Re: Screen for vitamin-D deficiency in all patients with persistent, nonspecific musculoskeletal pain

[Guest guest]

It's about time! Alternative doctors have been saying this for years. I

hope the rest of the medical professionals read this. Thanks for sending it

.

a

> Rheumawire

> Dec 16, 2003

>

> Screen for vitamin-D deficiency in all patients with persistent,

> nonspecific musculoskeletal pain

>

> Rochester, MN - Screening all patients presenting with persistent,

> nonspecific musculoskeletal pain for vitamin-D deficiency should be a

> standard practice in clinical care, say US researchers, writing in the

> December 2003 issue of the Mayo Clinic Proceedings [1]. They report on a

> study carried out at an inner-city primary-care clinic affiliated with

> the University of Minnesota, in which 93% of outpatients presenting with

> such pain were found to be vitamin-D deficient, many severely so. Five

> patients had undetectable levels of vitamin D, and all of the patients

> under 30 years of age (n=33) were deficient.

>

> " These findings are remarkably different from what is taught at medical

> school. We would expect vitamin-D deficiency in old persons or the

> housebound, " says lead researcher Dr Greg Plotnikoff (University of

> Minnesota, Minneapolis; currently at Keio University, Tokyo, Japan). " We

> found the worst vitamin-D deficiency in young personsespecially women of

> childbearing age. We were stunned to find no vitamin D at all in 5

> patients who had been told their pain was 'all in their head.' "

>

> All of the patients were at risk of misdiagnosis and suboptimal

> treatment of their pain condition, the researchers note. Severe

> deficiency of vitamin D is not asymptomatic, they comment: it results in

> a syndrome of persistent, nonspecific musculoskeletal pain, even before

> the clinical manifestation of osteomalacia bone pain.

>

> Vitamin-D deficiency causes muscle weakness and muscle aches and pains

> in both adults and children, comments Dr Holick (Boston

> University School of Medicine, MA) in an accompanying editorial [2]. The

> lack of vitamin D leads, via parathyroid hormone and calcium, to

> inadequate mineralization of the bone, so that the collagen matrix

> becomes rubbery, and in hydrating and expanding it exerts an outward

> pressure on sensory nerves. " This is the likely explanation of why

> patients with osteomalacia often experience a dull, unrelenting aching

> sensation in their bones, " Holick says, but he points out that " these

> symptoms are either dismissed or misdiagnosed as fibromyalgia by many

> physicians. "

>

> " A physical examination that includes application of minimal pressure

> with the thumb or forefinger on the sternum, anterior tibia, or radius

> and ulna often will elicit pain and discomfort, which is a helpful

> diagnostic sign for osteomalacia, " he adds.

>

> Plotnikoff et al's finding of vitamin D deficiency is " newsworthy " but

> is not unexpected, Holick comments in the editorial, citing several

> other recent studies that have found vitamin-D deficiency in US

> populations. " It is inconceivable with all the advances in modern

> medicine that vitamin-D deficiency should be a health concern in the

> US, " he writes. Most physicians assume that vitamin-D deficiency, which

> plagued children in the 17th through 19th centuries, has been

> eradicated, but it has again become a major health problem for all ages

> and races.

>

> There are a multitude of reasons for this, he comments. Extremely few

> foods naturally contain vitamin D, and fortification of foodstuffs with

> the vitamin was abandoned after an outbreak of vitamin-D intoxication

> during the 1950s (in a limited number of children in the UK). Most

> vitamin D (90% or more) comes from exposure to sunlight, but this has

> been discouraged in recent years by health-education messages aimed at

> preventing skin cancer. Some of these advise avoiding all direct

> exposure to the sun and always using a sunscreen when outdoors, but a

> sun protection factor of 8 reduces the capacity of the skin to produce

> vitamin D by 95%, Holick points out.

>

> All physicians should be alert to vitamin-D deficiency, Holick says.

> Patients should have their vitamin-D status tested once a year,

> preferably at the end of the fall season, to ensure that they do not

> become vitamin-D deficient before winter.

>

> Plotnikoff et al investigated 150 patients (ranging from 10 to 65 years

> old) who presented with persistent, nonspecific musculoskeletal pain.

> None of these patients had fibromyalgia, temporomandibular disorder, or

> complex regional pain syndrome, and none had any known medical condition

> that would interfere with the production or absorption of vitamin D,

> they note.

>

> They measured serum levels of 25-hydroxyvitamin D, a standard marker for

> vitamin-D status. As there is no universal consensus about what level

> constitutes vitamin-D deficiency, the researchers used a physiological

> definition of 20 ng/mL (50 nmol/L) or lessbelow this, serum levels of

> parathyroid hormone (PTH) increase, and even slight increases in serum

> PTH result in increased bone turnover and accelerated bone loss.

