Wednesday, November 09, 2016 Survey Results Reveal Traction Popular Among PTs Treating Neck Pain Authors of a new study write that although systematic reviews provide "limited support" for the use of cervical traction to manage neck pain, a recent survey of APTA Orthopaedic Section (OS) members revealed that most physical therapists (PTs) in the section use it, even when it's a less strongly indicated intervention. They believe that the high rate of use—and the variety of traction methods employed—point to the tendency of PTs to pursue "comprehensive plans of care." The study, e-published ahead of print in The Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free), is based on responses to a survey sent to 4,000 OS members nationwide. A total of 1,001 members responded to the questionnaire, which included 28 open- and closed-ended questions on demographics, adherence to classification criteria for traction, delivery methods used, and additional interventions, as well as 2 clinical scenarios. The scenarios focused on situations in which the respondent might use traction. The first described a case that pointed to the possibility of nerve root compression "and matched the characteristics of patients preliminarily identified as those who may benefit from traction”; the second involved a patient whose signs and symptoms were consistent with joint disease without neck-related arm pain. In the second scenario, the patient was described as having a positive response to a manual distraction technique "but did not necessarily fit the classification system for the use of traction." When they looked at the results of the survey, researchers found a combination of the expected and the surprising. In the first scenario—in which patients were more likely to benefit from traction—93.1% of respondents said that they'd incorporate traction into a plan of care. But unexpectedly, a sizable majority of respondents—78.7%—also said they'd use traction in the second scenario, wherein the patient's symptoms seemed to make them less likely to benefit from the intervention. "We were surprised by the response rate to the second scenario as clinical studies reveal conflicting results on the use of traction for patients with neck pain without neck-related arm pain," authors write. Other results from the survey: Overall, 76.6% of respondents reported that they use traction to treat neck pain—a much higher proportion than rates reported in an international study of health professionals who treat neck pain, in which only 28% indicated that they use traction. A higher proportion of PTs with American Board of Physical Therapy Specialties orthopaedic clinical certification used traction (88.6%) than those without the certification (73%). Of the 93.1% of respondents who said they'd use traction to treat the patient with the stronger clinical indication (the first scenario), the most common approach cited (41.6%) was intermittent mechanical traction while the patient was supine, and with 20 degrees of neck flexion. In the second scenario, where traction was not as strongly indicated, the 78.7% of respondents who said that they would use traction leaned toward manual traction (42.4%). A smaller percentage (22.4%) reported that they would use intermittent mechanical traction in the same supine/20-degree approach cited by respondents in the first scenario. Respondents indicated that traction is just 1 of several approaches they use to treat neck pain, citing stabilization exercises (90.5%), posture and body mechanics education (86.3%), mobilization techniques (85%), general exercise and fitness programs (70%), and massage or soft tissue mobilization (65.2%) as the most common additional interventions. Authors believe the survey points to a high degree of consistency among PTs when it comes to the use of traction for patients whose presentation and symptoms seem to indicate that traction would be helpful, but they were less certain about why the rates would be so high in cases that weren't as strongly correlated to efficacy. They have a theory, though. "During the clinical examination of a patient complaining of neck pain, [PTs] normally perform some version of manual distraction to assess whether it relieves the patient's pain and/or neck related arm symptoms," authors write. "If a patient reports a change in their neck and/or arm-related pain during a manual traction technique, it may seem intuitive to the clinician to consider this an appropriate intervention." Given that tendency, they write, the use of traction in these cases may have more to do with building a strong therapeutic alliance than employing a strongly clinically indicated intervention. "Studies reveal that a positive within-session change in a patient's symptoms and response to a particular intervention may be associated with a good outcome," authors write. "The patient's ability to notice immediate changes in [her or his] condition during an evaluation provides support for … [a] 'therapeutic alliance' between the health care provider and patient. Such alliances have been associated with better outcomes." Authors point out that traction is just 1 in a "vast array" of approaches used by PTs to treat neck pain as part of a "comprehensive plan of care." The study's authors were Timothy Madson, PT, MS, and John Hollman, PT, PhD. Madson is a certified clinical specialist in orthopaedic physical therapy. Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.