Treatment of Rhomboid Muscle Spasms with Myonal (Tolperisone)
Tolperisone (Myonal) 50-200 mg three times daily is a reasonable treatment option for rhomboid muscle spasms, with the 200 mg three times daily dose showing the most promising efficacy without the sedation typical of other muscle relaxants. 1
Mechanism and Clinical Profile
Tolperisone is a centrally acting muscle relaxant that works primarily by inhibiting voltage-gated sodium channels, distinguishing it from other muscle relaxants in its class. 2 Unlike traditional skeletal muscle relaxants such as benzodiazepines or cyclobenzaprine, tolperisone does not cause significant sedation or somnolence—a critical advantage for patients who need to maintain daily function. 3, 1
Dosing Strategy for Rhomboid Spasms
- Start with tolperisone 50-100 mg three times daily and titrate up to 200 mg three times daily based on response. 1
- The 200 mg three times daily dose demonstrated the greatest numerical pain reduction in acute muscle spasm trials (mean reduction of -4.4 on numeric rating scale versus -3.5 for placebo, p=0.0040). 1
- Treatment duration in clinical trials was 14 days, though tolperisone has been used safely for decades in clinical practice for longer durations. 2, 3
Safety Profile
Tolperisone is notably well-tolerated compared to other muscle relaxants:
- Somnolence occurred in only 1.2% of tolperisone-treated patients versus 2.6% in placebo, making it safer than benzodiazepines or other sedating muscle relaxants. 1
- The most common adverse events are headache (7.1%) and diarrhea (2.4%), both mild and self-limiting. 1
- No significant central nervous system depression or cognitive impairment has been reported, unlike with diazepam or other benzodiazepines. 1
Alternative and Adjunctive Treatments
While tolperisone addresses the muscle spasm pharmacologically, consider these evidence-based adjuncts:
- Ischemic pressure therapy applied directly to rhomboid trigger points can increase pressure pain threshold and reduce disability more effectively than traditional modalities alone. 4
- Postisometric relaxation techniques combined with traditional physical therapy (infrared radiation, ultrasound, TENS) significantly reduce neck and shoulder disability associated with rhomboid trigger points. 4
- For refractory myofascial pain, ultrasound-guided trapezius-rhomboid plane block with 10 cc of bupivacaine 0.25% and methylprednisolone 40 mg showed 70% reduction in pain intensity at 8-week follow-up. 5
When NOT to Use Tolperisone
If the clinical picture suggests spasticity rather than simple muscle spasm (e.g., in multiple sclerosis or post-stroke patients), alpha-2-delta ligands like gabapentin are preferred first-line agents with stronger guideline support. 6, 7 Tolperisone's evidence base is strongest for acute muscle spasm, not chronic spasticity syndromes.
Critical Clinical Pitfall
Do not confuse tolperisone with benzodiazepines or other sedating muscle relaxants when counseling patients about driving or operating machinery—tolperisone does not impair alertness or cognitive function at therapeutic doses. 1 This makes it particularly suitable for working patients with rhomboid spasms who cannot tolerate sedation.