What are the treatment options for mid to upper back trigger points and back pain?

Treatment Options for Mid to Upper Back Trigger Points and Back Pain

For mid to upper back trigger points and back pain, a combination of nonpharmacologic therapies including massage therapy, exercise therapy, and trigger point injections provides the most effective treatment approach. 1

Initial Assessment and Classification

When evaluating mid to upper back pain with trigger points, look for:

• Discrete, focal, hyperirritable spots in taut bands of skeletal muscle 2
• Pain that can be elicited with palpation and may refer to other areas
• Decreased range of motion in affected muscles
• Possible associated symptoms like headache or shoulder pain

First-Line Treatment Options

Self-Care Approaches

• Heat application to the affected area
• Self-massage techniques
• Activity modification to avoid positions that aggravate symptoms
• Motor control exercises that restore coordination and strength of muscles supporting the spine 1

Professional Nonpharmacologic Interventions

1. Massage Therapy:

   • Moderate-quality evidence shows massage provides short-term pain relief and improved function compared with other interventions for subacute to chronic back pain 3
   • Compression at myofascial trigger points is more effective than compression at non-trigger points or superficial massage for pain reduction 4

2. Exercise Therapy:

   • Individualized, supervised exercise programs that incorporate stretching and strengthening show the best outcomes 3
   • Exercise programs should be tailored specifically to target the affected muscle groups in the mid to upper back
   • Yoga (particularly Viniyoga style) has shown moderate effectiveness for chronic back pain 3

3. Spinal Manipulation:

   • Moderate-quality evidence supports spinal manipulation for both acute and chronic back pain 3
   • Most effective when combined with exercise therapy 3

4. Trigger Point Injections:

   • One of the most effective treatment modalities to inactivate trigger points and provide prompt relief 2
   • Can be performed with local anesthetics like lidocaine 5
   • Trigger point injection has been shown to be superior to intravenous NSAIDs for acute low back pain due to trigger points 6
   • Technique involves inserting a needle into the trigger point and injecting medication or performing dry needling 7

Injection Technique for Trigger Points

When performing trigger point injections:

1. Identify the trigger point through careful palpation of taut bands in the muscle
2. Use proper sterile technique with antiseptic skin preparation 8
3. Use a 25-28G needle for patient comfort 9
4. Insert the needle directly into the trigger point
5. Aspirate to ensure no blood return (avoiding intravascular injection) 5
6. Inject small amounts (0.5-1 mL) of local anesthetic such as 0.5% lidocaine 9
7. Consider multiple injections for areas with several trigger points

Pharmacologic Options

• NSAIDs: First-line pharmacologic treatment for inflammatory back pain 1
• Muscle Relaxants: Effective for short-term pain relief in acute back pain 1
• Corticosteroid Injections: May be considered for persistent trigger points that don't respond to other treatments 8
  • Dosage ranges from 4-30 mg depending on the size of the area being treated 8

Comprehensive Management Approach

For optimal results, implement a progressive treatment algorithm:

1. Begin with less invasive approaches:

   • Heat therapy
   • Self-care education
   • Activity modification

2. If inadequate response, add:

   • Professional massage therapy focusing on trigger points
   • Supervised exercise program with individualized strengthening and stretching

3. For persistent symptoms:

   • Trigger point injections with local anesthetic
   • Consider adding spinal manipulation
   • Multidisciplinary rehabilitation for complex or chronic cases 3

Common Pitfalls to Avoid

• Focusing only on pain relief without addressing underlying muscle dysfunction
• Neglecting to provide proper self-management strategies
• Overreliance on passive therapies without incorporating active exercise
• Performing trigger point injections without proper identification of the trigger point
• Using continuous traction, which has not been shown to be effective 3

Follow-up Recommendations

• Reassess after 2-4 weeks of initial therapy
• If symptoms persist despite comprehensive treatment, consider further evaluation for other potential causes
• For chronic cases, intensive interdisciplinary rehabilitation may be necessary 3