What is the management for thoracic back pain without trauma?

From the Guidelines

For patients with subacute or chronic upper back pain without red flags or prior management, conservative therapy should still be considered first-line. Management for upper back pain without injury typically involves a combination of self-care strategies, physical therapy, and medication, as supported by the American College of Radiology's guidelines for thoracic back pain 1.

Key Components of Conservative Therapy

• Gentle stretching exercises focusing on the upper back, neck, and shoulders for 5-10 minutes daily
• Heat therapy using a heating pad for 15-20 minutes several times daily to relax tight muscles
• Over-the-counter pain relievers like ibuprofen (400-600mg every 6-8 hours) or acetaminophen (500-1000mg every 6 hours) to manage pain and inflammation
• Maintaining good posture throughout the day, especially when sitting for long periods, and considering ergonomic adjustments to the workspace
• Gentle massage of the affected area can also provide relief

When to Seek Further Medical Attention

If pain persists beyond 2-3 weeks or worsens, it is essential to consult a healthcare provider who might recommend physical therapy or prescription muscle relaxants like cyclobenzaprine (5-10mg) or methocarbamol (750mg) for short-term use, as indicated by the most recent guidelines 1.

Rationale for Conservative Approach

The rationale behind starting with conservative management is based on the understanding that imaging is typically not considered useful for patients with subacute or chronic midback pain without neurologic symptoms, as noted in the study published in the Journal of the American College of Radiology 1. This approach prioritizes minimizing unnecessary interventions and focusing on symptom management and lifestyle adjustments to improve quality of life and reduce morbidity associated with upper back pain.

From the FDA Drug Label

Cyclobenzaprine hydrochloride tablets are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions Improvement is manifested by relief of muscle spasm and its associated signs and symptoms, namely, pain, tenderness, limitation of motion, and restriction in activities of daily living The management for upper back pain with no injury may include cyclobenzaprine as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 2, 2.

• Cyclobenzaprine should be used only for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use is not available.
• The goal of treatment is to provide relief of muscle spasm and its associated signs and symptoms, namely, pain, tenderness, limitation of motion, and restriction in activities of daily living.

From the Research

Management for Upper Back Pain without Injury

• The management of upper back pain without injury can be approached through a biopsychosocial framework, which includes lifestyle modifications, nonsteroidal anti-inflammatory drugs, physical therapy, and cognitive behavioral therapy 3.
• Conventional therapies are typically used first, and if pain persists for more than 6 weeks, imaging and specialist referral may be indicated 3.
• For acute neck or back pain with muscle spasm, cyclobenzaprine 5 mg three times daily can be used as monotherapy or in combination with ibuprofen 400 mg or 800 mg three times daily, with all treatments demonstrating significant improvements in patient-rated scales 4.
• Pharmacologic management of acute pain should be tailored to each patient, with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) being first-line treatment options for most patients with acute mild to moderate pain 5.
• Topical NSAIDs are recommended for non-low back, musculoskeletal injuries, while acetaminophen is well tolerated but should be used with caution in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 5.
• Ibuprofen has been shown to be consistently superior to paracetamol at conventional doses in a range of painful conditions, including acute post-operative pain, dysmenorrhoea, tension-type headache, migraine, osteoarthritis, and rheumatoid arthritis 6.

Treatment Options

• Acetaminophen: can be used as a first-line option for patients with acute low back pain, with comparable analgesic effects to loxoprofen 7.
• Ibuprofen: can be used as a first-line option for patients with acute mild to moderate pain, with superior efficacy to paracetamol in a range of painful conditions 6.
• Cyclobenzaprine: can be used as monotherapy or in combination with ibuprofen for acute neck or back pain with muscle spasm 4.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): can be used as first-line treatment options for most patients with acute mild to moderate pain, but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 5.