The effect of vitamin D repletion and proposed walking program exercise on chronic idiopathic low back pain: a randomized controlled trial

Abstract

Objective The aim was to evaluate the relationship between vitamin D deficiency and chronic idiopathic low-back pain (LBP), and to observe the effect of vitamin D correction and a proposed walking program exercise (WPE) on the severity of LBP.
Patients and methods In this randomized, controlled study, 110 patients (100 with deficiency and 10 with insufficiency of vitamin D3), 95 women and 15 men with chronic idiopathic LBP were randomly assigned to receive either oral vitamin D3 or oral vitamin therapy and a proposed walking program exercise (WPE). Group A included 55 patients, 50 with deficiency and five with insufficiency Group B included 55 patients, 50 with deficiency and five with insufficiency over 3 months. Visual analog scale 0–10 was used to assess the degree of pain intensity.
Results Findings have shown that 100% of the patients included in this study (n=110) (100 deficiencies and 10 insufficiencies) had an abnormally low level of vitamin D before treatment with vitamin D therapy and WPE. By the end of the study, all the 110 patients have normalized their vitamin D level after vitamin D oral therapy and WPE (100%). However, only 49 patients (group A) (44 deficiencies and five insufficiencies) reported disappearance of LBP after vitamin D oral therapy and only 51 patients (group B) (46 deficiencies and five insufficiencies) reported disappearance of LBP after vitamin D oral therapy and WPE so the total number of responders of both groups being 100 (90.9%) cases and the total number of nonresponders of both groups being10 (9.1%)
Conclusion After correction of vitamin D3 over 3 months, the authors found that the chronic LBP has improved. A combination of both (correction of vitamin D3 and WPE) is more beneficial in improving chronic LBP.

Full text

The effect of vitamin D repletion and proposed walking program
exercise on chronic idiopathic low back pain: a randomized
controlled trial
Mohamed Elwan, Mohamed Moneer
Department of Rheumatology and
Rehabilitation, Al-Azhar University, Assiut,
Egypt
Correspondence to Mohamed Elwan Sayed,
MD of Rheumatology and Rehabilitation,
Mallawy Minia, 61631, Egypt.
Tel: +20 862 570 582;
e-mail: drelwan77@yahoo.com
Received: 3 April 2020
Revised: 25 May 2020
Accepted: 7 July 2020
Published: 30 October 2020
Al-Azhar Assiut Medical Journal 2020,
18:325–329
Objective
The aim was to evaluate the relationship between vitamin D deficiency and chronic
idiopathic low-back pain (LBP), and to observe the effect of vitamin D correction and
a proposed walking program exercise (WPE) on the severity of LBP.
Patients and methods
In this randomized, controlled study, 110 patients (100 with deficiency and 10 with
insufficiency of vitamin D3), 95 women and 15 men with chronic idiopathic LBP
were randomly assigned to receive either oral vitamin D3 or oral vitamin therapy
and a proposed walking program exercise (WPE). Group A included 55 patients, 50
with deficiency and five with insufficiency Group B included 55 patients, 50 with
deficiency and five with insufficiency over 3 months. Visual analog scale 0–10 was
used to assess the degree of pain intensity.
Results
Findings have shown that 100% of the patients included in this study (n=110) (100
deficiencies and 10 insufficiencies) had an abnormally low level of vitamin D before
treatment with vitamin D therapy and WPE. By the end of the study, all the 110
patients have normalized their vitamin D level after vitamin D oral therapy and WPE
(100%). However, only 49 patients (group A) (44 deficiencies and five
insufficiencies) reported disappearance of LBP after vitamin D oral therapy and
only 51 patients (group B) (46 deficiencies and five insufficiencies) reported
disappearance of LBP after vitamin D oral therapy and WPE so the total
number of responders of both groups being 100 (90.9%) cases and the total
number of nonresponders of both groups being10 (9.1%)
Conclusion
After correction of vitamin D3 over 3 months, the authors found that the chronic LBP
has improved. A combination of both (correction of vitamin D3 and WPE) is more
beneficial in improving chronic LBP.
