What are the best management options for chronic trapezius (trapezius muscle) pain that persists for over 1 year without using muscle relaxers (e.g. cyclobenzaprine)?

Management of Chronic Trapezius Pain Without Muscle Relaxers

For chronic trapezius pain lasting over one year, a combination of topical NSAIDs and specific non-pharmacological interventions including massage therapy, TENS, and specific acupressure should be used as first-line treatment options rather than muscle relaxers.

First-Line Treatment Options

Pharmacological Interventions

1. Topical NSAIDs

   • Moderate-certainty evidence shows topical NSAIDs reduce pain (weighted mean difference -1.02 cm on a 10-cm VAS) 1
   • Provide high treatment satisfaction compared to placebo (OR 5.20) 1
   • Improve physical function (weighted mean difference 1.66 cm) 1
   • Have fewer systemic side effects than oral NSAIDs, making them safer for long-term use

2. Oral NSAIDs (if topical insufficient)

   • Use at lowest effective dose for shortest duration if no contraindications 2
   • Moderate-certainty evidence shows pain reduction (weighted mean difference -0.93 cm) 1
   • Note: Increased risk of GI adverse events (OR 1.77) compared to placebo 1

3. Acetaminophen

   • Can be used on a scheduled basis (up to 3000-4000mg daily) 2
   • Moderate-certainty evidence shows pain reduction at 1-7 days (weighted mean difference -1.07 cm) 1

Non-Pharmacological Interventions

1. Massage Therapy

   • Moderate-certainty evidence shows reduced pain (weighted mean difference -0.70 cm) 1
   • Short-duration moderate pressure massage leads to significant reduction (19.3%) in upper trapezius muscle activity 3

2. Transcutaneous Electrical Nerve Stimulation (TENS)

   • Low-certainty evidence shows pain reduction (weighted mean difference -1.94 cm) at less than 2 hours 1
   • Continued pain reduction at 1-7 days (weighted mean difference -1.18 cm) 1

3. Specific Acupressure

   • Low-certainty evidence shows pain reduction at less than 2 hours (weighted mean difference -1.59 cm) 1
   • Moderate-certainty evidence shows decreased pain at 1-7 days (weighted mean difference -2.09 cm) 1
   • Improves physical function (weighted mean difference 1.51 cm) 1

4. Physical Activity and Exercise

   • Recommended for chronic pain conditions 2
   • Focus on shoulder and neck exercises for trapezius pain 2
   • A case-control study showed significant improvement in aerobic capacity and fatigue in patients with exercise 1

Second-Line Treatment Options

1. Antidepressants

   • SNRIs (duloxetine, venlafaxine) for dual benefit of pain relief and mood stabilization 2
   • TCAs (amitriptyline, nortriptyline) for neuropathic pain components (use with caution in older adults due to anticholinergic effects) 2

2. Anticonvulsants

   • Gabapentin or pregabalin if neuropathic pain component is suspected 2
   • Requires gradual titration to effective dose 2

3. Biomechanical or Kinesio Taping

   • Both techniques show similar significant improvements in decreasing pain and improving function in trapezius myalgia 4

4. Cognitive Behavioral Therapy (CBT)

   • Strongly recommended for chronic pain management 2
   • Addresses pain catastrophizing and improves coping strategies 2

5. Interventional Procedures (for refractory cases)

   • Trapezius-rhomboid plane block may be considered for refractory myofascial pain syndrome
   • A small case series showed 70% decrease in pain intensity at 8 weeks follow-up 5

Important Considerations and Cautions

1. Avoid Opioids

   • Not recommended as first-line treatment for chronic pain 2
   • Limited evidence for long-term effectiveness 2
   • Risk of opioid use disorder and overdose 2

2. Avoid Benzodiazepines

   • Risk of dependence and cognitive impairment 2
   • Dangerous when combined with other medications 2

3. Chronic Pain Management Principles

   • Focus on function improvement rather than complete pain resolution 2
   • Regular reassessment of treatment efficacy is essential 2
   • For chronic, daily non-inflammatory pain, avoid repeated use of NSAIDs or glucocorticoids 1

4. Physiological Considerations

   • Chronic trapezius myalgia is associated with impaired microcirculation in the local muscle 6
   • Patients with neck pain show altered behavior of the lower trapezius muscle 7

Treatment Algorithm

1. Initial Approach:

   • Start with topical NSAIDs and non-pharmacological interventions (massage, TENS, specific acupressure)
   • Implement regular physical activity focusing on shoulder and neck exercises

2. If inadequate response after 4-6 weeks:

   • Add oral NSAIDs (if no contraindications) or acetaminophen
   • Intensify physical therapy with focus on trapezius muscle function
   • Consider adding SNRIs or anticonvulsants if neuropathic component is suspected

3. For persistent pain despite above measures:

   • Consider biomechanical or kinesio taping techniques
   • Implement CBT for pain management
   • Evaluate for trapezius-rhomboid plane block if available and appropriate

By following this evidence-based approach, chronic trapezius pain can be effectively managed without relying on muscle relaxers, with a focus on improving function and quality of life.