the joints, decreasing compression on nerves, and releasing the facet joints, to allow for increased range of motion.  Since the primary focus of this procedure is the active exercise component, and the need for one-on-one monitoring the patient for changes in their neurological response, some therapists justify this as a “Therapeutic Exercise” (CPT 97110) or “Therapeutic Activity” (CPT 97530), as opposed to the passive modality of “Mechanical Traction” (97012).  While reimbursement varies by location, but typically “Mechanical Traction’ is reimbursed at a much lower rate than the more active procedures. 

The protocol was developed back in the 1990’s by Joleen Ferguson, MSPT and a neurosurgeon, Perry Camp, MD.  Their hypothesis was that light distraction or unweighting of the cervical spine, would relieve compression on the cervical nerve roots, and provide a gentle stretch to the cervical musculature.  Thus, allowing for better performance in cervical range of motion exercises due to limited pain.  It also provided strengthening to the cervical musculature, which assisted in improving posture.  The protocol was performed in conjunction with a comprehensive, patient centered physical therapy program, including education in posture and body mechanics, core and cervical stabilization, ROM and strengthening exercises for the shoulder girdle and upper extremities.  The program would also include physical modalities for pain relief as needed.  Camp and Ferguson performed this protocol with thousands of patients over the years and found that after 4 to 6 weeks of performing these exercises at home, patients had a significant reduction in neck and arm pain, with improvement in range of motion and function.  Dr Camp would quip that “this procedure cost him a lot of lost surgical revenue”, as the patient would get better without his surgical interventions. 

The Use of Cervical Traction

The practice of spinal traction goes back to the fourth century BC, where Hippocrates first described it as a treatment for kyphosis. (1)  It was subsequently implemented in other spinal pathologies including cervical pain and myelopathy. To date, there is no accurate description of the mechanism of relief provided by cervical traction. The theory behind its efficiency emphasizes the widening of the intervertebral foramen upon traction, with separation of the facet joint. This is believed to relieve the sustained pressure on the nerve roots, and hence alleviate symptoms of radiculopathy. Other theories suggest that traction allows for cervical muscle relaxation and is not involved in intervertebral separation. 

Among the few studies with adequate statistical power, there is no evidence on the long-term benefits of cervical traction, although many articles suggest a definitive temporary relief. There is somewhat better evidence that cervical traction is often effective in the treatment of radiculopathy, with the rationale that traction will provide elongation of the spine, resultant increase in intervertebral space, relaxation of spinal muscles, opening of the neural foramen, and relief of nerve root compression.  It is interesting to note, that no research or reviews were found to include the use of Cervical Traction while performing Range of Motion Exercises, making the technique explained above, as unique in the care of cervical pain and radiculopathy.

Despite the limited quality evidence, Madson and Hollman, published “Cervical Traction for Managing Neck Pain: A Survey of Physical Therapists in the United States” (journal of orthopedic & sports physical therapy, March 2017) to examine the use of traction by physical therapists for patients with neck pain, including how and when traction is used, the delivery modes and parameters, supplemental interventions, and influence of professional demographics on usage.  Their population was selected from members of the APTA Orthopedic Section, including those with special ty certifications.  Most respondents reported that their use of cervical traction was consistent with proposed criteria that identify patients who are likely to benefit. They use various traction delivery modes/parameters within comprehensive plans of care incorporating multiple interventions. Variation in traction usage was associated with therapists’ professional characteristics, including training levels and ABPTS orthopedic clinical specialist credentialing. Therefore, Physical therapists employ traction consistent with a classification system that preliminarily identifies patients whom traction may benefit, as well as in patients who present with symptoms of neck pain alone who exhibit pain relief with a manual distraction technique during the patient examination. (6)

Therefore, accepted physiological effects of cervical traction include:

  • Increasing vertebral separation
  • Reducing cervical muscle activation
  • Reducing nerve conduction disturbances
  • Increases reflex arc strength
  • Increasing blood flow
  • Restoring cervical lordosis

Based on the literature available, the consensus is that cervical traction may be indicated with some efficacy in a variety of cervical pathologies:

  • Cervical disc disease
  • Facet joint Impingement
  • Spondylosis
  • Radiculopathy
  • Foraminal Stenosis
  • Myofascial tightness

Types of Cervical Traction

Cervical traction is administered by various techniques ranging from manual traction to mechanical motorized traction in a supine position, to seated cervical traction using an over-the-door pulley with attached weights. Duration of cervical traction can range from a few minutes to 20 to 30 min, once or twice weekly to several times per day. Anecdotal evidence suggests efficacy and safety, but most published studies on cervical traction are of low quality and include a small number of participants.

