This phase is normally the first 24-72 hours after the symptoms start and its aim is to settle any pain whilst maintaining the range of motion and function you have. 

When performing the exercises it is OK for there to be a little discomfort or the sensation of stretching to occur. Any feeling of discomfort should settle within 30 minutes of performing the movements, and over time the exercises will become easier. If you experience any sharp pain, attempt another exercise in the phase, and reattempt this movement at another time. Perhaps reducing the range you perform the movement or the amount of repetitions will help your symptoms. Remember the aim is to perform some mobility as this will help the middle back to return to its normal function.

Medication

In the initial phase the use of over the counter medication may be an option. Medications such as simple pain relief and anti-inflammatories may allow the condition to be more manageable.  Please consult your family doctor if you have any concerns with this impacting your current medication, or if any medical history may be impacted by the option of including this medication.

Wheat Bag

Depending on the level of discomfort in your middle back and loss of range, you may find it helpful to use a wheat bag to ease any irritation and also help with any muscle spasm in the area. The heat generated from the wheat bag may help reduce any tightness in the muscles of the middle back which can go into spasm as they try to protect the area, and may act as a middle back pain relief. Using the wheat bag two to three times during the day, especially applied before performing the mobility exercise may make things a little easier. Be careful the bag isn’t too hot and check your skin for any signs of a reaction.

Exercises

The focus of the exercises in this phase is to maintain the movement you have in your middle, whilst trying to ensure the muscles and joints surrounding the middle back remain as mobile as possible.  

With middle back pain it's quite common for the surrounding muscles and joints to tighten up which can result in further discomfort.  You also may find that any reduction in movement has a knock on effect to the neck or lower back as you are generally less active, and the muscles connecting between the middle back and other areas of the spine can also tighten up. We have included some basic neck and lower back mobility exercises which will hopefully address this, and will show you how to relieve middle back pain.    

In some of the exercises you will see the term ‘thoracic’ used. This is the scientific name for the middle part of your back. 

Some things to consider with the exercises:

• The first exercise is to ensure our neck mobility remains full. Simply perform 8-12 reps in each direction in a slow controlled manner. If there are any directions which are a bit more challenging, then you can focus on them to make sure there are no restrictions.
• The second exercise allows for middle back flexion and extension mobility but with a low level of demand, and is one of the best stretches for middle back pain. If you notice middle back pain when bending over, improving your middle back mobility may help with this activity. 
• The final exercise is focusing on your lower back range of movement. This exercise will still have an impact on your middle back so build up the range and intensity slowly. 
• How long and how often you do the exercises at this stage is not too important. The key is little and often, and as long as you get something done every couple of hours to maintain the range that will be beneficial. 
• You may find it helpful to do these exercises in a circuit type fashion, where you start off with exercise 1, have a rest, complete exercise 2 followed by a rest, continue this pattern until you complete all the exercises, and then restart.

This phase we are looking at increasing the middle back mobility exercises whilst still being mindful that certain movements could still be irritable, along with introducing a strength exercise to help with any muscle strain. This will be roughly the first 2-4 weeks of your rehab.

Education

When someone is suffering middle back pain it can be difficult not to irritate it with daily activities, such as picking items off the floor or simply standing up from a chair. Try initially to avoid repeatedly performing movements or tasks which constantly aggravate your symptoms. As the middle back pain settles down these irritations will become less frequent, but you may have to initially adapt how you perform certain tasks. There will be some activities which you cannot avoid and others which it takes you by surprise, don’t be too hard on yourself here as sometimes it is unavoidable. But where you can, try and reduce activities which will repeatedly cause you pain. 

As you improve the range of movement in your middle back, you should find that your general mobility improves throughout the day, and the direction which was causing you the most irritation will also settle. As you become less irritable with these movements you will be irritating the stiff joint less, which will cause your symptoms to settle over time.

If the exercises make things worse you should stop doing them and make an appointment with your family doctor or physiotherapist to ensure you are doing the right exercises, as they could in fact be making things worse.  If you do not experience any increase in pain then you are OK to continue.

You also need to be aware if the pain changes by becoming constant or not reducing with medication or exercise, or perhaps you start noticing other symptoms which are not common with musculoskeletal injuries, such as a fever, unexplained weight loss or any changes in the structure of your spine. If you notice any of these symptoms, this is when to see a doctor for middle back pain. 

The aim for these first few weeks is to make sure we gain full movement in the middle back, you should find that as this improves your symptoms will settle. 

