What are the management options for mid back musculoskeletal pain?

Management of Mid Back Musculoskeletal Pain

First-Line Treatment: Topical NSAIDs

Start with topical NSAIDs (with or without menthol gel) applied to the affected area 3-4 times daily, as this provides the strongest evidence for pain relief and improved physical function while minimizing systemic side effects. 1, 2

• Topical formulations reduce gastrointestinal and cardiovascular risks compared to oral medications 2
• This recommendation comes from the American College of Physicians and American Academy of Family Physicians with moderate-certainty evidence 1

Second-Line Pharmacologic Options

If topical NSAIDs provide inadequate relief after 3-5 days:

• Oral NSAIDs: Ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily 1, 3

  • More effective than acetaminophen for both pain relief and functional improvement 1
  • Use the lowest effective dose for the shortest duration 3
  • Consider gastrointestinal protection if risk factors present 3

• Acetaminophen: 650-1000 mg every 6 hours as needed if NSAIDs are contraindicated 1, 4

  • Less effective than NSAIDs but safer gastrointestinal profile 1
  • Do not use paracetamol as monotherapy for chronic musculoskeletal pain 1

Essential Non-Pharmacologic Interventions

Advise patients to remain active and continue ordinary activities within pain limits—bed rest worsens outcomes and delays recovery. 1, 5

• Exercise therapy provides moderate pain relief (approximately 10 points on a 100-point scale) with best outcomes using individualized, supervised programs incorporating stretching and strengthening 6, 7
• Self-management education should emphasize the favorable prognosis and importance of staying active 1
• Consider spinal manipulation by appropriately trained providers for short-term symptom relief 1, 7

Adjunctive Non-Pharmacologic Options

For patients preferring non-drug approaches or with medication contraindications:

• Acupressure: May reduce pain and improve function 1
• Transcutaneous electrical nerve stimulation (TENS): May reduce pain intensity 1
• Massage therapy: Moderate evidence for chronic musculoskeletal pain 1, 7
• Heat application: Use heating pads for short-term relief 1

What NOT to Do: Critical Pitfalls

Avoid opioids (including tramadol) for musculoskeletal pain—the risk of opioid use disorder outweighs any modest benefits. 1, 2

• The American College of Physicians and American Academy of Family Physicians explicitly recommend against opioid use for acute musculoskeletal injuries 1
• Approximately 2 million persons in the US have opioid use disorder from prescription opioids 2

Do not routinely order imaging unless red flags are present. 1

Red flags requiring immediate evaluation include:

• Progressive neurologic deficits 1
• Cauda equina symptoms (saddle anesthesia, bowel/bladder dysfunction) 1, 5
• Suspected infection (fever, IV drug use, immunosuppression) 1, 5
• Suspected malignancy (history of cancer, unexplained weight loss, age >50 with new onset pain) 1, 5
• Significant trauma 1

Avoid these ineffective or harmful interventions:

• Spinal injections (facet joint, trigger point, epidural for axial pain) 1, 6
• Prolonged bed rest 1, 5
• Glucosamine or chondroitin 1
• Antidepressants (SSRIs, SNRIs, tricyclics) for non-neuropathic musculoskeletal pain 1

Chronic or Persistent Pain (>4 weeks)

If pain persists beyond 4 weeks despite initial management:

• Assess for psychosocial factors: Fear-avoidance behaviors, catastrophizing, depression, work-related stress 1, 7
• Intensify exercise therapy: Supervised, progressive programs with stretching and strengthening 1, 6, 7
• Consider cognitive-behavioral therapy if psychological factors are prominent 1, 7
• Yoga or tai chi: Moderate evidence for chronic musculoskeletal pain 6

When to Refer

• Immediate specialist consultation if red flags present (progressive neurologic deficits, cauda equina syndrome, suspected infection or malignancy) 1, 6
• Multidisciplinary pain management referral if pain persists despite optimized treatment over 3-6 months 6, 8
• Do not refer for surgery in the absence of red flags or specific structural pathology 5

Common Clinical Pitfalls

• Do not assume pain intensity correlates with disease severity—mild pain can represent serious pathology 2
• Reassure patients that 90% of acute musculoskeletal pain episodes resolve within 6 weeks regardless of treatment 5
• Minor flare-ups may occur in the subsequent year but do not indicate treatment failure 5
• Avoid passive modalities (ultrasound, traction, TENS) as primary treatment—they lack evidence for meaningful benefit 1, 5