Manual Cervical Traction is preferred as a means of assessing the patient's response to the technique and as a treatment technique itself. Manual traction is a manual therapy technique in which the therapist uses his/her hands to pull a patient’s head in a cephalad direction. This allows for variables of duration, direction of force, and position can be rapidly assessed and easily changed dependent on the patient’s response. This is typically performed with the patient in a supine position, which is thought to provide the patient with the greatest ability to relax the musculature and allow for increased joint separation.  The clinician will be looking for pain to move from a distal to a proximal location and decrease in intensity as a favorable response. However, manual traction has a poor interrater reliability as it varies by the practitioners’ skills and strength.  Manual techniques are time consuming and not as cost effective as mechanical traction over time.  It also limits the patient from the benefits of using traction as a home program.

Static or intermittent mechanical traction is provided by a motorized machine or a pulley and weight system, Over the Door Traction.  Intermittent traction is typically with a mechanical device, where a repeated sequence of rest and traction is applied. It is believed to increase blood flow to the nerve roots and spine. Intermittent traction is often the method of choice for degenerative disc disease and/or joint hypomobility. While sustained or static traction is most often used for neck pain of muscle or soft tissue etiology, and/or disc herniations. However, intermittent traction was not able to achieve a more favorable outcome than its sustained counterpart, despite its theory of increasing blood flow to the spine and nerve roots (9).  There are a variety of mechanical devices designed to perform static and intermittent traction, however some are elaborate and expensive systems that are limited to the clinical setting, and others that are designed for home use, are limited in the ability to deliver intermittent traction, or in the ability to measure the amount of traction provided. 

The position of the patient for cervical traction is also a factor to consider.  It is believed that the supine position is best for allowing relaxation, and therefore the more significant joint separation can occur when compared to performing the procedure in a seated position.  This is primarily due to the increased effects of gravity on the spine, and the need for the cervical musculature to support the head and shoulders in a seated position. (11)  This is drawn out in the data available, but it is also noted that the difference is not consistently significant, and that supine is a less favorable for patients with difficulty assuming and maintaining a supine position, and it is more difficult to coordinate in the home environment, where the patient would likely have to lie on the floor, in order to set up the traction device on a door.  It is also possible to alleviate some of these limitations in sitting, by placing pillows in the patient’s lap, allowing them to support the upper extremities and allow the muscles to better relax.  This is a more practical way of applying cervical traction, that is more accessible to outpatient practices and home environment.  Over the door traction entails strapping a harness to the base of the skull and chin of the patient that is in a seated position.  The harness is connected to a rope in a pulley system over a door. The force is applied using weights (a sandbar or a waterbag) attached to the other end of the rope.

Research is variable on the ideal angle of pull for cervical traction.  It is noted that the greater the angle of pull, the greater the degree of separation that can be achieved in the posterior aspects of the lower cervical segments.  Some suggest as high as a 45-degree angle, where the majority range between 20 and 30-degrees of flexion.  Where Saunders suggests that 15 degrees is the ideal position to achieve both anterior and posterior separation, which is incorporated in the design of the Saunders Cervical Traction Device (8, 9).   However, this device and others on the market do not allow for incorporation of movement or adjusting the side-to-side angle of pull, which allows for more of a unilateral pull on the cervical spine, thus more specifically targeting area of impairment/dysfunction.   There is no firm consensus on the amount of traction force needed to produce a desired clinical result. It appears that at least 25–30 pounds of force are required to produce measurable separation of the cervical vertebrae. Others suggest significantly less weight to alleviate muscle tension, with the traction force must be at least the weight of the head to produce any significant decompression. 