The timelines here are merely a guide and you may find you can progress from this phase before 2 weeks, but equally it may take longer than 4 weeks, and this will depend on the level of restriction and the amount of tissue damage caused. A good marker on when to progress to Phase 3 is when you can perform the exercises pain free.  

There will be some movements which you find easy and may even offer some relief in the discomfort you are experiencing, others may be more challenging. You may also find it helpful to offer some variety on the angle you perform these exercises as it may make things a little easier. The point here is there is no set way to perform mobility exercises, and no two days will be the same. Don’t get discouraged by this and just make sure that you get something done at least once a day. 

These movements shouldn’t cause any spike in pain, but a little bit of discomfort is expected as you move into the restricted range.

Exercises

The aim of these exercises is to offer some basic mobility to the middle back without increasing your pain. Remember to start off easy and only increase the range after performing a few reps of each movement as a warm up. 

You can continue the neck and lower back mobility exercises from Phase 1 but it is likely that these would have less benefit as time moves on, and if you don’t notice any restrictions, you can stop these exercises altogether. 

Some things to consider with the exercises:

• The side lying thoracic rotation is an easy way to maintain movement in your spine without putting it under too much pressure. Perform these in both directions and they can act as perhaps one of the best exercises for middle back pain.
• The second exercise is a similar movement you did on the previous phase but a progression. It is working on the extension of the middle back and aims to move the joints further into the end of range. You could perform the flexion and extension exercise from the previous phase as a warm up to make it easier. 
• The final exercise ensures that the muscles on the back remain strong. When you perform this movement these muscles will need to contract to stabilise the movement. If initially this causes the muscles to go into spasm around the middle of your back, instead perform this with a lighter resistance band or less tension, or perhaps give it a few days rest before reattempting. If you notice middle back pain after lifting, strengthening these muscles may help with this activity.
• You may find it helpful to do these exercises in a circuit type fashion, where you start off with exercise 1, have a rest, complete exercise 2 followed by a rest, continue this pattern until you complete all the exercises, and then restart.

Acupuncture

Both Western and Chinese acupuncture may be helpful in this stage to alleviate some muscular tightness you may be experiencing. There could also be a place for acupuncture should you be struggling with sleep as it has been shown to aid sleep later in the day after the session. However, any joint tightness will not be affected by acupuncture alone, and the exercises will be best placed for this. Contacting your local acupuncturist who is appropriately trained may help you here if progress is slow.

Strapping

Kinesiology strapping is very popular for many musculoskeletal injuries. The idea is that the tape helps support the muscles and tendons at the point of pain, and therefore causes less pain when doing exercises or general daily activities. The evidence for kinesiology strapping is mixed, and because of that some people find it’s really helpful whereas others find it doesn’t offer them much at all. 

If you feel you are struggling to progress, or you feel your rehab is a little stagnant, or that general daily activities are still irritable, then it may be helpful to try this. 

You can leave the tape on for up to 5-7 days but at any point if it feels hot and itchy take it off straight away. Have a day's rest of no tape before reapplying, and ideally test with a small strip before applying a big amount to you. 

This video shows a general strapping method which you may find helpful in offering some support to the middle back muscles which may make daily activities and these new exercises less painful.

It’s likely that used alongside some of the other treatment methods it may offer some relief, but realistically on its own will not help completely alleviate your pain.

Symptoms

During this phase your symptoms whilst resting should start to settle and generally you will only find an increase in pain when performing movements which are restricted. You will also notice that general daily activities which were once limited, will slowly become a little easier. 

If you are struggling to progress through this phase, or you are experiencing middle back pain when breathing, middle back pain when coughing, or middle back pain when sneezing, it may be helpful to seek a face-to-face medical appointment. Equally if you have middle back pain during pregnancy, have middle back pain radiating to chest, or middle back pain and digestive issues, these would be markers of when to see a doctor about middle back pain. This will ensure you are on the right path and if required, so hands on treatment may be needed to help with your recovery. If however your symptoms are reducing and function improving, you can continue with this programme and onwards onto Phase 3 when you are ready.

Pacing

At this stage you should find you can do more day-to-day activities pain free. The temptation here is to go a bit overboard. A nice reminder to pace activities so that you don’t over do it, and that you spread these activities out as much as possible throughout the day.

This phase will be roughly 4 weeks from the start of your rehab and its aim is to build on the increased middle back range from Phase 2.

