T4 Syndrome

What is T4 syndrome?

T4 syndrome is a condition in which sometimes nerve become pinched or irritated at the level of the fourth thoracic vertebra (T4), which leads to diffuge pain, tingling numbness, parasthesia in the arm, upper back and chest region.

T4 syndrome is a diagnosis of exclusion when all other diagnoses do not fit the clinical sample. It is an infrequent occurrence of symptoms involving upper limb paraesthesia, weakness with reduced thoracic movement, and tenderness on palpation of the T4 vertebra.

It was originally theorized these symptoms exist because of sympathetic nerve fibers converging at T4. It is thought that the head and neck are given sympathetic outflow from T1 to T4. The upper trunk and upper extremities are thought to be supplied by T2 to T5. This could account for the symptoms in the neck, head, and upper extremities.

Clinically Relevant Anatomy

A typical thoracic vertebra has a total of 6 joints with neighboring vertebrae: 4 synovial joints and 2 symphyses.

There are 2 major types of joints between the vertebrae

• Symphyses between vertebral bodies
• Synovial joints between articular processes

In thoracic regions, the joints are structured vertically and limit flexion and extension, but facilitate rotation. The thoracic spinal nerves mostly innervate respiratory, visceral, and lower back areas however, T1 and 2 do also give some of the upper limbs.

Epidemiology

• T4 syndrome is an infrequent occurrence with little high-quality proof to prove it as a diagnosis so caution should be utilized when diagnosing this as the primary pain driver.
• Given the anatomical complexity of the thoracic and shoulder areas, the potential sources of pain in this region are too many.
• In the worse case scenarios, red flag questions to rule out long-standing visceral issues should be asked specifically as regards:

• Cardiac
• Respiratory
• Renal
• Gastroesophageal conditions
• Cancer.

Symptoms of T4 syndrome

T4 syndrome is an exclusion diagnosis: once other issues have been excluded then it can be indicative of T4 syndrome.

• Symptoms can take place following a change in normal routine in the essence of a new job or hobby.
• These signs and symptoms might be the result of thoracic dysfunction and its impacts on the sympathetic nervous system.
• Typical presentation includes:

• Diffuse radiating arm pain, pins and needles and tingling numbness sensation in the arm
• Difuge pain, tingling numbness, Paresthesia to the upper limbs and hands in a “glove” presentation
• Neck pain
• Headaches
• Upper limb pain (bilateral or unilateral)
• Pain around the T4 area
• Scapular pain
• Reduced hand dexterity
• “Heaviness” in upper extremities
• Hands swollen
• Thoracic spine stiffness
• Tenderness on palpation of the T4 vertebra.

Less common symptoms:

• Pain around the chest wall
• Worse pain at night
• Pain on deep breathing
• Pain on coughing or sneezing
• Symptoms are often uneven and seen in the neck, head, and upper extremities (unilateral or bilateral).

Diagnostic Procedures

T4 syndrome is an exclusion diagnosis with not enough clinical criteria to assist the diagnosis. Radiographs are no aid in the diagnosis but may help with finding out other conditions. Subjective and objective assessments can also help to aid in excluding other diagnoses.

Examination

There is no proof of examinations that involve T4 syndrome. Unfortunately, a great deal of literature presents on shoulder pain, yet little is present in the area of periscapular or rib pain. It can be concluded that the intervertebral joint surrounding T4 is hypermobile in patients with T4 syndrome. During the objective examination it may be useful to assess:

• An overall observation of patient posture in sitting, standing, and provocative movements
• Thoracic AROM
• Cervical AROM
• Shoulder AROM
• Passive thoracic and cervical ROM
• Shoulder and cervical strength.

Neurological assessment

• (dermatomes, myotomes, reflexes) to identify whether nerve root or peripheral nerve lesions were
  exist.

Differential Diagnosis

Red flag questions should be asked extensively to find out any cardiac, respiratory, or visceral issues. Thoracic pain is also common with cancer metastases so earlier to any manual therapy make sure to find out if cancer is a cause of pain. After red flags are cleared it is then necessary to find out another differential diagnosis especially in potential T4 syndrome as this is an infrequent condition, therefore, other diagnoses are more likely. These can include:

• Thoracic Outlet Syndrome
• Carpal tunnel syndrome
• Ulnar nerve entrapment
• Cervical disc disease or degeneration
• Visceral disease
• Neurological disease
• Fibromyalgia
• Myelopathy
• Causalgia (Complex Regional Pain Syndrome)
• Cardiac disease

Medical Treatment of T4 syndrome

• After noticing other conditions involving finding out red flags and differential diagnosis, pain management should start.

