What are the treatment options for chronic myofascial back pain?

Treatment of Chronic Myofascial Back Pain

Begin with a structured exercise program as the foundation of treatment, combined with heat therapy and manual therapies, reserving pharmacologic interventions for inadequate response to these first-line nonpharmacologic approaches. 1, 2

Initial Nonpharmacologic Treatment (Weeks 0-6)

Exercise Therapy (Primary Treatment)

• Implement a supervised exercise program incorporating stretching, strengthening, and motor control exercises. 1, 2 Exercise therapy demonstrates good evidence of moderate efficacy and should be the cornerstone of treatment for chronic myofascial back pain. 3, 1
• Motor control exercise (MCE) specifically targets restoration of coordination, control, and strength of spinal-supporting muscles, moderately decreasing pain scores and improving function in short- to long-term follow-up. 3, 2
• The specific type of exercise matters less than patient adherence—different exercise regimens show similar effectiveness. 2

Heat Therapy

• Apply superficial heat (heat wraps) for moderate pain relief and disability reduction. 3, 2 Moderate-quality evidence shows heat wraps moderately improve pain at 5 days and disability at 4 days compared to placebo. 3
• Combining heat with exercise provides greater pain relief than exercise alone. 3, 2

Manual Therapies

• Incorporate massage therapy, which shows moderate effectiveness for chronic myofascial back pain. 1, 4
• Deep tissue massage, myofascial release techniques, and spray-and-stretch methods target trigger points characteristic of myofascial pain. 4, 5
• Spinal manipulation provides moderate effectiveness for pain relief and functional improvement. 1, 2

Additional Nonpharmacologic Options

• Consider acupuncture or dry needling for trigger point treatment. 3, 4 Fair evidence supports acupuncture's effectiveness for chronic low back pain. 3
• Cognitive-behavioral therapy demonstrates good evidence of moderate efficacy for addressing psychosocial factors that complicate chronic myofascial pain. 3, 1
• Yoga (particularly Iyengar yoga) results in moderately lower pain scores and improved function at 24 weeks compared to usual care. 3, 1
• Tai chi produces moderate pain improvement compared to wait-list controls. 3, 1

Pharmacologic Treatment (If Inadequate Response After 4-6 Weeks)

First-Line Pharmacologic Therapy

• Add NSAIDs (naproxen or ibuprofen) as first-line pharmacologic therapy. 1, 6 The American College of Physicians recommends NSAIDs for patients with inadequate response to nonpharmacologic therapy. 1
• Topical NSAIDs or topical lidocaine can be applied directly to painful trigger point areas. 3

Muscle Relaxants (Adjunctive)

• Consider short-term cyclobenzaprine (5-10 mg three times daily) as an adjunct to rest and physical therapy for relief of muscle spasm. 7 Cyclobenzaprine is FDA-approved for acute, painful musculoskeletal conditions and should be used only for short periods (up to 2-3 weeks). 7
• Cyclobenzaprine produces clinical improvement whether or not sedation occurs, though dry mouth is the most frequent adverse reaction. 7

Second-Line Pharmacologic Therapy

• Add tramadol or duloxetine (starting at 30 mg daily, titrating to 60 mg daily) if NSAIDs provide inadequate response. 1, 6
• Tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) can be considered as part of a multimodal strategy. 3, 1

Advanced Interventions (If Refractory After 8-12 Weeks)

Procedural Interventions

• Refer to pain management for trigger point injections, which physically denervate the neural loop of the trigger point. 4, 5, 8
• Consider dry needling or onabotulinumtoxinA injections for persistent trigger points. 4, 8
• Low-level laser therapy combined with NSAIDs largely decreases pain intensity and moderately improves function. 3

Multidisciplinary Rehabilitation

• Refer for intensive multidisciplinary rehabilitation combining physical, psychological, and educational interventions. 1 Good evidence supports interdisciplinary rehabilitation as moderately effective for chronic low back pain. 3

Opioids (Last Resort Only)

• Consider opioids only after documented failure of all other therapies and only when potential benefits clearly outweigh risks. 1, 6 This requires thorough discussion of risks including substance use disorder screening. 6

Critical Pitfalls to Avoid

• Do not prescribe bed rest—it leads to deconditioning and worsens outcomes. 1, 6 Emphasize remaining active. 6
• Avoid routine imaging for nonspecific myofascial back pain—findings are often nonspecific and do not improve outcomes. 1, 6
• Do not use TENS—it shows no difference compared to sham TENS for pain intensity or function. 1, 2
• Avoid lumbar supports—they have not shown clear benefits for chronic back pain. 3, 2
• Strongly avoid interventional procedures such as epidural injections, radiofrequency ablation, and joint injections—these lack evidence of benefit. 6
• Recognize that cyclobenzaprine is indicated only for acute conditions (up to 2-3 weeks) and has not been found effective for spasticity. 7

Expected Outcomes and Realistic Expectations

The magnitude of pain benefits from nonpharmacologic therapies is typically small to moderate (10-20 points on a 100-point visual analogue pain scale, or 2-4 points on the Roland-Morris Disability Questionnaire). 3, 1 Effects on function are generally smaller than effects on pain. 1 Symptoms often resolve with early intervention, but as myofascial pain enters the chronic stage, it becomes increasingly refractory to treatment. 4, 5