Keywords:
exercise, low-back pain, vitamin D
Al-Azhar Assiut Med J 18:325–329
©2020 Al-Azhar Assiut Medical Journal
1687-1693
Introduction
Vitamin D deficiency is a common problem among
Egyptian people who are not exposed to sunlight due to
their special habits and their jobs. There is also a high
incidence of vitamin D deficiency among healthy
Egyptian women during childhood, childbearing age,
pregnancy, and lactation, and also there is a high
incidence of vitamin D deficiency during the elderly,
geriatric period [1]. There is a strong relationship
between vitamin D level and skin exposure. Vitamin
D is produced either through photosynthesis in the
skin with exposure to ultraviolet B radiation or through
dietary sources. Avoidance of sun exposure reduces the
synthesis of vitamin D by the skin [2]. Women have
low levels of 25(OH)D than men [3–5]. This may be
due to the differences in body fat composition,
resulting in greater fat storage of vitamin D in
women [6]. As Egypt is an Islamic country, women
have traditional habits like the wearing clothes that
cover the whole body apart from face and hands.
Clothing habits may be responsible for the high
prevalence of vitamin D deficiency [7].
Vitamin D deficiency has skeletal and extraskeletal
disorders including chronic pain [8] and bone
fragility [9]. There are many presentations of
vitamin D deficiency, but low-back pain (LBP)
presentation is a well-recognized one [10–12]. LBP
is defined as pain between the costal margins and
inferior gluteal folds and is usually accompanied by
painful limitation of movement; it is often influenced
by physical activities and posture in most cases [13].
LBP may be classified by duration as acute (pain lasting
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Original article 325
©2020 Al-Azhar Assiut Medical Journal | Published by Wolters Kluwer - Medknow DOI: 10.4103/AZMJ.AZMJ_64_20
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for <6 weeks), subchronic (6–12 weeks), or chronic
(>12 weeks) [14]. Walking is a fundamental human
activity that is easy to perform, has a low risk of injury
and is associated with many health benefits [15,16]. It
has been shown that ambulation time over 8 ft
(2.4384 m) walkway correlated with higher serum 25
(OH) D concentrations [17], while many researches
have investigated exercise and advice to remain active as
a management strategy for LBP [18,19].
This study aimed to evaluate the relationship between
vitamin D deficiency and chronic idiopathic LBP, and
to observe the effect of vitamin correction and a
proposed walking program exercise (WPE) on the
severity of LBP.
Patients and methods
This study was carried out on 110 patients; 95 women
and 15 men of those attending the outpatient clinic of
our institution with their age ranging from 15to 45
years) having LBP of more than 3 months. The study
was approved by the ethical committee of AL-Azhar
Assiut faculty of Medicine and an informed consent
was obtained from each participant. The pain had been
classified as idiopathic on top of exclusion of other
causes of back pain by means of radiographic
evaluation. The patients were then subdivided into
two groups.
Group A: included 55 patients, 50 with deficiencies
and five with insufficiencies were treated with oral
vitamin D3 therapy. Group B: included 55 patients;
50 with deficiencies and five with insufficiencies were
treated with oral vitamin D3 therapy and a proposed
WPE in the form of:
Walking for 20 min under sunlight in the midday every
other day for 3 months.
Patients were first seen to assess LBP by history and
clinical examination and the presence or absence of
neurologic manifestation. Patients with
spondyloarthropathies or any other diagnosis of
inflammatory LBP, mechanical LBP fibromyalgia,
and those with a history of surgery or trauma to the
back were excluded. Patients with chronic liver disease
or renal impairment were also excluded.
Plain radiography on sacroiliac joints were done to
exclude sacroiliitis.
Plain radiography and MRI on the lumbosacral spine
were performed to exclude spinal malformations,
spondylosis, disk prolapse, spinal stenosis, pyogenic
abscesses, masses, or metastatic lesions.
The following investigations were done:
Serum 25-hydroxyvitamin D [25(OH)D], Serum
PTH, bone-specific alkaline phosphatase (ALKP),
serum Ca total and ionized, complete blood count,
erythrocyte sedimentation rate, and C-reactive protein
were done to exclude infections and malignancy.
We used the visual analog scale (VAS 0–10) to assess
the degree of pain before and after correction of
vitamin D and a proposed WPE as an outcome
measure for pain. We treated all patients in both
groups according to the Holick protocol (Weekly
Pearl 50 000 IU of vitamin D3 for a period of 8
weeks given to the patient to replenish the deficient
vitamin D). In the maintenance phase 50 000 IU
vitamin D3 is administered every 2 weeks. It is
recommended to measure the serum level of 25 (OH
D) after 2–3 months of treatment; and if the level is
above 30 ng/ml the maintenance therapy should
continue [20]. Vitamin D deficiency is typically
diagnosed by measuring the concentration of the 25-
hydroxyvitamin D in the blood, which is the most
accurate measure of stores of vitamin D in the body.
The reference range for deficiency and normal:
(1) Deficiency: less than 20 ng/ml insufficient:
20–29 ng/ml.
(2) Normal: 30–100 ng/ml [21].