For neurological symptoms

• Prescribe gabapentinoids or if the pain is ongoing consider intramuscular injections of 1 to 2 mL of 0.5% bupivacaine at the 4th thoracic paraspinal level.
• Physiotherapy and conservative management are the first treatment options.

Physical Therapy Treatment

After analgesia has been upgraded and if the pain is still an issue with functional deficits, physiotherapy is the primary treatment option for T4 syndrome. Different types of manual therapy techniques have been shown to have some effect on symptom relief.

• Thoracic joint mobilization techniques are the basics in treating T4 syndrome.
• These mobilizations have been shown to have analgesic mechanisms due to their effect on the sympathetic nervous system.

Joint Manipulation

• A passive, high velocity, low amplitude thrust is applied to a joint complex within its anatomical limit with the intent to regain optimal motion, and function, and/ or to decrease pain.

Joint Mobilisation

• A manual therapy technique comprising a continuum of skilled passive movements to the joint complex that is given at varying speeds and amplitudes, that can involve a small-amplitude/high-velocity therapeutic movement (manipulation) with the intent to regain optimal motion, and function, and/ or to decrease pain.

Soft tissue mobilisation

Light pressure or slow skin rolling techniques have been shown to have analgesic effects in the short term

• Goals of Soft Tissue Mobilization:
• Break down or decrease adhesions
• Increase range of motion
• Lengthen muscles and tendons
• Decrease swelling and edema
• Reduce pain
• Restore functionality

Soft Tissue Mobilization Techniques

Physiotherapists are specially trained to use their hands to push, pull and knead the muscles, ligaments, tendons, and nerves in precise ways to help bring the patient pain relief and return the patient to functionality. Specific techniques for soft tissue mobilization involve

• Sustained pressure – Pushing straight on the restricted tissue and holding.
• Unlocking spiral – Pushing on the affected tissue in alternating clockwise and counterclockwise rotating movement.
• Direct oscillations – Rhythmic pushing on the affected tissue
• Perpendicular mobilization – Pushing on the myofascial tissue at right angles
• Parallel mobilization – Pushing along the seams of muscles
• Perpendicular strumming – Rhythmic pushing along the muscle border, followed by the rubber on top of the muscle
• Friction massage – pushing across the bulk of the muscles, tendons, and ligaments

Massage

Effleurage (Stroking)

• The hands are passed rhythmically and continuously over a patient skin, only in one direction, with the goal of increasing blood flow in that direction, stretching tissues, relaxing the patient, and aiding the dispersal of waste products.
• The word effleurage is coming from French, meaning “to skim”.
• It includes stroking movements of the hands sliding over the skin and is normally the first and last technique (as well as being used between other techniques) applied in a massage session.
• Effleurage can be used with different tempos and pressure based on the stage of the condition and whatever the desired effect of the massage is.

Aims of Effleurage

• Introduce touch to the patient
• Put the patient at ease
• Warm the superficial tissues
• Relax the muscles
• Permit the patient to palpate and sense the condition of the tissue
• Stimulate the peripheral nerves
• Improves blood and lymph flow, thus aiding in the removal of waste products
• Stretch tissues
• Relax the patient before the end of the session.

Petrissage (Kneading)

• The skin is pulling up, pressed down and squeezed, pinched and rolled.
• Alternate squeezing and relaxation of the tissues stimulate local circulation and can have a pain-relieving effect on some muscular disorders.
• Petrissage is coming from a French word, meaning “to knead”.
• The basic motion is to compress, pick up and then release the soft tissues.
• It is usually used when a deeper effect than effleurage is desired, and it is techniques include:

• Squeezing
• Picking up
• Shaking
• Rolling
• Wringing

Percussion/Tapotement Manipulations

• Including hacking, clapping, beating, pounding, or vibrations.

Myofascial Release

• Myofascial release is a manual technique for stretching the fascia pointing to release fascia restrictions.
• Fascia is located between the skin and the beneath structure of muscle and bone and joints are the muscles, organs, and skeletal structures in our body.
• Fascia may become affected by injuries, stress, trauma, and poor posture.

Trigger Point Therapy

• Trigger point therapy involves the applying of pressure to tender muscle tissue in order to reduce pain and dysfunction in other parts of the body.
• Trigger points are active centers of muscular hyperactivity, which mostly cross over with acupuncture points.

Deep Transverse Frictions

• Transverse frictions are transverse connective tissue therapy applied directly by the fingers.
• Oscillating pressure is given across the direction of the tissue fibers.
• Mostly used on tendon or ligament injuries to help break down thickened, pain-producing scar tissue.

