Treatment of Chronic Myofascial Back Pain
Initial Nonpharmacologic Treatment
- The American College of Physicians recommends beginning 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
- Exercise therapy demonstrates good evidence of moderate efficacy and should be the cornerstone of treatment for chronic myofascial back pain, with the specific type of exercise mattering less than patient adherence 1, 2, 3
- Motor control exercise 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 2, 4
- Applying superficial heat, such as heat wraps, provides moderate pain relief and disability reduction, with moderate-quality evidence showing heat wraps moderately improve pain at 5 days and disability at 4 days compared to placebo 2, 4
- Combining heat with exercise provides greater pain relief than exercise alone 2, 4
- Massage therapy, including deep tissue massage, myofascial release techniques, and spray-and-stretch methods, shows moderate effectiveness for chronic myofascial back pain 1
- Spinal manipulation provides moderate effectiveness for pain relief and functional improvement 1, 2
- Cognitive-behavioral therapy demonstrates good evidence of moderate efficacy for addressing psychosocial factors that complicate chronic myofascial pain 1, 3
- Yoga, particularly Iyengar yoga, results in moderately lower pain scores and improved function at 24 weeks compared to usual care 1, 4
- Tai chi produces moderate pain improvement compared to wait-list controls 1, 4
Pharmacologic Treatment
- The American College of Physicians recommends adding NSAIDs, such as naproxen or ibuprofen, as first-line pharmacologic therapy for patients with inadequate response to nonpharmacologic therapy 1, 6
- Topical NSAIDs or topical lidocaine can be applied directly to painful trigger point areas 5
- Tramadol or duloxetine can be added if NSAIDs provide inadequate response, starting at 30 mg daily and titrating to 60 mg daily 1, 6
- Tricyclic antidepressants, such as amitriptyline 10-25 mg at bedtime, can be considered as part of a multimodal strategy 1, 5
Advanced Interventions
- Low-level laser therapy combined with NSAIDs largely decreases pain intensity and moderately improves function 4
- Intensive multidisciplinary rehabilitation combining physical, psychological, and educational interventions is moderately effective for chronic low back pain 1, 3
Critical Pitfalls to Avoid
- Bed rest should not be prescribed as it leads to deconditioning and worsens outcomes, and patients should be encouraged to remain active 1, 6
- Routine imaging for nonspecific myofascial back pain should be avoided as findings are often nonspecific and do not improve outcomes 1, 6
- TENS should not be used as it shows no difference compared to sham TENS for pain intensity or function 1, 2
- Lumbar supports should be avoided as they have not shown clear benefits for chronic back pain 2, 4
- Interventional procedures such as epidural injections, radiofrequency ablation, and joint injections should be strongly avoided as they lack evidence of benefit 6