Contraindications For Cervical Traction

There are no scientific reports that accurately describe the contraindications and relative contraindications for cervical traction. Probable contraindications and/or relative contraindications to cervical traction listed in the literature vary widely, making for a long list of possibilities.  Traction is clearly contraindicated in the presence of any disease resulting in structural compromise or instability.

These and other probable or possible contraindications may include the following:

  • Acute undiagnosed cervical trauma, including whiplash-associated disorders
  • Unstable spondylolisthesis or atlanto-axial instability
  • Prior surgical stabilization or decompression
  • Severe Osteoporosis
  • Ligamentous instability
  • Rheumatologic disorders affecting connective tissue, including rheumatoid arthritis and ankylosing spondylitis
  • Untreated hypertension
  • Vertebral-basilar artery insufficiency
  • Temporal Mandibular Joint (TMJ) Disfunction
  • Midline herniated nucleus pulpous

Complications

Complications are rare, providing patients are adequately screened for conditions that are contraindicated. (1) Postprocedural increase in peripheral nerve pain and a decrease in central pain, increase in neurological symptoms, or sudden disappearance of central pain are alarming signs of traction-induced spinal cord compromise.  An increase in dizziness or light headedness may be an indication of vertebral-basilar artery insufficiency.  It is strongly advised to consult dynamic X-rays first to clear the patient of instabilities that could be aggravated by traction. When applying cervical traction, one must be aware of additional risk factors including increased blood pressure, respiratory compromise, and temporomandibular joint compression due to the required harness for certain mechanical devices.

Summary

It is with this understanding of the historical use of cervical traction, in all of its methods of application and contraindications, as well as the need to advance to a more active, patient involved, procedure that is specific to achieving functional improvement in range of motion and posture, as well as decreasing symptoms, that we are proposing the “Cervical Range of Motion Exercises with Over the Door Traction” Protocol, using the Range Master C-Trax Device. 

This procedure is to help those with limitations in cervical range of motion as the result of pain and stiffness, as well as those with pain that radiates into the shoulder or arm with neck motion. It is designed to allow the individual to move their cervical spine, while unweighting the joints of the spine, decreasing compression on nerves, and releasing the facet joints, to allow for increased pain free range of motion.  It is performed in a seated position to allow for greater mobility of the cervical spine in the over the door traction device.  The seated position has been found to be more convenient for set up by the patient and it has been found to be more comfortable for the patient to perform the exercises, than in a supine position.  It was also found that placing pillows in the patient’s lap, decreased the muscle activity of the cervical spine and shoulders, allowing to increase the patient’s ability to relax between exercises.  The patient should position themselves facing the door, with the chair close to the door, to allow for the 25-30 degrees of cervical flexion, which allows for the greatest release of the compression on the nerves during the rest period.  Finally, it was found in the development of the protocol, that the required weight for the patient to feel relief and perform the exercises was significantly less than indicated in the literature.  Typically only 5-10 lbs of weight is required, but can be increased to as much as 15 lbs for large or muscular necks.  Such a weight range limits the negative impact and significant contraindications for cervical traction.  However, it is still very important for the procedure be initiated by a physical therapist, who performs a comprehensive assessment and provides it in conjunction with a well-rounded treatment plan.  With that in mind, If these exercises increase pain or numbness in the neck or arm, or if it results in dizziness, it should be stopped immediately, and the individual should consult their Physical Therapist or Medical Provider.

Procedure

This procedure will require 25 minutes of uninterrupted time.

Equipment needed:

Over the Door Traction device, comfortable chair, 2-3 pillows and a timing device.

Set Up:

Place the over the door traction device over a door that you can leave it on in between uses.  Place the chair facing the door and position so that the head is in line with the pulleys and allows the neck to rest in approximately 25-30 degrees of flexion.  Place the pillows in the lap and rest the arms on the pillows to unweight the shoulder.   Fill the weight bag with the appropriate amount of water to equate to the desired weight, as prescribed by the therapist.  Place the harness over the head, with the pads supporting the base of the skull in the back and the chin in the front.

Procedure:

While sitting in the chair with arms supported and head resting in approximately 25-30 degrees of flexion, allow approximately 5 minutes to relax and allow the traction to relax the neck.

