T – what….T4
“T4 Syndrome” is a clinical pattern involving upper extremity paraesthesia and pain with or without symptoms into the neck and/or back. Mobilizations of the upper thoracic spine can reproduce or eliminate symptoms. In reality T4 syndrome should be called ‘upper thoracic syndrome’ as symptoms may not be derived solely from the 4th vertebra.
T4 syndrome can present with unilateral or bilateral glove distribution of paraesthesia into the hands and forearm, and may not be in a dermatomal distribution when affecting the hands. In addition patients may have weakness, hand clumsiness, upper extremity coldness, sense of fullness, tightness, and a deep aching pain. Night or early morning pain or paraesthesia is also common. Typical occupations in which T4 syndrome may be a differential diagnosis are those involving forward stooping and bending or sedentary seated positions.
Pain and paraesthesia may also be reported in patient’s upper limbs in combination with their neck, upper thoracic and cranial pain with no abnormal neurological signs.
Two thoughts exist as to the cause of the upper thoracic pain – the first is due to hypomobile thoracic segments which initiate the pain while the other more favorable thought is that the sympathetic nervous system may be the path for referral from the thoracic spine to the head and arms. The autonomic nervous system can provide a pathway for dysfunctions in the thoracic spine that maybe expressed in the lower cervical spine and upper limbs. Thus dysfunction of the sympathetic nervous system from T4 can result in referred pain in the head, neck, upper thoracic and upper limbs.
In addition the proximity of the sympathetic chain to a thoracic joint dysfunction can predispose the ganglion to mechanical pressure which may lead to the onset of symptoms.
A case report on T4 syndrome was reported by Conroy et al. 2005 in which a 28 year old female student presenting with pain across both shoulders and down the arms. Symptoms were preceded by paresthesia – tingling into palm of both hands, if the pain worsened a headache and tingling across the face would develop. Limb symptoms were bilateral.
The patient in the case reported that symptoms began a couple of hours upon rising in the morning and that sitting in lectures or studying for > 1 hr would exacerbate the pain across their shoulders. Neither changing positions nor walking would ease the pain though it was reported that hot showers and massage to their shoulders and upper back would occasionally relieve their pain.
It was reported in the case that the patient’s symptoms (arm and shoulder) started gradually 2 months previously at the end of a period of intense studying slumped into flexion on a couch. And that three weeks prior to visiting the physiotherapist she had gone swimming which had been a first in 2 years, the following morning after her swim it was reported that her thoracic spine was stiff and that over the next 3 days her shoulder and arm pain worsened and began interrupting the patient’s sleep at which time she went to the hospital and was placed on Tilcotil, Tramol and Diazepam. The medications eased the patient’s symptoms but 4 days after her symptoms worsened.
From examination it was found that the patient had an increased lordosis, decreased thoracic kyphosis and increased angulation at the cervico-thoracic junction with an increased cervical lordosis. It was also found that all thoracic movements were pain-free but restricted early in range and that flexion of the thoracic spine occurred from above T4 with little movement below T4. In addition PA pressure over T4 reproduced the pain across the patient’s shoulders.
Treatment for the case reported by Conroy et al. 2005 consisted of grade III central PA mobilization of T4 thoracic vertebrae for 20s with the patient lying prone or in slight thoracic flexion to restore the mobility of the T4/5 joint. Over the four treatments – the patients mid-thoracic pain localized to T4 and upper limb, neck and head symptoms disappeared. The patient discontinued the pain meds she was prescribed at the hospital.
Mobilizations were progressed in further thoracic flexion and full range was achieved by the 6th treatment three weeks from initial assessment. The patients shoulder pain on the left would occasionally develop when studying or at the computer but with correction in posture to sit straight or use of a hot pack over her shoulders eased her pain. In addition the patient was referred to a Pilates exercise program for upper back mobility and general trunk stabilization to help aid the patient in maintaining a normal spinal position and work on the muscle imbalances around the upper thoracic spine.
Joint mobilization for those with T4 syndrome aids to activate the descending inhibitory pain pathways –> hypoalgesic effect as there is a close relationship between pain reduction and sympathetic excitation thus supporting the role of spinal mobilizations as a treatment option for those with T4 syndrome.
Conroy, JL., Schneiders, AG. Case Report – The T4 Syndrome. Manual Therapy 2005; 10: 292-296.
Evans, P. The T4 Syndrome Some Basic Science Aspects. Physiotherapy 1997;83 (4) 186-189.