 Be familiar with the pathology of a patient with a typical T4 syndrome.  Be familiar with the typical subjective and objective signs of a patient with T4 syndrome.  Be familiar with the most widely used physiotherapy treatment protocol for a patient with typical T4 syndrome.

 Unknown origin  May sometimes be associated with outonomous nervous system involvement  Not necessarily T4 which is affected, one or more levels can be affected between T2-T7  T4 is almost always involved

 Intermittent symptoms  Widely spread headache (dull, painful or a pressing sensation)  Arm and hand symptoms (tingling or a dead sensation) – glove type and never a specific dermatome  Interscapular areas is stiff during rotation  Diffuse posterior neck pain in some patients

 Symptoms are relieved: Changing position Rubbing or shaking the area  Active flexion often slightly reduced  Hypomobility of T3/4, T4/5 or T5/6  Local segmental muscle spasm  One spinal process is usually slightly rotated and deeper in comparison with the others  Tenderness over T4  Loss of PAIVM between T3 and T4  Interspineous and laminar hypertrophy

 Mobilising techniques  Relief of muscle spasm  Postural correction exercises