What is the best treatment for muscle spasms in the back after physical therapy?

Treatment for Muscle Spasms in the Back After Physical Therapy

For muscle spasms in the back after physical therapy, a combination of heat therapy and exercise is the most effective treatment approach, with cyclobenzaprine as a short-term adjunct for relief of acute symptoms.

First-Line Treatments

Heat Therapy

• Moderate-quality evidence shows that superficial heat is more effective for acute or subacute low back pain, providing short-term reduction in pain and disability 1
• Heat wrap therapy significantly reduces pain after five days compared to placebo in patients with acute and subacute low back pain 2, 3
• A combination of heat plus exercise provides greater pain relief and improved function compared with exercise alone 1
• Moist heat penetrates deep tissue faster than dry heat and shows the greatest pain reduction when applied immediately after exercise-induced muscle soreness 4

Exercise Therapy

• Moderate-quality evidence shows that exercise results in small improvements in pain relief and function compared with no exercise for chronic low back pain 1, 5
• Motor control exercise (MCE) moderately decreases pain scores and slightly improves function in short to long-term follow-up compared with minimal intervention 1, 6
• Low-quality evidence shows that exercise results in small improvements in pain and function for radicular low back pain 1

Pharmacological Management

Muscle Relaxants

• Cyclobenzaprine is FDA-approved as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 7
• Clinical studies demonstrate that cyclobenzaprine is effective for muscle spasm, local pain, tenderness, and limitation of motion 7
• Cyclobenzaprine should be used only for short periods (up to two or three weeks) as adequate evidence for more prolonged use is not available 7
• Start with 5mg dose in patients with mild hepatic impairment and titrate slowly upward 7

Adjunctive Therapies

Massage

• Moderate-quality evidence shows that massage improves short-term pain relief and function compared with other interventions for patients with subacute to chronic low back pain 1
• A combination of massage plus another intervention (exercise, exercise and education, or usual care) is superior to the other intervention alone for short-term pain relief 1
• Low-quality evidence shows no serious adverse events with massage, although soreness during or after massage therapy may occur 1

Multidisciplinary Rehabilitation

• Moderate-quality evidence shows that multidisciplinary rehabilitation is associated with slightly lower short-term pain intensity and disability compared with physical therapy alone 1
• Multidisciplinary rehabilitation is associated with moderately lower long-term pain intensity and improved function compared with physical therapy 1

Treatment Algorithm

1. Immediate intervention (0-48 hours after spasm onset):

   • Apply heat therapy (preferably moist heat) for 15-20 minutes every 2-3 hours 4, 8
   • Consider cyclobenzaprine 5-10mg three times daily for severe spasms, for up to 2-3 weeks only 7

2. Early recovery phase (2-7 days):

   • Continue heat therapy before exercise sessions 1
   • Begin gentle, supervised exercise focusing on motor control and muscle strengthening 1, 5
   • Gradually increase exercise intensity as tolerated 5

3. Rehabilitation phase (1-4 weeks):

   • Progress to more comprehensive exercise program with individual tailoring and supervision 5
   • Consider massage therapy as an adjunct to exercise 1
   • Discontinue muscle relaxants as symptoms improve 7

4. For persistent symptoms (>4 weeks):

   • Consider multidisciplinary rehabilitation approach 1
   • Evaluate for other potential causes of persistent muscle spasms 1

Important Considerations and Pitfalls

• Avoid prolonged use of cyclobenzaprine beyond 2-3 weeks as evidence for longer use is lacking 7
• Be aware that exercise may initially cause muscle soreness and increased pain, but these are generally mild and transient 1
• Heat therapy carries a small risk of skin flushing, but serious adverse events are rare 1
• Lumbar supports have not shown clear benefits for back pain with muscle spasm 1
• TENS shows no difference compared to sham TENS for pain intensity or function 1
• Traction shows no clear differences compared to other active treatments for back pain with or without radiculopathy 1