Low Vitamin D Level and Chronic Pain   Frank Barnhill M.D.

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A study published in the November 2008 issue of the medical journal Pain Medicine has suggested a strong link between chronic muscle and bone pain and low levels of vitamin D or cholecalciferol.

In the study quoted, patients accepted into the Mayo Clinic Comprehensive Pain Rehabilitation Center were tested for vitamin D levels at time of admission. The researchers found that patients suffering significant levels of pain, also suffered low levels of vitamin D. In addition, when compared with pain clinic patients with normal vitamin D levels, patients with very low vitamin D levels reported more physical disability, emotional distress and a worse overall health perception.

Surprisingly, patients with chronic pain who also had low vitamin D levels required nearly twice as much narcotic pain medication.

The study cited vitamin D levels below 20 ng/ml (nanograms per milliliter) as being low or inadequate.

Causes of low vitamin D level include:

Inadequate dietary intake (in the U.S. milk of one of the best sources of vitamin D)

Having skin with darker pigmentation which limits ultraviolet radiation absorption (UVB exposure is required to convert vitamin D in our skin to its active form)

No or limited exposure to “natural sunlight” or ultraviolet B radiation

Your body uses vitamin D to regulate calcium and phosphorous metabolism and promote normal growth and repair of bone. Vitamin D in the foods you eat is converted to the “active form”, vitamin D3 or cholecalciferol, when UVB ultraviolet light and basic vitamin D interact in your skin.

Your skin has several outer layers that serve to protect the blood vessels, nerves and other cells, which lie beneath. It’s in the base of this outer layer called the “epidermis” that most of the conversion of “plain vitamin D” to vitamin D3 occurs.

In addition, epidermal layers closer to the surface contain melanin, the pigment that gives our skin closer. Melanin serves to protect all of those sensitive structures in the deeper part of our skin from excessive radiation. So, as a general rule, the darker our skin, the more difficult it is for sunlight to interact and convert vitamin D to its active form.

Those of us with calcium, phosphorus and vitamin D deficiencies are often plagued with osteoporosis, fragile bones, poor dentition and problems with our muscles. Advocates of natural medicine feel that deficiencies in these three muscle-bone metabolites contributed to disorders like fibromyalgia. (A word of caution: no studies have been done to conclusively prove this association!)

Since these studies are relatively new, there aren’t a lot of examples of vitamin D helping pain in a person with fibromyalgia and similar muscle disorders. However, I’ve long suspected muscle diseases were associated nutritional deficiencies and have been treating several patients with vitamin and mineral supplements.

Here is Jeanne’s story:

At age 32, Jeanne started experiencing morning stiffness, feelings of swelling and fullness in her shoulder-arm-back-thigh muscles and easy fatigue. A rheumatologist diagnosed her as having a non-specific muscle disorder (myalgias) when all of her blood tests and nerve studies were found to be normal.

Here are the conditions for which she was tested:

Rheumatoid arthritis

Sedimentation rate (chronic inflammation)


Lupus Erythematosis

Lyme Disease

Chronic mononucleosis

Vitamin B12 deficiency

Thiamine deficiency

Rocky Mountain Spotted Fever


Typhus/ borrelia

Lead toxicity

Chronic street drug abuse

By age 36, despite therapy with muscle relaxants, anti-inflamatories, gabapentin and non-narcotic pain medications, Jeanne was clearly much worse. She was so stiff in the mornings, she could hardly get out of bed. On cold days, nothing seemed to work right and she stayed wrapped in blankets by a space heater.

I referred her to another rheumatologist and this time he agreed Jeanne had “fibromyalgia”. Of course, he warned her there was no know cure for the disease and simply changed her muscle relaxants and offered her narcotic pain relievers to use when the pain was “unbearable”.

By the age of 38, Jeanne developed a major depression because she “wasn’t able to live a normal life”. She started “citalopram”, a serotonin enhancing antidepressant, and even though her depression started “lightening up” in about 10 weeks, her pain worsened. Within a few short weeks, she had progressed to walking with a cane for balance, to a rolling walker out of necessity.

It was obvious things were getting rotten , so I discussed “alternative therapies with her and she agreed to try “targeted” vitamin-mineral supplements since nothing else appeared to be working. We started daily maximal doses of all of the B vitamins, vitamin C, vitamin D, folic acid, zinc, calcium, selenium, iron, and omega fatty acids (fish oils) and I asked her to be patient as we waited on further blood tests.

A few days later, Jeanne’s vitamin D test came back as abnormal at 14 ng/ml (nanograms per milliliter). I increased her vitamin D3 supplements and stressed patience again. Nothing was going to happen in less than 10 to 12 weeks.

She reluctantly agreed to start a water aerobic exercise program at the local YMCA, even though the pain was almost unbearable at times. I asked her to wear “long johns” (insulated underwear) to bed at night and if her hands and feet were cold or blue, to add gloves and thick socks.

All of that was about 20 weeks ago.

Ten weeks ago, Jeanne returned to my office without the walker. She was once again using the cane, but she was happy to be able to walk without “that thing”. Her pain levels were much more tolerable and she thought her joint stiffness was about 25% less.

When I saw Jeanne again last week, she didn’t have the cane and was walking “normally”. She said her stiffness and muscle aches were maybe 50% better and she was only using about 75% of her pain medications compared to just six months ago. She was clearly optimistic that she would further improve and her depression was somewhat better. She was enjoying life much more and could define her limitations and knew when to stop if her pain intensified.

I consider our “therapeutic trial” to be a success thus far. When it comes to chronic pain and disability, a successful therapy is one in which pain and suffering have been reduced at least 50% of the time. Jeanne was close to that “magic number”.

Does this mean that vitamin D helped Jeanne?

I don’t know that for sure, but I do believe all of the vitamins and supplements together with aerobic exercise probably contributed to her improvement.

There are studies that indicate aerobic exercise, such as water resistance walking, improves quality of life in persons with muscle and joint disorders. Some of my patients have indeed improved using water-based exercise with non-narcotic pain medications.

However, my preliminary opinion is that Jeanne has improved faster and experienced less pain and disability as compared to those patients.

As far as nutritional therapy and all of my other fibromyalgia patients go, all of us will just have to wait patiently. The jury is still out.

In the meantime, we’ll also keep a close eye on Jeanne and I’ll let you know!

Let me re-emphasize this point:

Currently, no studies have conclusively shown inadequate Vitamin D levels cause or sustain chronic pain cycles. It’s seems highly likely that persons suffering from long-standing muscle or bone pain would benefit from taking vitamin D if their blood levels are low. In addition, testing for other vitamin and mineral deficiencies should be done in anyone suffering chronic muscle and joint problems.

Dr. Frank

References: Pain Medicine 2008;9:979

U.S. National Institutes of Health

These health tips are offered for your common sense use and are not intended to take the place of a visit to your doctor.  Your use of the materials implies your understanding that nothing herein contained represents individual medical advice.

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