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Diagnosis: T4 Syndrome
Monday January 18, 2010


Of the hundreds of patients he’s treated in his 18 years of practice, John Duffy, PT, OCS, estimates he’s evaluated and treated just 10 patients with T4 (fourth thoracic) syndrome.

The syndrome, which produces a complex pattern of painful symptoms thought to be caused by a sympathetic nervous system reaction to a hypomobile thoracic segment, is rare and can be confused with a variety of other problems.

Nonetheless, PTs should keep the possibility of T4 syndrome in mind when diagnoses with similar symptoms have been ruled out, says Duffy, who treats patients at Phoenix Rehabilitation and Health Services Inc. in Pennsylvania With proper treatment, many patients with T4 syndrome can get rapid relief of their symptoms.
T is for Thoracic

Australian physiotherapist Geoffrey Maitland first described T4 syndrome in the 1950s as a thoracic vertebral segmental rotation dysfunction, says Sandy Burkart, PT, OCS, PhD, who practices out of the Palm Beach Institute of Sports Medicine in Boca Raton, Fla., and is a teacher and consultant with Functional Rehabilitation Associates.

The syndrome always affects the fourth thoracic segment, Burkhart says, but segments T2 through T7 also can be involved. Symptoms include upper back stiffness, a glove-like distribution of pain or numbness in one or both forearms or hands — usually in just one — and local tenderness at a thoracic facet joint. A patient with the syndrome might also experience headaches, an increase of symptoms when taking a deep breath, and, occasionally, chest pain.

No one knows exactly what causes the syndrome, but it may be because of faulty postural alignment, joint hypomobility, or stiffness, Burkart says.

Onset varies, with some patients unable to recall a precipitating event, while others reporting the symptoms began after an injury or vigorous upper body movement. Researchers postulate that because of the pathway provided by the autonomic nervous system, dysfunction in the thoracic spine can result in the pain in the limbs, neck, and head.

T4 syndrome is three times more common in women than men, with symptoms that typically worsen at night, Burkart says. The syndrome is usually seen in adults, but less frequently in the elderly, who tend to be stiffer and don’t rotate as easily as younger people. “And we usually don’t see it in [children] because they’re more flexible than adults,” Burkart adds.

Since research has been limited to case studies and small numbers of patients, T4 syndrome has a more theoretical than empirical basis, Duffy says. Still, many clinicians believe T4 syndrome is a legitimate condition, and because the upper thoracic spine plays a significant role in the motion and well being of the cervical spine, it must be addressed, he says.

D is for Diagnosis
Because T4 syndrome is rare, it’s usually a diagnosis of exclusion, says Francois Prizinski, DPT, OCS, a facility director at Keystone Physical Therapy in Pittsburgh. A thorough patient history and physical examination will help narrow the possibilities and should be done before any mobilization techniques are used. “A clinician should first rule out myelopathy/[upper motor neuron] signs, cardiac pain, thoracic outlet syndrome, a systemic illness, thoracic tumor, polyneuritis, fibromyalgia, and nerve root compression,” Prizinski says.

If a patient complains of thoracic pain along with neurological impairments such as memory loss, bladder incontinence, and ataxia, normal pressure hydrocephalous must be ruled out, Burkart says.

Another diagnosis to consider is complex regional pain syndrome, previously known as reflex sympathetic dystrophy, which can occur following an accident, fall, or surgery.

Whether MRIs, CT scans, or X-rays can pinpoint the cause of thoracic pain is a tricky question because those tests can produce many false positives, Burkart notes. In a classic study published in the Journal of Bone and Joint Surgery, MRI tests revealed that 73% of the 90 asymptomatic people studied were found to have an upper thoracic disc abnormality, 37% had a herniated thoracic disc, and 29% had radiographic evidence of spinal cord compression.

M is for Mobilization
“T4 syndrome is most successfully treated with mobilization and manipulation techniques followed by neuromuscular re-education,” Prizinski says.

Ice, electrical stimulation, NSAIDs, and techniques to reduce abnormal neural tension also can be used. Burkart finds that patients usually respond well to treatment in the first 72 hours, and the problem often is resolved within three weeks.

To determine the best course for manual treatment, Prizinski suggests using a Fear Avoidance Beliefs Questionnaire. Patients with low FABQ scores should respond well to a high velocity/thrust technique, while a gentler course would work better for patients with high scores, he says.

A patient’s response to thoracic spine mobilization may indicate whether T4 syndrome is the culprit behind the pattern of symptoms.“If you work on that area and there’s no relief or reproduction of symptoms, the problem is probably not T4 syndrome,” Duffy says.

Barbara Marquand is a contributing writer for Today in PT.

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Monday January 18, 2010
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