Swedish Massage

Swedish massage techniques incorporate long strokes, kneading, friction, tapping, percussion, vibration, effleurage, and shaking motions. The sequence of use is usually,

• Effleurage: Gliding strokes with the help of palms, thumbs, and/or fingertips
• Petrissage: Kneading movements with the help of hands, thumbs, and/or fingers
• Friction: Rotational pressures using the palms of hands, thumbs, and/or fingers
• Vibration: Oscillatory movements that shake or vibrate the whole body
• Percussion: Brisk hacking or tapping
• Passive and active movements: Bending and stretching.

Exercise therapy

Shoulder roll

• Start with standing with the arms down at the sides.
• Roll the shoulders backward in a pendular motion, completing five rotations.
• Then complete five rotations forward.
• Do it further for sequence 2–3 times.

Arm circles

• Start with standing with the arms out to the sides, parallel to the floor, with the palms facing down.
• Gently circle the arms forward, making small circles initially and eventually larger ones.
• Do it 10 times.

Overhead arm reach

• Start with sitting in a chair, or standing, facing forward, with the feet on the floor.
• Extend one arm above the head and reach to the left.
• Bend the torso until a person feels the stretch in the right lat and shoulder.
• Return to the beginning position.
• Repeat five times, then perform the same thing with the opposite arm.

Chair rotation

• Start with sitting sideways in a chair.
• One side should be resting against the back of the chair.
• Keeping the legs stationary, rotate the torso to the right, reaching for the back of the chair with the hands.
• Hold the upper body in rotation, using the arms to stretch deeper and deeper as the muscles loosen.
• Hold for ten seconds.
• Repeat three times on each side.

Cat-Cow

• Start on all fours with the neck neutral.
• The palms should be directly under the shoulders, and the knees should be directly beneath the hips.
• On an inhale, tuck the pelvis and round out the mid back.
• Draw the navel toward the spine and drop the head to relax the neck.
• After five to ten seconds, exhale and return to a neutral spine position.
• Turn the face toward the ceiling, allowing the back to sink toward the floor. Hold for five to ten seconds.
• Repeat this sequence 3 to 5 times.

Knee to chest

• Start with lying faceup on the floor.
• Bend one leg and take it to the chest.
• Hold for 10 seconds, then release.
• Repeat with the opposite leg.
• Complete this sequence 5 times.

Thoracic extension

• For best results, the person needs a foam roller or a chair.
• If the person using a foam roller, position it under the thoracic spine.
• Allow the head and glutes to fall on either side.
• Extend the arms above the head to deepen the stretch.
• If the person using a chair, sit facing forward and permit the upper body to fall over the back of the chair.
• Extend the arms above the head for a deeper stretch.
• Hold either position for seconds, then release.
• Repeat three to five times.

Strengthening exercises

Strengthening the muscles in the back, shoulders, and neck is vital to decrease and prevent pain. Some of these moves include dumbbells or resistance bands, and some use just the body weight.

Row

Use a thera band or a light to medium dumbbell to complete this move.

• Affix the thera band to a pole or another stable surface and grasp each handle, extending the arms.
• Pull the handles straight back by bending the elbows, keeping them close to the body.
• They should feel the lats working.
• If the person using a dumbbell, hold it in one hand and brace yourself on a wall with another hand, arm extended.
• allowing the dumbbell to hang down.
• Keeping the neck neutral and the knees soft, pull the dumbbell directly up with a tucked elbow.
• Do three to five sets of ten repetitions.

Face pull

• Use a thera band to complete this move.
• Stable the band to a firm surface above eye level.
• Grab each handle with an overhand grip.
• Pull directly toward the face, flaring the upper arms out to the sides and squeezing the shoulders together.
• Stop, then back to the starting position.
• Complete three sets of ten reps.

Scapular squeeze

• While standing with the arms down by the sides, squeeze the shoulder blades together.
• Hold for 3 to 5 seconds, then release.
• Repeat five to ten times.

Wall angel

• Stand with the back flat against a wall.
• A person can require stepping her feet out slightly to allow the back to completely soften against the wall.
• Extend the arms out to create a “T” shape against the wall, then bend the elbows to create 90-degree angles.
• Gently move the arms up and down in a “snow angel” motion, ensuring that they stay flat against the wall the whole time.
• When the fingers touch above the head, return to the starting position.
• Complete three sets of ten reps.

Reverse dumbbell fly

• Take two light dumbbells and stand, hinged at the waist at a 45-degree angle, with the arms hanging straight down.
• Keeping the neck neutral and the gaze down, start to lift the arms out to the sides and up.
• Squeeze the shoulders in one sync at the top of the movement.
• Complete 3 sets of ten to twelve reps.

