Vitamin D and Musculoskeletal Pain: Part I

Written By: admin - Jun• 22•10

A few months back I came across a fascinating and important document.  I was so impressed with the work that I contacted its author, Dr. Stewart Leavitt, PhD and asked him if he cared to be interviewed on the subject on the Skeptic’s Health Journal Club, to which he graciously obliged.  Previously I had not run into any serious technical difficulties blogging and was not dismayed that I had no idea how to record a phone call.  I did know I wanted to record it digitally, as I had visions of podcasts and happy Journal Club readers listening to the latest interviews and breaking news on their morning commutes, dancing through my head.  As the time for the interview drew nearer I realized I had no idea how to digitally record a phone call, but being fairly good with computers (or stupid) I was not dismayed.  Eventually I jury rigged something involving a Magicjack phone, computer speakers and some third party software.  Suffice it to say the attempted phone call sounded like something akin to the drum solo in “Inagadadavida.”  However, Dr. Leavitt was kind enough to call me back on my cell phone and take an hour out of his day to chat about vitamin D and blogging in general.  As this was a bit of an awkward and embarrassing “interview” I kept meaning to get back to the topic but put it off for a time, after which, as readers here may know I broke my hand, which again put a damper on things.  However, finally at this time I want to return to what I believe is a tremendously important topic.

Vitamin D is turning out to be quite the “miracle drug.”  One can almost here a patent medicine salesman from days gone by,

“Step right up, step right up, get your miracle elixir of vitamin D, do you suffer from colds, suffer no more as this little bottle of goodness from the sun is the bane of the common cold and all the infectious scourges of mankind.  Are your bones weak and frail get strong and healthy bones from the same bottle only $10 for a three month supply.  This little wonder puts to flight the risk of cancer, diabetes, heart disease, why it may even cheer you up if you’re feeling blue.” 

Probably would have run him out on a rail.  Oddly, there is a significant, accumulating and strong evidential basis that correcting vitamin D deficiency has a very beneficial effect in all these areas, resistance to infection, cancer, diabetes, heart disease and even additional benefits.  I will dig out references if anyone is interested, however this is not our topic for discussion today.  Instead there is yet another quite large benefit from vitamin D that has been for the most part neglected even on the cutting edge vitamin D websites such as the Vitamin D Council and Grassroots vitamin D, namely, the role of vitamin D in pain management and more specifically in musculoskeletal pain syndromes.

Dr. Leavitt is quite qualified to write on this topic as both someone who has been involved in clinical pain management for many years and as an author of  numerous peer-reviewed articles in the field.  What caught my eye however was a 50 some page document that Dr. Leavitt has compiled for us examining the state of research on vitamin D in pain management.  While this lengthy document was not published in the medical literature it was peer-reviewed, and by more, and likely more qualified individuals than an average journal submission. As I spend a great deal of my time on this site pointing out the, to my vantage, erroneous positions and glaring errors often seen in conventional medical opinion I will stop now with touting the clear credentials of the document and begin to look at the actual reasoning and findings, however, suffice it to say that from a conventional medical perspective this is an authoritative document.

In addition to this lengthy document, Dr. Leavitt has also put together a synopsis of the document as well as a patient hand-out.  However, neither to my mind does sufficient justice to the impact of the full document or perhaps I wish to emphasize different points.  To begin to get a sense of the significance for what Dr. Leavitt is getting at here it is perhaps first worthwhile to consider the scope of the problem.  As is noted, perhaps somewhat commonsensically, in the practitioner guideline to the research, pain is the most common complaint leading patients to seek medical care.  Certainly, analgesics of one form or another, have proven themselves to be both legal and illegal “blockbuster” drugs.  Recent fiascoes as seen with Vioxx have shown that the regulatory system is no firewall to extremely harmful therapies making it to market for treatment of pain.  More specifically as is noted in the introduction,

“In the United States, more than half of all adults participating in surveys have reported longterm persistent or intermittent pain, with the lower and upper back, neck, shoulders, hips, and knees mentioned most frequently [APF 2007; NPF 2008; Watkins et al. 2008]. For lower-back pain alone, an annual incidence of 50% and a lifetime prevalence of up to 80% have been reported [Nachemson et al. 2000]. In more than 8 out of 10 cases, the causes are nonspecific, without evidence of injury, disease, or neurological or anatomical defect [Deyo 2002; Deyo and Weinstein 2001]. More than a quarter (28%) of patients with chronic pain rate the effectiveness of medical treatments as poor, and most (77%) believe that new options are needed to treat their pain [APF 2007; NPF 2008].

While I have perhaps been more fortunate then many in regards to such pain, I certainly fit in the 80% who has known lower back pain at some point in their life.  Musculoskeletal pain is an enormous medical problem of great clinical significance.  Additionally, while on occasion, there is a clear anatomical abnormality, such as a ruptured vertebral disc that might allow for targeted surgical intervention, likely often as not, there is no clear diagnostic abnormality to pinpoint the precise cause of what may be severe pain.  Not infrequently, even this lack of a clear diagnostic signal for intervention is not enough however, to dissuade the surgeon’s knife.

