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Vit. D and Chronic Low Back Pain

PostPosted: Mon Jun 04, 2007 5:23 pm
by DrBlood
Hello, I am new to this group. Thank you in advance for allowing me to join.

One thing that I wanted to bring to light, if it has not been posted elsewhere, is what newer research is stating on Vitamin D and back pain.

If anyone is suffering from chronic low back pain of unknown origin and is not able to shake it, Vit. D deficiency is a possible culprit. There are a couple good published papers on the topic. There is one in Spine Journal, a very prestigious orthopedic journal, that was published by a couple of MDs. They did blood tests on participants that had chronic low back pain of no apperent cause for 6 months or longer and tested them for Vitamin D levels, among others. The vast majority were vitamin D deficient and were treated only with Vit. D supplementation. Clinical improvement was made in all participants that were vit. d deficient.

Hope you find that interesting.


PostPosted: Mon Jun 04, 2007 7:02 pm
by Dean
Hi DrBlood,

Welcome to the group. I just went to PubMed and did a quick search and came up with two studies that confirm that Vitamin D deficiency can present as chronic low back pain:

Spine. 2003 Jan 15;28(2):177-9.
Vitamin D deficiency and chronic low back pain in Saudi Arabia. Al Faraj S, Al Mutairi K. Department of Medicine, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia.

STUDY DESIGN: Initial assessment involved 360 patients (90% women and 10% men) attending spinal and internal medicine clinics over a 6-year period who had experienced low back pain that had no obvious cause for more than 6 months. The patients ranged in age from 15 to 52 years.

RESULTS: Findings showed that 83% of the study patients (n = 299) had an abnormally low level of vitamin D before treatment with vitamin D supplements. After treatment, clinical improvement in symptoms was seen in all the groups that had a low level of vitamin D, and in 95% of all the patients (n = 341).

CONCLUSIONS: Vitamin D deficiency is a major contributor to chronic low back pain in areas where vitamin D deficiency is endemic. Screening for vitamin D deficiency and treatment with supplements should be mandatory in this setting. Measurement of serum 25-OH cholecalciferol is sensitive and specific for detection of vitamin D deficiency, and hence for presumed osteomalacia in patients with chronic low back pain.

And this second study is also closely related:
Am J Phys Med Rehabil. 2006 Nov;85(11):916-23.
Vitamin D deficiency: implications in the rehabilitation setting.Heath KM, Elovic EP. Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, Newark, New Jersey 07103, USA.

OBJECTIVE: Vitamin D deficiency, which can result from inadequate sun exposure, dietary intake, or problems with absorption, is rarely documented in the rehabilitation literature. Most likely, it is rarely thought of by the rehabilitation profession. This is problematic because vitamin D deficiency can present as musculoskeletal pain, which is commonly seen in both outpatient clinics and inpatient rehabilitation units.

RESULTS: A direct correlation was noted between vitamin D deficiency and musculoskeletal pain. At-risk populations are not acquiring enough vitamin D through sun exposure, and the current recommended daily
allowances from dietary sources including supplements are too low to compensate for this lack of sun exposure. Treatment of vitamin D deficiency produced an increase in muscle strength and a marked decrease in back and lower-limb pain within 6 mos.

CONCLUSION: Vitamin D deficiency should be included in the differential diagnosis in the evaluation of musculoskeletal pain complaints in the rehabilitation setting, and treatment of any identified deficiency should be considered a potentially important component of the treatment regimen.

Thanks for the tip. This should be very simple for a family doctor to check with a blood test... and even simpler to remedy.

For overall general health, I always try to get 15 minutes of sunshine a day and I take a multi-vitamin mineral supplement. They say it's good to get outside even on cloudy days.


PostPosted: Tue Jun 05, 2007 8:07 pm
by DrBlood
Hello again,
Yes, it is a simple blood tests. As written by Faraj, serum 25-OH cholecalciferol is easily obtainable. I beleive in his study he recommended a daily dose of 5000IU (international units) of Vit. D. I always recommend patients take at least 1000IU daily in supplement form and try to get the rest from some gold old fashioned sunshine. Vit. D toxicity is hard to reach. I have seen some studies go as high as 10,000IU daily.

I also recommend that my patients get a hsCRP test for a general inflammatory screening from their PCP or I will do it in my office. New research is pointing to the inflammatory aspect of diet and lifestyle as a cause of pain and disease. Polyunsaturated Fatty Acids (PUFAs), specifically the omega-6 (n6) found in most foods americans eat are pro-inflammatory versus the omega-3 (n3) being anti-inflammatory. Arachidonic acid (AA)(n6) fights over the COX enzyme with eicosopentanoic acid (EPA). If you have excessive n6, AA wins the battle. Hence the need for cox inhibitor NSAIDs.