Lat pulldown

• Sit or stand beneath a resistance band attached to a stable surface overhead.
• Pull down on the band until the upper arms are parallel to the floor.
• Pause at the bottom, squeezing the lats, then return to the initial position.
• Complete 3 sets of ten to twelve reps.

Superman

• Start with lying on the stomach with the arms extended above the head.
• Keeping the neck neutral, lift the arms and legs off the floor at the same time.
• Make sure a person is using the back and glutes to lift.
• Stop briefly at the top, then return to the initial position.
• Complete three sets of ten reps of the superman exercise.

Stretching exercise

Child’s Pose

• Start on the floor on all fours.
• With the big toes touching, spread the knees as far apart as they will go and sit the glutes back onto the feet.
• Sit straight up with the arms extended above the head.
• On the next exhale, hinge at the waist and drop the upper body forward between the legs.
• Permit the forehead to touch the floor, the shoulders to spread, and the glutes to sink back.
• Hold for at least ten seconds.

Butterfly

• Put the palms on opposite shoulders and bring the elbows together to touch.
• Hold for 10 to 15 seconds, then release.
• Repeat three to five more times.
• Reverse the movement and do a further 10 circles.

Upper trapezius stretch

• While standing straight or sitting in a chair, take one hand and place it on the back of the head.
• Take the hand and tuck it behind the back.
• Using the other hand, slowly pull the head toward the right shoulder.
• Hold this for ten to fifteen seconds.
• Repeat on the opposite side.

Levator scapulae stretch

• While standing straight or sitting in a chair, turn the neck 45 degrees to the left.
• Bend the neck downward (imagine a person looking into a shirt pocket).
• A person may use the left hand for a greater stretch.
• Hold this for ten to fifteen seconds.
• Repeat on the opposite side.

Functional movements

Downward Dog

• Used by strength experts and yogis alike, this is another useful mobility exercise for thoracic extension and opening up the front of the shoulders.
• Start in a plank position.
• Exhale to push the hips up, away from the floor, and bend at the hips until a person makes an upside down Inhale to press the chest through the arms towards the legs.
• Exhale to shift the weight forward, returning to the plank position again.
• Repeat five times.

Windmill

• This is a fantastic choice for many ability levels, since a person lying on the floor.
• Start with lying on the floor on one side of the body with the knees bent and stacked in front of the hips.
• The arms should be straight out in front of you at shoulder height, and also stacked.
• Keeping the legs together, reach the top arm up toward the ear, and continue to circle it up over the head, opening the shoulders and chest toward the sky, until the arm is reaching the opposite direction from where it began.
• Turn the gaze to follow the moving arm.
• Stay in this position and take two to three deep breaths, then slowing retrace the movements, moving the arm, head, chest, and shoulders back to the initial position.
• Repeat three times, then perform five reps on the opposite side.

Assisted thoracic extension on a foam roller

• Put the roller on the floor horizontally and sit in front of it, facing away from the roller.
• Lean against it so the bottom of the shoulder blades is resting on it.
• Put the hands behind the head to support the neck.
• Using your breath, open your chest and bend backward over the roller, forming an arc in your upper back.
• If the neck feels supported, release the hands to reach the arms up and back as well.
• Stay here and breathe deep into all sides of the rib cage, permitting the body to soften towards the floor.
• Stay for a breath or two and then return the arms to the side.
• Repeat three to four times.

Child’s Pose with an exercise ball

• This exercise will open the chest while maintaining support for the entire arm throughout the twist.
• Start with kneeling on the floor facing an exercise ball.
• Sit back on the heels and open the knees wider than the hips.
• Put both hands on the exercise ball and roll it forward until a person bending forward as if in a child’s pose.
• Bring the chest as low as you may toward the knees without pain in the shoulder.
• Breathe in this position for two deep breaths.
• Then, keeping up two hands on the ball, roll the ball to the right so that the chest is opening to the ride side. Looking under one arm, focus on breathing and lengthening the spine.
• Return to the center then repeat the twist to another side, looking under the other arm.
• Repeat to the center and then roll up to the initial position, one vertebra at a time.
• Complete 3 to 5 repetitions on each side.

Side Angle Pose (Parsvakonasana)

• Start with Sitting on the edge chair with the legs open wide.
• Straighten one leg to create a lunge-like position in the limbs.
• Keeping up the spine straight, lean over the bent leg, slide the arm down the lower leg toward the ankle, and reach the arm towards the floor.
• On the inhale lift the opposite arm up and over the head, reaching it to the sky or to the opposite.
• Keeping up the lifted arm straight, focus on opening the arm and chest and look up toward the ceiling.
• Exhale to return to the initial position, lifting back up to a seated position with both legs bent.
• Repeat on the opposite side.
• Complete three to four reps on each side.

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