T4 syndrome is a clinical pattern mainly based on subjective symptoms of paraesthesias and numbness of upper extremity in a glove-like distribution (Conroy and Schneiders, 2005; Jowsery and Perry, 2010).

The literature on this topic is based on case reports. There are no high-quality studies available.

Cause

There is limited scientific evidence about the cause of the condition. A number of theories have been proposed:

• a possible autonomic phenomenon (Evans, 1997)
• a noxious stimuli affecting the dorsal horn and spinal medulla (Mellick and Mellick, 2006)
• Hypo-mobility of the thoracic joints (Jowsey and Perry, 2010)
• Postural stresses (e.g. prolonged sitting, stooping and bending) can be factors in the development of the condition.

Prevalence

There is no recorded incidence within the literature regarding the prevalence of this condition. T4 syndrome is more common in women than men (4:1) seen between the ages of 30 and 50 and tends to follow a non-traumatic presentation (DeFranca and Levine, 1995).

Presentation

Patients complain of paraesthesia and numbness of upper extremities usually in a glove-like distribution. Symptoms can be present in the hand, forearm and/or entire upper extremity. Symptoms tend to be distributed bilaterally and follow a non-dermatomal pattern. Patients may complain of clumsiness in the hands and a generalised weakness in grip strength as well as upper extremity coldness.

Objectively head forward postures can be observed with tightness across the anterior pectoral muscles. Cervical and thoracic range of motion is usually normal but palpation of upper thoracic segments is stiff and can elicit symptoms.

There are no tests to specifically diagnose T4 syndrome. Grip strength (hand-held dynamometer) may be useful (Mellick and Mellick, 2006).

Full neurological examination is recommended to exclude the presence of cervical or thoracic myelopathy (dermatomes, myotomes, Hoffman’s, clonus, Babinski).

First, consider supported self management (SSM) and review conservative treatment options

Link to exit/redirection routes and health improvement.

Treatment

There is no strong evidence (randomised controlled trials) concerning specific physiotherapy treatment or management for patients with T4 syndrome. Treatment options are based on single case reports (lower level evidence) (Conroy and Schneiders, 2005; Jowsey and Perry, 2010, Mellick and Mellick, 2006). Treatment must therefore be based on sound clinical reasoning.

Treatment options may include:

• Mobilisation and manipulation
• Stretches
• Strengthening
• Postural correction
• Ergonomic advice

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Consider general progression/escalation advice.

Conroy, J.L/ and Schneiders, A.G. 2005. The T4 Syndrome, Case Report. Manual Therapy, 10 (4): 292-296

Jowsey, P. and Perry, J. 2010. Sympathetic nervous system effects in the hands following a grade 111 posterior-anterior rotatory mobilisation technique applied to T4: A randomised, placebo-controlled trial. Manual Therapy 15(3): 248-253

Mellick,G.A. and Mellick, L.B. 2006. Clinical presentation; Quantitative Sensory testing and therapy of 2 patients with Fourth Thoracic Syndrome. Journal of Manipulative and physiological therapeutics, 29 (5): 403-407 Link Here (link correct as of 13/12/19). NHS Scotland Athens username and password may be required.