Unlike it’s more recent roles in myriad physiologic processes, vitamin D has been known to be central to bone metabolism for decades.  It mediates these effects, in conjunction with pararthyroid hormone(PTH), in large part by controlling the absorption of calcium from the gut, the urinary excretion of calcium and phosphorus and the absorption or resorption of calcium in bone.

To gain a fuller understanding of this we need to first understand a little bit more about vitamin D metabolism.  When one either eats vitamin D3 or has it produced from the skin in response to sunlight it looks a little something like this

From here the body does something that it does with a number of important regulatory molecules, it tags it in someway to indicate what to do with it.  In this case it tags it in the liver with a hydroxyl (OH) group at position 25 so it now looks like this,

This 25 hydroxyvitamin D is the type that is most common in the blood stream and is the type measured by a vitamin D3 level test.  While 25 hydroxyvitamin D has some physiologic activities, the vast number of receptors and the larger number of activities are modulated only after another OH tag has been added to make 1,25 dihydroxyvitamin D, tag you’re it,
This is the molecule that is believed to bind to the various vitamin D receptors and mediate vitamin D’s many and varied effects.  However, because it is such a powerful and pluripotent molecule it is regulated tightly meaning that its’ half-life is very short, on the order of hours.  So there is little point in measuring blood levels of 1,25 dihyroxyvitamin D as they they will vary greatly from time to time depending on the needs of the moment.  What is important from a health standpoint is if there are enough blood and tissue reserves of 25 hydroxyvitamin D ready to be activated in the kidney to the 1,25 dihydroxy form.
We need to look at just a couple more molecules (well a molecule and an element but you’ll see what I mean) here to see where all this is going.  So one of the useful things that vitamin D does is help to increase the absorption of calcium from the gut.  Calcium, for a number of reasons that we don’t have time to go into, is an important element that needs to be regulated.  So when the body senses that calcium in the blood is low it responds by releasing a small polypeptide hormone from the parathyroid glands called, well uh, parathyroid hormone – makes sense huh.  Parathroid hormone in turn tells the kidney to start making more 1,25 hydroxyvitamin D from 25 hydroxyvitamin D so that more calcium will end up over time getting absorbed from the gut.
What happens however, if there isn’t enough 25 hydroxyvitamin D floating around to be activated by the kidney?  Well in this case parathyroid hormone has a last resort option.  It begins robbing calcium from the bone to ensure that calcium levels are kept steady.  This can lead to problems like thinned bones, osteopenia, and soft, malformed bones, osteomalacia.  In other words, in the absence of increased active 1,25 dihydroxyvitamin D correcting the problem, as a last resort the body will begin cannibalizing the skeleton in the same way that a starving individual might cannibalize protein from muscle.
None of this relates to the new “sci-fi” sounding findings of vitamin D’s effects on antimicrobial peptides like the cathelicidins or its modulation of expression of possibly some 2,000 different genes, we really don’t know or fully understand all that vitamin D does, but this stuff about calcium and parathyroid hormone is old hat.  I realize I have gotten far afield of Dr. Leavitt’s review of the literature in this area but I wanted to clearly lay out the basis for vitamin D in bone metabolism before going further.
It seems to me that looking at vitamin D in terms of musculoskeletal pain makes eminent sense as Dr Leavitt further comments,
“it appears that soothing the daily musculoskeletal aches and pains plaguing many patients may be as simple, well tolerated, and economical as taking a daily supplement of vitamin D. Experts have recommended that vitamin D inadequacy should be considered in the differential diagnosis of all patients with bone or joint pain, myalgia, fibromyalgia, or chronic fatigue syndrome [Shinchuk and Holick 2007]. However, this seems to be unknown or overlooked by many healthcare providers.

While I have laid out the pathophysiology of vitamin D deficiency in bone metabolism you may be like me thinking, well, it really can’t often be that simple, how could this be overlooked?  In part two, next week, we will look at the evidence for it often really being that simple.  As for being overlooked, I know my personal experience. In a recent post I mentioned how I asked my orthopedic surgeon for his views on vitamin D and calcium in terms of my broken hand. While it was quite polite, if I had to summarize the gist of the response was basically along the lines of, “you silly goose, you have a broken bone, why do you care about vitamin D and calcium levels?”  If orthopedic surgeons have nothing intelligent to say about vitamin D and calcium levels in broken bones is it any wonder that no one is talking about this issue in musculoskeletal pain?

You can also read more of Dr Leavitt’s writings on vitamin D and musculoskeletal pain as well as other related topics at his website pain-topics.org.

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4 Comments

  1. suZen says:

    Interesting though not surprising and I swear Paul, it's the simple things that have been ignored that need to be brought to light. Thank you for doing that!!!!

    Now Paul, am I going to triple my Vit. D just to read the itsy bitsy print type of your quoted material, or get a screen magnifier? :)
    Suzen

  2. PDM says:

    Yea that's lot's of what I'm getting at in a complicated way!

    You don't need to triple the vitamin D or A for that matter, I'll skip the small font. You know "control +" increases the font size (at least with firefox) can get rid of lots of adds too

  3. Anonymous says:

    Very good sharing this.

  4. Anonymous says:

    Is there a correlation between low levels of vitamin D and Hypothyroid conditions?

    Oldphart in Kansas