  • Flexion:  Gently dip the chin down toward the chest within a pain free range of motion, and slowly return to the starting position.  Repeat 5 – 10 times within the first 30 seconds.  Return to the resting position and relax for the remainder of 5 minutes.
  • Side Bending:  Gently dip an ear toward the shoulder in one direction, then all the way over to the other side, through pain free range of motion.  Repeat 5 – 10 times within the first 30 seconds.  Return to the resting position and relax for the remainder of 5 minutes.
  • Rotation:  Gently turn the chin to the shoulder in one direction, then all the way toward the other shoulder, through a pain free range of motion.  Repeat 5 – 10 times within the first 30 seconds.  Return to the resting position and relax for the remainder of 5 minutes.
  • Cervical Retraction:  Looking at the door and keeping the chin level with the floor, gently pull the chin back and chest up till a stretch is felt, then allow the neck to move back forward toward the door.  Repeat 5 – 10 times within the first 30 seconds. 
  • Return to the resting position and relax for the remainder of 5 minutes.

About the Author 

Tim Conley is a Physical Therapist and Licensed Athletic Trainer, who works as a consulting clinical specialist for RangeMaster Physical Therapy.  He is a 1987 graduate of the University of Puget Sound with his degrees in Physical Therapy and Physical Education with an emphasis in Sports Medicine.  He has worked in a variety of Outpatient Physical Therapy and Sports Medicine settings, with specialties in Orthopedics, Aquatic Therapy, Industrial Rehabilitation, and Sports Medicine.  As the Rehabilitation Director for Providence St. Mary Medical Center, Walla Walla, WA for over 25 years, Tim had the opportunity to develop a multitude of specialized physical therapy programs and worked with interdisciplinary teams to develop effective treatment protocols in a variety of specialties.  This includes the Cervical Range of Motion Exercises with Cervical Traction Protocol. 

References

  • Abi-Aad KR, Derian A. Cervical Traction. [Updated 2021 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-
  • Baez, Shelby; Hoch, Johnanna; Uhl, Timothy; The Effectiveness of Cervical Traction and Exercise in Decreasing Neck and Arm Pain for Patients with Cervical Radiculopathy: A Critically Appraised Topic; International Journal of Athletic Therapy and Training; September 2017; p4-11
  • Cai C, Ming G, Ng LY. Development of a clinical prediction rule to identify patients with neck pain who are likely to benefit from home-based mechanical cervical traction. Eur Spine J. 2011;20:912-922
  • 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 Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38:A1-A34.
  • Childs JD, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain. J Orthopedic Sports Phys Ther. 2004;34:686-696; discussion 697-700
  • Fater, Dennis CW, Kernozek, “Comparison of cervical vertebral separation in the supine and seated positions using home traction units, from Physiotherapy Therapy and Practice, 24(6); 430-436, 2008
  • Fritz, Julie M.; Thackeray, Anne; Brennan, Gerard P.; Childs, John D. Exercise Onley, 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, Journal of Orthopaedic & Sports Physical Therapy Feb2014, Vol. 44 Issue 2, p45
  • Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007; 87:513-524.
  • Madson, Timothy J.; Hollman, John H., Journal of Orthopedic & Sports Physical Therapy Mar2017, Vol. 47 Issue 3, p200
  • Romeo, Antonio; Vanti, Carla; Boldrini, Valerio; Ruggeri, Martina; Guccione, Andrew; Pillastrini, Paolo; Bertozzi, Lucia; Cervical Radiculopthy:  Effectiveness of Adding Traction to Physical Therapy- A Systematic Review and Meta-Analysis of Randomized Controlled Trials; Physical Therapy Vol 98 (4) April 2018: p231-242
  • Saunders HD. Use of spinal traction in the treatment of neck and back conditions. Clin Orthop Relat Res. 1983:31-38
  • Saunders HD 1999 Frequently asked questions about cervical traction. Edina, MN, The Saunders Group, Inc
  • Young, Ian; Michener, Lori; Cleland, Joshua; Aguilera, Arnold; Snyder, Alison: Manual Therapy, Exercise, and traction for Patients with Cervical Radiculopathy: A Randomized Clinical Trial; Physical Therapy Vol 89 (7) July 2009; p632-642