1. T-4 Syndrome
Wilharnus van den Berg

2. What is T-4 Syndrome?
T4 Syndrome is a clinical pattern that involves upper extremity paraesthesia and pain with or without symptoms in the neck and/or back
Symptoms may not be solely derived from the 4th vertebra
Can also be referred to as "upper thoracic syndrome"

3. Pathophysiology The exact cause of T4 syndrome is still widely debated
Two major thoughts exist on the cause of the pain
First theory is that hypomobile thoracic segments give rise to the pain and other symptoms then follow

4. Pathophysiology cont...
Secondly and more favored is that symptoms are of sympathetic origin
The sympathetic nervous system provides pathways for referral of symptoms from the thoracic region to the upper extremities, head and neck
Thus a proximal problem/dysfunction can give rise to distal symptoms

5. Causes and risk factors
Sympathetic chain is in very close proximation to the thoracic spine
Thoracic joint dysfunction can lead to mechanical pressure on the ganglia and give rise to the referred symptoms
Sustained extreme postures may lead to relative ischemia in various tissues which in turn contributes to symptoms of sympathetic origin

6. Predisposing factors
New job or hobby that requires prolonged bending and or stooping
Bad postures and prolonged sustained position in front of a computer
In a 2005 case report by Conroy et al. A patients' symptoms started after swimming for the first time in 2 years and studying for a prolonged period of time.
According to DeFranca et al.1995 the prevalence of T4 syndrome is four times higher in females than in males

7. Signs and symptoms Symptoms may present unilaterally or bilaterally
Symptoms may develop suddenly or gradually
Symptoms may refer to ribs,chest and back
Symptoms generally worsen with activities that involve twisting, lifting, arching backwards, bending, sitting for prolonged periods of time and coughing or sneezing.

8. Signs and symptoms cont...
Symptoms may include
Diffuse pain in the arms and may be felt in the upper back and neck
Pins and needles
Numbness
Muscle spasm and stiffness
Restricted mobility around affected thoracic joint

9. Management and Rx
Conroy et al.2005 reported that hot showers and upper back massage occasionally relieved pain
Grade 3 central PA mobilisations of T4 increased T4/5 mobility and relieved the patients pain
Over 4 treatments, pain localized over T4 with distal symptoms disappearing

10. Management and Rx cont...
Joint mobilization stimulates descending inhibitory pain pathway. Therefore the sensation of pain is decreased.
Spinal mobilization is a good treatment option for T4 syndrome.

11. References NMS dictate
Conroy,JL., Schneiders,AG. Case Report - T4 Syndrome. Manual herapy 2005;10;
Evans, P. The T4 Syndrome Some Basic Science Aspects. Physiotherapy 1997; 83(4)
DeFranca, CG., Levine, LJ. The T4 Syndrome. J Manipulative Physiol Ther 1995; 18910: 34-7
T4 Syndrome (internet). Available from: physioadvisor.htm. Retrieved on