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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 325-329

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


Department of Rheumatology and Rehabilitation, Al-Azhar University, Assiut, Egypt

Date of Submission03-Apr-2020
Date of Decision25-May-2020
Date of Acceptance07-Jul-2020
Date of Web Publication30-Oct-2020

Correspondence Address:
Mohamed Elwan
MD of Rheumatology and Rehabilitation, Mallawy Minia, 61631
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_64_20

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  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.

Keywords: exercise, low-back pain, vitamin D


How to cite this article:
Elwan M, Moneer M. The effect of vitamin D repletion and proposed walking program exercise on chronic idiopathic low back pain: a randomized controlled trial. Al-Azhar Assiut Med J 2020;18:325-9

How to cite this URL:
Elwan M, Moneer M. The effect of vitamin D repletion and proposed walking program exercise on chronic idiopathic low back pain: a randomized controlled trial. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Nov 25];18:325-9. Available from: http://www.azmj.eg.net/text.asp?2020/18/3/325/299576




  Introduction Top


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],[4],[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],[11],[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 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 Top


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 Top


The results of this study are presented in Tables 1.2.3 in [Table 1].
Table 1 Demographic and clinical findings of patients

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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 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).
Table 2 LBP by VAS and vitamin D3 levels after vitamin D oral therapy alone and with WPE for 3 months

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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]).
Table 3 Symptomatic response to oral therapy with vitamin D alone and with WPE in both groups

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  Discussion Top


The relation between vitamin D deficiency and idiopathic LBP has long been reported [22],[23],[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 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 μ vitamin D3 daily for 6 weeks) failed to demonstrate a beneficial effect for people with nonspecific LBP [34].


  Conclusion Top


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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    Tables

  [Table 1], [Table 2], [Table 3]



 

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