What is the best treatment approach for contractures following a back spasm?

Treatment of Contractures After Back Spasm

Initiate immediate range-of-motion exercises and static stretching combined with moist heat application, while considering muscle relaxants like eperisone or tizanidine for pain relief and muscle decontracture. 1, 2, 3

Immediate Non-Pharmacological Management

Begin range-of-motion exercises immediately to prevent contracture progression, performing them several times daily as recommended by the American Heart Association. 1 The key distinction here is that back spasm-related contractures differ from neurological spasticity—they represent acute muscle shortening from pain and inflammation rather than upper motor neuron dysfunction. 4, 3

Stretching Protocol

• Perform static stretching exercises daily when pain and stiffness are minimal, ideally before bedtime. 2
• Apply superficial moist heat for 15-20 minutes before stretching to improve muscle extensibility. 2
• Hold terminal stretch position for 10-30 seconds before slowly returning to rest position. 2
• Avoid excessive force or pain during stretching, as this can worsen muscle guarding and contracture. 2

Positioning Strategies

• Maintain proper body alignment and antispastic positioning to reduce reflex hyperexcitability. 1
• Use supportive devices (cushions, foam, pillows) to maintain optimal joint positioning and prevent deforming forces. 5, 2

Pharmacological Management

The evidence strongly supports muscle relaxants for acute back spasm with contracture, as the underlying mechanism involves persistent involuntary muscle shortening and local inflammation rather than spasticity. 3

First-Line Oral Agents

• Eperisone 50 mg every 8 hours is particularly effective for acute low back pain with muscle contracture, providing prompt pain reduction and progressive muscle decontracture without CNS adverse effects. 3 This agent works by inhibiting spinal reflexes and regulating blood supply to skeletal muscles, addressing the ischemia that occurs when contracture compresses small blood vessels. 3

• Tizanidine is recommended by the American Heart Association for chronic conditions and is FDA-approved for spasticity management. 1, 2 However, it causes more CNS sedation than eperisone. 3

• Oral baclofen is the American Academy of Neurology's preferred first-line agent for spasticity, particularly effective for flexor spasms and concomitant pain. 1 However, this is more relevant for neurological spasticity than simple back spasm contractures.

Agents to Avoid

Do not use benzodiazepines (diazepam) during recovery phases, as they impair neurological recovery and cause excessive sedation without addressing the underlying contracture mechanism. 1, 2

Treatment Algorithm Based on Severity

Mild Contractures (Minimal functional limitation)

1. Static stretching with moist heat 2-3 times daily 2
2. Range-of-motion exercises several times daily 1
3. Consider eperisone if pain limits exercise compliance 3

Moderate Contractures (Interfering with daily activities)

1. All measures from mild contractures 1, 2
2. Add muscle relaxant (eperisone 50 mg TID or tizanidine) 1, 3
3. Implement submaximal aerobic exercise avoiding excessively strenuous activity 2
4. Consider serial casting if contracture persists beyond 2-3 weeks 1

Severe Contractures (Fixed deformity, significant functional impairment)

1. Serial casting to gradually restore range of motion 1
2. Pharmacological management as above 1, 2
3. Consider surgical correction if contracture restricts movement, causes pain, or impedes rehabilitation after conservative measures fail 1

Critical Pitfalls to Avoid

Do not expect rapid results from short-duration stretching. Recent evidence indicates that stretches applied for less than 30 minutes daily over less than 3 months are unlikely to produce meaningful changes in joint mobility. 6 This challenges the traditional assumption that brief daily stretching is sufficient. 6

Do not apply passive movements alone without active exercise. A Cochrane review found very low-quality evidence that passive movements increase joint mobility, with one study showing only a 4-degree improvement (95% CI 2-6 degrees). 7 The American Heart Association emphasizes active range-of-motion exercises over purely passive interventions. 1

Do not neglect the vascular component. Muscle contracture compresses small blood vessels, inducing ischemia and release of nociceptive compounds. 3 This is why eperisone's dual mechanism (spinal reflex inhibition plus improved muscle blood supply) may be superior to traditional muscle relaxants. 3

Coordinate orthotic use carefully with medical specialists, as prolonged use beyond necessary healing periods can paradoxically cause stiffness and decreased range of motion. 2 Additionally, contraindications like cardiac compromise, osteoporosis, or fracture risk must be evaluated. 2

Monitoring and Progression

Track improvement using objective measures:

• Hand-to-floor distance for lumbar flexibility 3
• Resistance to passive movement 3
• Antalgic rigidity assessment 3
• Pain scores at rest and with provocation 3

Most patients with acute back spasm contractures treated with eperisone show prompt pain reduction within 3 days and progressive decontracture over 10 days. 3 If no improvement occurs within 2 weeks of conservative management, reassess for underlying structural pathology or consider escalation to serial casting or specialist referral. 1