>

> Overall, 140 of 150 patients (93%) were found to have deficient levels

> of vitamin D, regardless of immigrant status, sex, race, or season. Mean

> serum levels of 25-hydroxyvitamin D were 12.08 ng/mL, which is in the

> moderately severe to moderately deficient range, the researchers

> comment.

>

> Previous studies have identified vitamin-D deficiency in immigrant

> populations, they note. In their own study, just over half of the

> patients were from immigrant populations. Among these, vitamin-D

> deficiency was found in all (100%) of the East African (n=34) and

> Hispanic (n=5) individuals and in 89% (39/44) of Southeastern Asians.

> The researchers comment that, unexpectedly, they also found vitamin-D

> deficiency in all of the African American (n=22) and American Indian

> (n=10) individuals and in 83% (29/35) of white patients.

>

> The degree of severity of vitamin-D deficiency was inversely

> disproportionate by age groups. All of the younger patients (6 of whom

> were aged 10 to 19, 27 aged 20 to 29) were deficient and had

> significantly lower levels of serum 25-hydroxyvitamin D (mean 9.18

> ng/mL) than those aged 50 or more (mean 13.3 ng/mL). These young adults

> are at high risk of failure to develop optimal peak bone mass, the

> researchers comment. Women of childbearing age had significantly lower

> levels (mean 9.56 ng/mL) than older women (14.09 ng/mL), and the level

> of deficiency found in these younger women puts them at risk of bearing

> children with adverse fetal effects or severe neonatal illness. Nearly

> half of these younger women were severely or profoundly vitamin-D

> deficient, they note. Men were equally deficient (mean 11.72 ng/mL),

> even though they accounted for only 29% (44/150) of the study

> participants.

>

> Of the 5 patients who had undetectable levels of 25-hydroxyvitamin D, 4

> were under 35 years of age and 3 were nonimmigrants (1 was a white

> 23-year-old female, 2 were African American). All of these patients had

> had extensive contact with the healthcare system and had been variously

> diagnosed with dysthymia, joint disease, stress reaction, and/or major

> depressive disorder; all were taking nonsteroidal anti-inflammatory

> drugs (NSAIDs), and 2 were also on antidepressants. In none of these

> patients was osteomalacia suspected.

>

> Discussing the limitations of their study, Plotnikoff et al point out

> that they took only 1 measurement and investigated only patients with

> nonspecific musculoskeletal painthey did not have matched controls in

> the general population. They also note that the level of vitamin D found

> in their study is much lower than those reported in other studies, even

> in 1 study that looked specifically at patients with painful conditions

> (fibromyalgia and systemic lupus erythematosus) and was conducted at a

> geographically similar latitude (and hence similar sunshine levels).

> Nevertheless, the findings may reflect the background prevalence of

> hypovitaminosis D, and the presence of nearly universal hypovitaminosis

> D in Minnesota cannot be ruled out, the researchers caution.

>

> " These results support screening of all outpatients with persistent,

> nonspecific musculoskeletal pain for hypovitaminosis D. These patients

> are at high risk for the consequences of unrecognized and untreated

> hypovitaminosis D, " say Plotnikoff et al. The findings of this study

> show that those at risk include populations who have, until now, been

> considered low risk, including nonelderly, nonhousebound, and

> nonimmigrant patients of either sex. Nonimmigrant women of childbearing

> age may be at particularly high risk, they add.

>

> " Because osteomalacia is a known cause of persistent, nonspecific

> musculoskeletal pain, screening all outpatients with such pain for

> hypovitaminosis D should be standard practice in clinical care, " the

> researchers conclude.

>

> " A prospective US trial to assess management of persistent, nonspecific

> pain by prescription vitamin-D replenishment is urgently needed, " they

> add.

>

> " The take-home message from Plotnikoff and Quigley's observations is

> that when patients with nonspecific skeletomuscular pain are evaluated,

> their serum 25-hydroxyvitamin D levels should be obtained, " says Holick

> in the editorial. " Physicians should discard the laboratory-reported

> lower limit of the normal range. A serum 25-hydroxyvitamin D level of at

> least 20 ng/mL is necessary to minimally satisfy the body's vitamin-D

> requirement. Maintenance of a serum level of 25-hydroxyvitamin D of 30

> to 50 ng/mL is preferred. "

>

> Zosia Chustecka

>

> Sources

>

> 1. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in

> patients with persistent, nonspecific musculoskeletal pain. Mayo Clin

> Proc 2003 Dec; 78(12):1463-70.

>

> 2. Holick MF. Vitamin D deficiency: what a pain it is. Mayo Clin Proc

> 2003 Dec; 78(12):1457-9.

>

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