Statistical analyses
Statistical analyses were performed using SPSS version
22 (IBM Corporation, Chicago, Illinois, USA). Mean,
SD, and range were estimated. It was assessed with the
analysis of variance test followed by Tukey’s test and P
values of less than 0.05 were deemed statistically
significant.
Results
The results of this study are presented in Tables 1.2.3
in Table 1.
The mean for age was 28.8±8.1 (18–38) in insufficiency
of vitamin D (IVD) and 30.52±10.4 (16–45) in
deficiency of vitamin D (DVD) (P=0.621); the
female-to-male ratio was 14/86 in DVD and 1/9 in IVD.
Our study was done on 110 patients having
chronic idiopathic LBP. One hundred cases have
326 Al-Azhar Assiut Medical Journal, Vol. 18 No. 3, July-September 2020
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vitamin D3 deficiency with a mean 25-OH
Cholecalciferol (7.3±5.3) and LBP by VAS (mean
±SD of 8.5±1.27) and mean of PTH (110.3±139.7),
mean of ALKP (128.42±70.7), Mean of serum Ca
total (8.9±0.8) and ionized (1.08±0.09) And 10 cases
have vitamin D3 insufficiency with a mean of 25-OH
Cholecalciferol 22.2±1.1 and LBP by VAS with mean
±SD of 8.0±1.1, mean of PTH (58.63±12.33), mean
of ALKP (86.9±21.92), Mean of serum Ca total (8.7
±0.49) and ionized (1.09±0.12). After correction of
vitamin D3 in the two groups (Table 2), we found in
group A the mean of vitamin D3 deficiencies (31±1.8)
and mean of LBP by VAS (0.87±0.83) and the mean
of vitamin D3 insufficiencies (40±2.5(35–64), mean of
LBP by VAS (0.89±0.86) and in group B the mean of
vitamin D3 deficiencies (37±0.83), mean of LBP by
VAS (0.28±0.58), the mean of vitamin D3
insufficiencies (45±1.9(30–70), and mean of LBP
by VAS (0.20±0.4).
So, all the 110 patients have normalized their vitamin
(100%) after vitamin D oral therapy and WPE;
however, only 49 patients (group A) (44 deficiencies
and 5 insufficiencies) reported disappearance of LBP
after vitamin D oral therapy and only 51 patients
(group B) (46 deficiencies and five insufficiencies)
reported disappearance of LBP after vitamin D oral
therapy and WPE. The total number of responders of
both groups was 100 (90.9%) cases and total number of
nonresponders of both groups was 10 (9.1%) (Table 3).
Discussion
The relation between vitamin D deficiency and idiopathic
LBP has long been reported [22–24]. A recent
retrospective study reported a strong association
between the severity of LBP and the deficiency of
vitamin D [25]. Not only LBP, but also other
musculoskeletal pain syndromes have also been related
to VDD; Plotnikoff and Quigley [23] found a high
prevalence (93%) of vitamin D deficiency among both
children and adults presenting to a university primary care
clinic in Minneapolis with persistent, nonspecific
musculoskeletal pain. Faraj and Mutairi [24] examined
patients attending spinal and internal medicine clinics in
Saudi Arabia over 6 years who suffered from LBP with no
obvious cause for more than 6 months and found that
Table 1 Demographic and clinical findings of patients
Insufficiency of
vitamin D [mean
±SD (range)]
Deficiency of
vitamin D [mean
±SD (range)]
P
value
Sex (no. of
males/no. of
females)
1/9 14/86 –
Age 30.52±10.4
(16–55)
28.8±8.1
(18–38)
0.621
LBP and its
duration per
month
15.9±4.5 (12–24) 15.72±9.5
(6–36)
0.954
LBP by VAS
(0–10)
8.0±1.1 (5–10) 8.5±1.27 (8–10) 0.220
Mean of 25-OH
cholecalciferol
level (ng/ml)
22.2±1.1
(21–24.1)
7.3±5.3
(2.8–19.6)
0.0001
PTH (pg/ml) 58.63±12.3
(42–78.3)
110.3±139.7
(30.4–972.78)
0.251
ALKP (IU/l) 86.9±21.92
(66–118)
128.42±70.7
(58–346)
0.73
Serum Ca total
(mg/dl)
8.7±0.49 (8–9.2) 8.9±0.8
(6.4–11.6)
0.845
Serum Ca
ionized (mg/dl)
1.09±0.12
(0.9–1.2)
1.08±0.09
(0.9–1.4)
0.874
ALKP, alkaline phosphatase; LBP, low-back pain; VAS, visual
analog scale.
