Low Back Pain in Multiple Sclerosis

Low back pain is very common in the general population, but even more so among people with multiple sclerosis (MS). Though many with MS share this aspect of their disease experience, why they do can vary, as causes range from physical changes (such as uncontrolled muscle contractions) to practical challenges (like those related to mobility).

It's also possible for people with MS to experience what healthcare providers call "mixed pain," meaning more than one MS process is causing their low back discomfort.

In addition to the physical challenges of MS recent research indicates that fatigue and mental health conditions such as depression and anxiety are closely associated with significant pain in people with MS.

Likewise, research has shown that lifestyle factors which people with MS and those supporting them can address are also associated with pain. These include tobacco use, fatigue, and an unhealthy diet and insufficient exercise—both of which can contribute to obesity.

The most effective course of treatment must be tailored based on what exactly is responsible for the pain. Research indicates that the percentage of people with MS who experience low back pain could be as high a 41.6%. Addressing both mental health and modifiable lifestyle factors can help to reduce or prevent pain in people with multiple sclerosis.

Spasticity

Spasticity is a common symptom in MS and is mostly caused by demyelination, where nerve signals to muscles are slowed or interrupted. While spasticity technically refers to an increase in muscle tone and uncontrolled muscle contractions, people with spasticity often describe a variety of sensations like:

• Stiffness
• Tugging
• Pulling
• Aching
• Squeezing
• Tightening

Spasticity tends to vary from person to person, like other symptoms of MS. For instance, a person may notice a mild tightening of his or her legs that does not affect daily functioning. Others may experience severe leg spasticity that causes painful cramping that interferes with movement.

While spasticity most commonly affects a person's calves, thighs, groin, and buttocks, it can also cause tightening and aching in and around the joints and lower back.

Prevention and Treatment

Treatment of spasticity that affects your lower back usually entails a combination of both medication and physical therapy. These therapies may include:

• Heat therapy
• Massage therapy
• Physical therapy including stretching and range-of-motion exercises
• Muscle relaxants like Zanaflex (tizanidine) and Fleqsuvy (baclofen oral suspension) 
• A benzodiazepine
• Oral cannabis
• Orthotic devices
• Self-care (exercise, stretching, and relaxation techniques)

Avoiding triggers is, of course, an important way to prevent worsening of your spasticity in your lower back. Examples of triggers that may irritate your spasticity include:

• Heat exposure (the result of which is called the Uthoff phenomenon)
• Sudden changes in position or movement
• Tight or irritating clothing
• A full bladder or bowel
• Infection

People whose spasticity does not respond to the above may require one or more of the following treatments.

FDA approved medications are:

• Lioresal (baclofen), a muscle relaxant and intrathecal baclofen therapy (ITB), in which a pump and catheter are surgically implanted to locally deliver the medication
• Fleqsuvy (baclofen oral suspension)
• Zanaflex (tizanidine)
  

There are other medications that can be used "off label" for treatment in specific situations. These include:

• Diazepam
• Neurontin (gabapentin)
• Botox injections

Lhermitte's Sign

One classic cause of back pain in multiple sclerosis is a phenomenon called Lhermitte's sign, which refers to a shock-like sensation or a "wave of electricity" that moves rapidly from the back of a person's head down through their spine.

This sensation occurs when a person bends their neck forward (for example, when removing a necklace or tying their shoes). The sensation is short-lived and goes away once a person moves their head back up.

Lhermitte's sign is due to MS lesions in the cervical spine, the neck region of the spinal column or backbone.

Prevention

Certain medications, such as the anti-seizure drug called Neurontin (gabapentin) can help prevent the pain from occurring in the first place. Neurontin is generally reserved for those who find Lhermitte's sign to be debilitating.

Muscle and Mobility Problems

Another culprit for low back pain in MS is related to issues stemming from immobility. For instance, if a person with MS is using their cane or another mobility-assistive device improperly, low back pain may develop.

In order to compensate for an MS-related issue like a numb or tingling leg or foot, a person's gait may be impaired, or they may distribute their weight unnaturally, which can put a strain on the lower back. Sitting in a wheelchair all day can also put excess pressure on one's back.

Prevention and Treatment

Strategies to prevent or combat these musculoskeletal causes of low back pain include:

• Proper training on using your specific mobility-assistive device
• Physical therapy
• Heat therapy
• Massage

Nonsteroidal anti-inflammatories (NSAIDs) can also be helpful in the short-term to relieve acute inflammation. That said, be sure to talk to your healthcare provider before taking one. NSAIDs can cause kidney, liver, heart, or stomach problems and are not safe or appropriate for everyone.

There is limited research on the benefit of cannabidiol (CBD) for those with MS. Recent findings indicate that it may improve mobility by reducing spasticity, inflammation, pain, fatigue, and depression. Given that CBD is widely available, those with MS may want to consult their healthcare provider about giving it a try.

When MS Is Not the Cause

It's important to note that a lot of people experience low back pain, regardless of whether or not they have MS. This is why it's essential to undergo a proper diagnosis for your low back pain and not just assume it's from your disease.

Examples of common causes of low back pain in the general population include:

• Sciatica or other lower spine nerve root compression
• Spinal stenosis
• Nonspecific musculoskeletal sprain/strain from trauma or injury

Much less common, but more serious causes of lower back pain include:

• Cancer that has spread to the spine (metastatic cancer)
• Cauda equina syndrome
• Infection (e.g., vertebral osteomyelitis or spinal epidural abscess)
• Compression fracture in the vertebrae (a break in a bone that helps form your backbone); people with MS may be at particular risk for this due to use of corticosteroids

Finally, sometimes a person thinks their pain stems from their lower back when it's actually referred pain, meaning the source of the pain is not in the muscles and ligaments of the back.

Examples of sources of referred pain include:

• Pelvic conditions like pelvic inflammatory disease
• Prostatitis
• Kidney infection
• Herpes zoster
• Abdominal aortic aneurysm
• Digestive tract problems like pancreatitis or peptic ulcer disease

A Word From Verywell

Lower back pain can be debilitating and it may take some trial and error to find the right treatment, but in most cases your healthcare provider can find ways to help you feel better, both physically and mentally.

Be upfront about your pain, how it has progressed, and what seems to make it worse, and be sure to mention any other symptoms you are experiencing, even if they seem unrelated.