Education

A good marker on when to progress onto this phase is when your middle back mobility exercises from the previous phase are pain free. At this stage the pain in your middle back should have settled but it is not uncommon that certain movements could still be irritable. We will address any potential further loss of range or strength in this phase. 

The timelines on when to start this phase are only a guide, where some people can start before the 4 weeks but others may take a little longer. 

After a period of reduced activity due to the pain you have been experiencing, you would expect there to be a general loss in strength in your back muscles. We will continue one of the strength exercises from the previous phase but you should begin to increase in the resistance to make it more challenging. 

The mobility exercises from Phase 2 may help act as a warm up before performing the more challenging movements of the new exercises.

Exercises

In this phase we have increased the sets you complete for each exercise, along with progressively making certain movements more challenging. 

Some things to consider with the exercises:

• The first exercise is a progression from the rotation exercise you performed in the previous phase. This is now performed in sitting so there will be more load going through the joints so it may be a little harder. You could perform the rotational exercise from the previous phase as a warm up to make it easier. 
• The second exercise has continued from the previous phase, and aims to maintain the strength of the muscles of the back.  Aim to increase the resistance from what you were doing in the previous phase by either using a band with greater resistance, or simply standing further away from your anchor point. 
• The final exercise is a progression from the previous phase aiming to work your middle back into extension. If this becomes challenging you can progress onto this after a few more days recovery. You can also complete this movement sitting on a chair which has a low back rest to lean over. The benefit of this exercise with the foam roller is you can focus specific joints on your middle back to mobilise, and as your symptoms have settled you should have more confidence to move up and down your middle back targeting specific areas.
• You may find it helpful to do these exercises in a circuit type fashion, where you start off with exercise 1, have a rest, complete exercise 2 followed by a rest, continue this pattern until you complete all the exercises, and then restart.

This phase would be roughly 8 weeks from the start of your rehab.

Education

This phase may not be appropriate for everyone and if you can perform all your daily activities pain free and have no intention of returning to sport, you can stop at Phase 3. However after a period of reduced activity you would expect your general strength to be reduced, so it may help with certain activities you are struggling with. 

If you intend to return to sport you should continue with these exercises. 

Similar to Phase 3 the timelines here are merely a guideline and may vary. You may find that you are able to start this phase before 8 weeks if the symptoms have settled and you aren’t challenged by the exercises.

You should continue the mobility exercises from Phase 3, with the aim to maintain full range of motion. However you would not necessarily need to do as many sets as you previously did, and you may not need to do all the mobility movements every day, you could potentially alternate which days you perform certain movements. 

The aim in this phase is to increase the strengthening exercises through range.

Exercises

You should continue the mobility exercises from Phase 3, and you can use the exercises from Phase 3 as a warm up before attempting these new exercises. 

The focus of these exercises is to further challenge the strength of the shoulder and neck muscles, and introduce some strength work with your arms above your head. 

Some points to consider with the exercises. 

• All the strength exercises should be performed in a slow and controlled manner. 
• The second exercise will be working the muscles in your back and as it is single leg will be more challenging. If this is too difficult you can perform this movement on two legs to start with. 
• The final exercise should be performed one arm at a time. This will challenge the muscles in your back and help bring the middle back portion of your spine into extension under load. You can also complete this exercise using a dumbbell. 
• These exercises should not cause a spike of pain, but you may find that there is a bit of discomfort for roughly 30 minutes after exercising, which is OK.

Return to Sport or Activity

Depending on your sport or activity of choice, you may want to perform some upper body weight bearing exercises such as a plank or press ups. It may also be suitable to do higher level dumbbell strengthening exercises to further increase your strength. 

As a general rule, try and aim for two pain-free training sessions at a reduced duration or intensity before increasing. 

For example, if you normally play 60 minutes of tennis, aim to play for 30 minutes in a non-competitive environment for two non-consecutive days. 

Having a day's rest between sessions allows you to have appropriate rest and for your body to repair and become stronger. 

Once you have found a duration or intensity you can tolerate with no flare up, aim to increase the next session by 10%. This can seem like a slow and conservative process however the research has shown this is the optimum level of increase to avoid an overuse injury. Increasing duration or intensity by more than 10% significantly increases your chance of injury, so only increase one or the other by this amount. As you will have been away from your sport for a number of months, you will have lost some of your fitness conditioning in this time and will need to build up slowly.

Over time you will be able to slowly return to your pre-injury level of activity without regressing back to any acute flare-up.