Vitamin D Deficiency

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Original Editors -Nicole Hess & Shannon McMullen from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Vitamin D is a fat-soluble vitamin that is naturally present in very few foods, added to others, and available as a dietary supplement. It is also produced endogenously when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis. Vitamin D obtained from sun exposure, food, and supplements is biologically inert and must undergo two hydroxylations in the body for activation. First in the liver, secondly in the kidneys. It is a necessary vitamin for calcium absorption and is therefore linked to bone density disorders when deficient. 

Prevalence

The aged population is susceptible due to****  

Characteristics/Clinical Presentation

• General muscle weakness, falls, fractures, and decreased functional status and decreased progress during inpatient rehabilitation especially in the older population. 
• Bone decalcification is hard to detect without medical imaging and diagnostic tests.Radiographs typically show decalcification in the spine, pelvis, and lower extremities with transverse fracture-like lines in the affected bones and areas of demineralization in the matrix of the bone.
• In children with rickets this may present with bowing of the long bones with widening, fraying, and clubbing in areas of active bone growth. This is more prominent around the metaphyseal ends of the long bones and sternal ends of the ribs.
• Be suspicious of patients that have kidney or liver disease or malfunction as they are important in vitamin D synthesis in the body.
• Diseases of the small intestine, cholestatic disorders of the liver, biliary obstruction, and chronic pancreatic insufficiency increase the risk of developing osteomalacia or affect vitamin D synthesis or absorption. An example of this would be when Cystic Fibrosis effects the pancreas, it leads to a deficiency in fat-soluble vitamins (including vitamin D).
• Risk factors for vitamin D deficiency: decreased sun exposure, decreased intake in the diet, kidney/liver diseases or a pathology that reduces vitamin D receptor sites in tissues, and age. The hormone, 7-dehydrocholesterol, synthesizes vitamin D when exposed to sunlight through the epidermis. By age 65, this hormone level in the body diminishes by 25% which is why there is an increased risk for deficiency in the older population. It is also a risk factor for myofascial trigger points, severe bone pain, myalgia, and skeletal deformities especially if it becomes chronic (osteomalacia). The pain is said to sometimes mimic polymyositis or muscular dystrophy.
  

Associated Co-morbidities

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Medications

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Diagnostic Tests/Lab Tests/Lab Values

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Etiology/Causes

• Low intake of vitamin D in diet 
• Decreased sun exposure 
• Intestinal malabsorption problems, often associated with aging 
• Long-term uses of anticonvulsants, which accelerate breakdown of the active forms of vitamin D
  
  

Systemic Involvement

1. Musculoskeletal System: Severe vitamin D deficiency may be associated with non-specific musculoskeletal pain, causing bone, muscle, and/or joint pain. 

Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

• Fibromyalgia 
• Rheumatic diseases 

Case Reports/ Case Studies

Case Report #1  [Full article available at www.najms.org/article.asp] 

Authors:
Clement Z, Ashford M, and Sivakumaran

Abstract:

• Vitamin D deficiency is extremely common in multiple myeloma, and it represents a surrogate for clinical multiple myeloma disease status. Patients may complain of dull, persistent, generalized musculoskeletal aches and pains with fatigue or decrease in muscle strength.
• This case highlights that vitamin D deficiency is common in patients with multiple myeloma, and can cause generalized musculoskeletal pain and increase the risk of falls, yet it often goes unrecognized. In patients with non-specific musculoskeletal pain, and inadequate sun-exposure medical practitioners must have a high index of suspicion for vitamin D deficiency.
  

Patient Characteristics:

• 63 year old man with multiple myeloma
• Current reactivation of herpes zoster
  

Subjective: Chief complaints include:

• Generalized weakness
• Nonspecific musculoskeletal pain
• Reported multiple falls
  

Examination:

• Pale presentation with a depressed affect
•  Resting tremor, generalized bony tenderness, worse on movement and weight bearing
• Muscle weakness
• Waddling gait
• Bone studies showed features of osteomalacia with a very low Vitamin D level of less than 20 nmol/L
  

Past Medical History:

• Previously diagnosed with solitary plasmacytoma in 2001, which then progressed to smoldering myeloma in 2004
• 2007 the indolent version of his myeloma transformed to a more aggressive form of myeloma with non-specific musculoskeletal chest pain, anorexia, weight loss, and tumour-lysis requiring hospital admission and plasmapheresis.
• June 2010 the patient was admitted to hospital after multiple falls and zoster reactivation including ophthalmic zoster of the right first and second trigeminal branches.
  

Intervention: Physical Therapy

Co-intervention: Received 3,000 nmol/L daily of Vitamin D supplementation
Outcomes: 4 months later

• Significant decrease in his generalized musculoskeletal pain
• Bloods showed a normalized level of Vitamin D of 109 nmol/L
• Decrease in alkaline phosphatase to 182 U/L
• Currently undergoing palliative rehabilitation.

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Resources

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Recent Related Research (from Pubmed)

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References

Goodman C, Snyder T. Differential Diagnosis for Physical Therapist: Screening For Referral. Missouri: Saunders Elsevier; 2013.

Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd ed. Missouri: Saunders Elsevier; 2009.

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