A group out of LA is trying to make it a law that pain=inflammation. If you are pro-inflammatory by diet and lifestyle, you are also subjecting yourself to any kind of pain as well as the heart disease, diabetes, arthritis, alzheimers, etc, all which are documented inflammatory conditions.

Sorry to bore everyone with that, just some interesting facts on health.

Thanks Again

PostPosted: Sun Aug 12, 2007 6:21 pm
by #1 Dinosaur
Sorry to be so tardy in responding to this, but I'm a relatively new Dean-admirer and although I've explored most of the rest of his site, this is the first time I've waded into the forum.

The study cited above about the possible role of vitamin D in chronic back pain is so seriously flawed as to be laughable. They only studied people with back pain. How do you know that 83% of people WITHOUT back pain don't also have suboptimal vitamin D levels? (hint: you don't.)

It's analogous to MRIs and ruptured disks: it's been estimated that 20% of the population (without back or leg pain) walk around with herniated disks on MRI. The causal relationship is far from clear.

I have no problem with recommending that everyone get sufficient vitamin D, either from sunlight or a supplement. But I'm leery of calling it a primary cause of chronic low back pain. Of those who improved with the addition of supplementation, how do you know they didn't also receive things like PT and rehab which were more likely responsible for their improvement?

Full disclosure: I tend to be generally anti-supplement, given how vitamined up most of our food supply tends to be. I tell my patients, "All they do is give you very expensive urine."

PostPosted: Sun Aug 12, 2007 9:53 pm
by Dean
Hi Dr. Dino,

Welcome, glad to have you join my humble little forum.

You raise a good point here and one I hadn't thought of:

#1 Dinosaur wrote:The study cited above about the possible role of vitamin D in chronic back pain is so seriously flawed as to be laughable. They only studied people with back pain. How do you know that 83% of people WITHOUT back pain don't also have suboptimal vitamin D levels? (hint: you don't.)

It's analogous to MRIs and ruptured disks: it's been estimated that 20% of the population (without back or leg pain) walk around with herniated disks on MRI. The causal relationship is far from clear.

I didn't dwell on the above study for long since it was conducted in Saudi Arabia and thus involved subjects who had extreme Vit. D deficiency probably due to avoidance of the sun. A rare situation for most people.

At one point, I thought about pointing that out lest anyone jump to the Chronic Back Pain = Vit. D Deficiency blunder, but I never did get around to it.

Your argument is a more important point to consider before reading too much into these studies.


PostPosted: Mon Aug 20, 2007 2:54 am
by randolph
The studies DrBlood cites are epidemiological studies; that is, they show a statistical association between two things: somebody gets an intuitive hunch that there might be some relationship between two things, then does a statistical study ... but the statistical study does NOT NECESSARILY reveal a cause-effect relationship. That can only be revealed by further research to discover if, in this case, vitamin D deficiency is related to the biological mechanisms that CAUSE back pain (a MUCH harder thing to discover than doing a statistical study ... which might explain why we seem to love statistical correlations that really prove nothing). Correlation does not imply causation.

Misunderstanding this apparently subtle distinction between these two types of research accounts for lots of medical misunderstanding. One example is the recent hysteria (it caught me for a while), that getting our kids vaccinated exposed them to higher risk of becoming autistic. A statistical link was reported ... and taken by some media to indicate a causal link. Latest research (which also includes clearer, epidemiological examination of the statistical facts) indicates, there is no real relationship ... and the benefits associated with vaccinating our kids still far outweigh the risks.

A better example comes to mind. There is a strong, statistical correlation between folks with sciatica symptoms and their MRIs that reveal bulging/herniated, lower lumbar discs. At first blush, microdiscectomy seems quite a reasonable treatment. But better epidemiological study reveals that lots of folks who are Asymptomatic for sciatica, also have MRIs that show bulging/herniated discs. Add the fact that a significant % of microdiscectomies do not alleviate sciatica symptoms, and ... again ... life is messy as usual. There are enough microdiscectomy "successes" to make it a profitable part of the back pain treatment industry ... but anybody without a financial interest in the facts (like the surgeons), has sufficient reason to question whether the correlation between sciatica symptoms and bulging/herniated discs is also the entire story of what causes sciatica. In my reading of pubmed, Merck's Manual, etc., I still haven't found a discussion of the actual biology that is happening with sciatica ... just a lot of superbly educated guesses. If you're one of the lucky ones who gets better with microdiscectomy, HooptyDo! But what if you aren't? What happened to the power of statistical correlation?

DrDino gives us a valuable warning: the non-medical media frequently gets it wrong when reporting on medical issues ... look for the hidden agenda (especially true of those selling supplements, meds, treatments or biomedical devices) ... and follow the money. Some reporters like Jerome Groopman out of the NYTimes are quite good ... but beware the STATISTICAL report designed to instill fear and doom, and sell you a product to relieve that fear. In the real world, few diseases have just one cause and can be cured by one thing; most diseases are mulitifactorial, and require treatments that are rarely slam-dunks.