By Jeffrey Tucker, DC
The cervicothoracic junction is not limited to C7-T1 because this area is integrated into treatments, just like it is in our bodywork, nerves, vessels, muscles, fascia, bones, and other structures and functions remote from this area.
For example, let’s recognize the influence of the lower body on this area. A rhythmic, alternate facilitation and inhibition of the sternocleidomastoid (SCM) and upper trapezius muscles occurs when an individual walks or runs. These muscles pull into the cranium and influence several systems, especially the airway and respiratory system.
In addition, activities influence posture and balance, such as extensor muscle facilitation from the positive support mechanism of the proprioceptors of the foot and interactions of the cloacal and gait reflexes. These factors must be kept in mind because any structural strain may disturb the normal activity of the stomatognathic system.
If the patient obtains temporary relief from your therapy, it indicates that you are on the right track. Even if relief lasts only an hour or two, it tells you that some factor is causing the fault.
An example is when a patient experiences temporary relief from cervicothoracic pain after our hands-on mobilization, manipulation, stretching, and strengthening exercises, and it returns two or more hours later. Patients will tell us, “I just went on a walk.” The pain comes back, so we investigate the patient’s feet (maybe they need orthotics), posture, ergonomics at work, and daily activities to identify contributing factors to the pain. We focus on exercises to target specific muscle imbalances or weaknesses.
However, if symptoms return, are we smart enough to ask if it is related to bloating or discomfort after a certain meal or food is eaten? Then, we might think of TMJ issues or assess for food intolerances or allergies, such as lactose intolerance or gluten sensitivity. In this instance, I’d consider suggesting an elimination diet or adding HCL and digestive enzymes to help pinpoint specific triggers.
I’m working with cases like these now because patients were not getting relief from other practitioners. One woman has upper thoracic area pain with respiratory issues related to a post-COVID infection. She has a lingering cough and was diagnosed with adult-onset asthma. She experiences temporary relief from symptoms after using moist heat packs and ultrasound sessions with her physical therapist.
She heard that I have TECaR therapy, which creates deep warming in the tissues. First, we talked about her environment for potential allergens or irritants, such as dust and pet dander, and suggested adding a work and home air purifier. We did five daily TECaR sessions in a row and I put her on a supplement called BosPro from EuroMedica, which targets the 5-LOX pathway to reduce lung inflammation. So far, so good!
Another patient has migraines and experiences temporary relief after getting acupuncture. She came in to try laser and TECaR. We talked about potential triggers, such as stress, diet, and sleep patterns. She was already utilizing lifestyle modifications and stress management to reduce the frequency of migraines. I used my thermography device (WellVu), and it showed numerous “hotter spots” in the suboccipital and C-T area. I started her on Stopain Clinical Migraine topical, and I got deep into her suboccipitals and C-T area with my hand, TECaR, and multiradiance laser. We have reduced the frequency of her migraines so far.
Another patient with anxiety and shoulder tension feels temporarily better after cognitive-behavioral therapy (CBT) sessions. Her therapist helped her identify the specific thought patterns and situations that exacerbate her anxiety. We worked on developing breathing strategies for her to do day and night. Therapy includes doing TECaR relaxation techniques, and then I teach her restructuring postural gravity line exercises. I put her on a clinically studied echinacea extract supplement called AnxioCalm (EuroMedica) for calming, and I’m impressed with how she’s doing.
Another 65-year-old male patient with eczema feels temporary improvement after using a topical steroid cream. I went over potential irritants or allergens in every skin care product and his environment. When looking at long-term management strategies, he had never done a liver cleanse, so I had to convince him to try that. I gave him three products (Andrographis, glutathione, Total Liver Support) for liver support and used TECaR hyperthermia to boost his elimination and immune system. Again, so far, so good.
Harold Perry was the first person I could find who had charted pain patterns from the TMJ to unilateral neck shoulder pain, so he deserves a mention. The jaw can refer to the C-T area, so I include checking for muscle imbalance in the masseters, temporalis, digastrics, and pterygoids. I do go intraoral with my finger, and I can use the laser or TECaR for a multimodal approach. Referred pain intensity from the jaw to various body regions (neck, shoulder, jaw, arm, upper back) suggests a significant connection in this region. Learn to assess and treat conditions that may involve referred pain from the jaw to the cervicothoracic junction and surrounding areas.1,2
Don’t forget that several organs can refer pain to the cervicothoracic area.
Heart conditions like angina or heart attacks can cause referred pain to the neck, shoulders, and upper back, including the cervicothoracic area.
Lung conditions, such as pleurisy, pulmonary embolism, or tumors, can refer pain to the upper back and cervicothoracic region.
Gallbladder issues, such as gallstones or inflammation, can cause pain that radiates to the shoulder blade and upper back.
Liver conditions can sometimes refer pain to the right shoulder and upper back.
Conditions like pancreatitis or peptic ulcers can cause referred pain to the back, including the cervicothoracic area.
Esophageal issues, such as GERD, can cause referred pain to the upper back and chest.
The take-home reminder is that cervicothoracic area pain can originate from various organs, making it difficult to sometimes determine an accurate diagnosis. I’m a fan of second-opinion evaluations, especially if I don’t see any change within a few sessions. 3,4,5,6,7
It’s “easy” when we have a neck-shoulder problem that is a neck-shoulder problem. Don’t forget that C4-C7 segmental levels also may be symptomatic in patients with tennis elbow. The mid to upper thoracic spine is often stiff into extension. Mobilizing these segments improves pain, grip strength, and function at the elbow with a stronger effect when delivered with a supportive and empathetic approach.
