| Visit 1 |
Initial evaluation, manual traction (30 seconds×3 reps), mechanical traction (15 pounds intermittent×3 minutes), workplace ergonomic assessment setup, home exercise program, and patient education (including, education about coughing contributions). |
Mechanical traction was poorly tolerated by the patient, and the traction was discontinued after 3–4 minutes because the arm pain increased from 3/10 to 5/10. |
| Visit 2 |
Manual traction (30 seconds×3 reps), mechanical traction (20 pounds intermittent×10 minutes) and deep cervical flexor strengthening exercises (in clinic and for a home exercise program). |
Manual traction reduced resting symptoms. Again, there was no reduction of pain with mechanical traction thus this intervention was terminated. |
| Visit 3 |
Reverse sustained natural apophyseal glides at the cervico-thoracic junction to increase motion in the upper thoracic spine. The patient was educated in the self-mobilization of the median nerve. Educated again about the significance of the continued coughing. |
The patient’s symptoms were more irritated at the start of the session secondary to the coughing. There were no within session symptom changes. |
| Visits 4–8 |
The patient returned reporting a gradual increase in sleep duration. Continued therapy was directed at the upper thoracic spine. Progression of the deep cervical flexor strength program to functional postures. |
The patient demonstrated 75% or greater AROM of the cervical spine before feeling any left arm symptoms. |
| Visits 9–12 |
Occasional arm pain – only triggered with a cough. Progressed strengthening of the triceps. Increased extensor stretch to the upper thoracic spine with the use of the mobilization belt and extension proximal to this. |
Full AROM of the cervical spine without arm pain. Return of left triceps strength to 4+/5. |