Table 2 LBP by VAS and vitamin D3 levels after vitamin D oral therapy alone and with WPE for 3 months
Deficiency of vitamin D [mean±SD (range)] Insufficiency of vitamin D [mean±SD (range)]
LBP by
VAS
(0–10)
Mean of 25-OH Cholecalciferol
measurement (ng/ml)
LBP by
VAS
(0–10)
Mean of 25-OH cholecalciferol
measurement (ng/ml)
Responders to vitamin D oral therapy for 3
months (group A)
0.87±0.83
(0–3)
31±1.8 (30–50) 0.89±0.86
(0–4)
40±2.5 (35–64)
Responders to vitamin D oral therapy and
WPE for 3 months (group B)
0.28±0.58
(0–2)
37±0.83 (30–45) 0.20±0.4
(0–1)
45±1.9 (30–70)
Pvalue 0.066 0.01 0.114 0.01
LBP, low-back pain; VAS, visual analog scale; WPE, walking program exercise.
Table 3 Symptomatic response to oral therapy with vitamin D
alone and with WPE in both groups
Deficiency of
vitamin D [n
(%)]
Insufficiency
of vitamin D
[n(%)]
Total
[n
(%)]
Total number of patient 100 (100) 10 (100) 110
(100)
Responders to vitamin D
oral therapy (group A)
44 (44) 5 (50) 49
(44.5)
Responders to vitamin D
oral therapy and WPE
(group B)
46 (46) 5 (50) 51
(46.4)
Total number of
responders
90 (90) 10 (100) 100
(90.9)
Total number of
nonresponders
10 (10) 0 10
(9.1)
WPE, walking program exercise.
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about 83% had abnormally low levels of vitamin D. All
patients showed significant improvement after correction
of their vitamin D level. The authors concluded that
screening of patients with chronic LBP for vitamin D
deficiency should be mandatory [24]. Plehwe and Carey
described two patients with failed spinal fusion for chronic
LBP, who were subsequently found to have severe vitamin
D deficiency. The patients responded well to vitamin D
supplementation. The authors recommended the need for
the attending surgeons to be aware about the vitamin D
status in their patients as VDD may result in failure of
spinal fusion surgery with substantial costs of further
surgery and hospitalization [26]. Schwalfenberg
reported six cases of improvement of chronic LBP or
failed back surgery after vitamin D repletion in a Canadian
family practice setting [27]. Moreover, low physical
activity has also been associated with LBP [28].
Numerous management strategies have been tried for
nonspecific LBP and are recommended in most evidence-
based guidelines [14], including exercise programs [29].
Vitamin D has the potential to decrease pain and
inflammation by modulating sensory neuron
excitability [30]. It has been shown that ambulation
time over 8 ft (2.4384 m) walkway correlated with
higher serum 25 (OH) D concentrations [17].
In this study, we aimed at evaluating the effect of
vitamin D correction and WPE on idiopathic
chronic LBP. We found that a combination of both
is more beneficial in improving this chronic LBP.
Regarding vitamin D supplementation, in line with
our results, several studies have reported on the
beneficial effects of vitamin D for patients with
deficiency [24,26,27].On the other hand, a recent
meta-analysis has reported on the pooled results
from three studies prescribing vitamin D3 for
nonspecific LBP (dosage ranging from 25 to 179 μg
daily and treatment duration ranging from 6 to 16
weeks) failed to show a beneficial effect on pain
intensity compared with a placebo (weighted
MD=1.90, 95% confidence interval: −7.06 to 10.86,
P=0.678, n=3) [31]. The authors suggest that the
effect of vitamin D supplementation is not different
for individuals with nonspecific LBP or LBP resulting
from osteoporosis or vertebral fractures. Moreover, the
active form, alfacalcidol (1 μg daily for 12 months) was
less effective than no intervention [12 months (0–10
pain scale): 95% confidence interval: −0.52 to 0.72,
P=0.752] or other conservative/pharmacological
interventions for individuals with LBP resulting
from osteoporosis or vertebral fractures [32,33].
Another randomized, controlled trial that prescribed
an overall dosage (179 μvitamin D3 daily for 6 weeks)
failed to demonstrate a beneficial effect for people with
nonspecific LBP [34].
Conclusion
This study demonstrated that after correction of
vitamin D3 within 3 months chronic LBP was
improved and after correction of vitamin D3 and
using WPE a combination of both is more
beneficial in improving this chronic LBP.
Current clinical guidelines for managing chronic LBP
should include assessment of vitamin D status, and
recommend physical activity and regular exercise in
those found to be deficient.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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