Respiratory mechanism and altered breathing patterns are closely related to C7-T1 and the first rib attachments. Part of my exam is to observe lateral chest expansion. If I see diminished lateral thrust of chest movement with inspiration on one side, I usually find a hypertonic psoas on that same side. The diaphragm is reactive to the psoas, and the patient’s diaphragm is related to the scalene and SCM muscular activity. A localized disturbance in the muscle may cause improperly functioning muscle proprioceptors, trigger points, fascial disharmony, and subluxation.
The ribs, sternum, and thoracic vertebrae can be rigid too. Intervertebral discs and costal cartilage facilitate joint movement between these structures. This movement includes:
Flexion extension ranging from four degrees at T1 to 12 degrees at T12.
Lateral movement that typically allows six to seven degrees per vertebral segment.
Rotation ranging from nine degrees at T1 and two degrees at T12.
Checking simple range of motion (ROM) also feels good to “stuck” patients.8
During shoulder elevation, the scapula tilts posteriorly, with the activation of key stabilizing muscles, such as the serratus anterior and the lower trapezius. Therefore, the thoracic spine must be able to extend to allow for optimal scapular tilting and rotation. Thoracic extension predominately occurs in the lower portion of the thoracic spine as opposed to the upper region because of the orientation of the facet joints and ribs. During shoulder elevation, around 37 degrees of extension in the lower thoracic spine has been observed in comparison to seven degrees in the upper thoracic region.8
Regarding forward head or slumped posture, we might not notice that a reduction in peak expiratory flow occurs in those using a smartphone for longer than four hours per day. Slumping postures can inhibit the diaphragm and increase the activity of the scalenes, promoting the forward head posture and trunk flexion.
The Lovett Brother concept is a chiropractic and osteopathic theory that describes a functional relationship between specific vertebrae. This relationship is used to explain patterns of motion and misalignment in the spine.
For example, C6 corresponds to T12, C7 relates to T11, and T1 relates to T10. I still check the Lovett Brother segment and treat it if needed. Keep in mind, these are functional pairs, and the Lovett Brother concept suggests that each vertebra has a corresponding vertebra with which it works in conjunction.
If T1 is paired with T10, they influence each other’s alignment and function. Sometimes, it might be easier to sustain pressure on the lower thoracic vertebrae to facilitate gentle rotation or lifting pressures, allowing the nervous system and local connective tissue to accommodate and remodel.
The Lovett Brother concept was widely accepted in my time as a young chiropractor, but there is a lack of robust research evidence to support its clinical validity. Most of the support comes from cases and anecdotal reports rather than large-scale clinical trials. Some patients have shown improvements in spinal function and pain relief following treatments based on this concept. Nonetheless, the Lovett Brother concept remains an intriguing theory for me.9
Dr. Jeffrey Tucker is in active private practice in Los Angeles, CA. His website is www.DrJeffreyTucker.com
References
1. Greene CS. Commentary on the death of Dr. Harold T. Perry, Jr. Journal of Oral & Facial Pain and Headache. 2012; 26(2):82. doi:10.11607/jofph.2682
2. Alketbi N, Talaat W. Prevalence and characteristics of referred pain in patients diagnosed with temporomandibular disorders according to the diagnostic criteria for temporomandibular disorders (DC/TMD) in Sharjah, United Arab Emirates. FlOOORes. 2022 Jun 14;11:656. doi: 10.12688/flOOOresearch. 109696.2. PMID: 36249999; PMCID: PMC9490275.
3. Cleveland Clinic. Referred pain. Cleveland Clinic [Internet]; 2023 Sept. Available from: https://my.clevelandclinic.org... symptoms/25238-referred-pain.
4. Gower T. Why does my middle and upper back hurt? WebMD [Internet], 2024 Jun. Available from: https://www.webmd.com/backpain...
5. Watson K. How does referred pain work? Healthline [Internet], 2019 Oct. Available from: https://www.healthline.com/abo... about-us
6. Jin Q, Chang Y, Lu C, Chen L, Wang Y. Referred pain: characteristics, possible mechanisms, and clinical management. Front Neurol. 2023 Jun 28:14:1104817. doi: 10.3389/fneur,2023.1104817. PMID: 37448749; PMCID: PMC 10338069.
7. Oliva-Pascual-Vaca A, Gonzalez-Gonzalez C, Oliva-Pascual-Vaca J, Pina-Pozo F, Ferragut-Garcias A, Fernandez-Dominguez JC, Heredia-Rizo AM. Visceral origin: an underestimated source of neck pain. A systematic scoping review. Diagnostics (Basel). 2019 Nov 12;9(4):186. doi: 10.3390/diagnostics9040186. PMID: 31726685; PMCID: PMC6963844.
8. Esteban-Gonzalez P, Sanchez-Romero EA, Villafane JH. Analysis of the active measurement systems of the thoracic range of movements of the spine: a systematic review and a meta-analysis. Sensors (Basel). 2022 Apr 15;22(8):3042. doi: 10.3390/s22083042. PMID: 35459026; PMCID: PMC9026805.
9. Blum C. Lovett brothers: the relationship between the cervical and lumbar vertebra [Internet], J Vertebral Subluxation Res. 2004 April. Available from: https://www.scribd.com/documen... Lovett
