This concludes our series on patient "M," who entered my office in January hoping that manipulation would provide her some relief.
M denied any trauma and said the problems had started two months ago. However, questioning revealed her symptoms had been building up long before things got to a crisis level that prompted her to seek care. After a negative blood test and no luck with medication, her primary care doctor thought she had a nerve problem and sent her to a neurologist. MRI studies to her brain, neck and back, along with EMGs to her legs, were all negative. The neurologist thought M had a muscle problem and sent her to a rheumatologist, who diagnosed her with fibromyalgia.
When M told me all this on her first visit, it just didn't feel right based on her history and symptoms. We discovered many of her complaints were from a subclinical iron deficiency (discussed in part 1 of this series) and a subclinical B12 deficiency (discussed in part 2). I suspected there might be a third nutrient deficiency as well.
Vitamin D Deficiency
M's all-over muscle pain started around September 2010 and increased to a level that, by Halloween, prevented her from working. M also had muscle weakness – a gradually increasing irritant that became more pronounced until the weakness was accompanied by pain. By the time she saw me, she had been under care for nine weeks and none of the various medications she'd tried had helped. She came into my office desperate and was hoping "cracking my back would help the pain."
To say she was surprised when I told her I suspected she had nutritional deficiencies was an understatement. Following one week of iron and two weeks of iron and vitamin B12, her remaining symptoms were muscle soreness (predominately in her upper back, trapezius, lower back and glutes) and fatigue (80 percent improved after the iron and B12).
Her doctor didn't mention that a vitamin D deficiency may be confused with fibromyalgia, but I did. "Remember when the fibromyalgia really hit you?" I asked. "Yes, it was just after Halloween," she said.
I replied: "You told me you normally don't spend much time outdoors – and that was before you picked up the third part-time job in late June. Sun exposure is how we make vitamin D. You have brown skin, which means you need more sun to make vitamin D than your light-skinned friends. To make matters worse, the sun isn't strong enough in the winter to make any vitamin D. We build up our vitamin D stores in the spring, summer and fall, but you haven't been outdoors since June. You do not drink milk or take supplements which, for most people, are the chief sources of dietary vitamin D. It's now the end of January, so you've been living off your vitamin D reserves – or what's left of them – for seven months."
Even though I suspected she had a vitamin D problem, a short trial to see if there was a response was not an option for two reasons:
- Unlike iron and vitamin B12, the basic blood test for vitamin D [known as 25-hydroxy vitamin D, aka 25(OH)D] is not subject to a false negative, nor are other less-accurate tests routinely ordered. Therefore when it comes to vitamin D, you are either deficient, low, within the normal range, within the optimal range or have elevated levels.
- Because vitamin D is fat soluble, it is a slow process to both raise levels and reduce symptoms. In some cases, very high doses are required for months.
My Patient's Results
When M's blood test results came back, she told me, "The doctor's assistant called and said my vitamin D was very low. I have to take a vitamin D pill each day for three months." Her weekly dose was 50,000 IU.
I saw her a week later and she said, "When I took the iron and B12 , I felt the difference within days. I don't feel any difference and it's been two weeks." I explained that vitamin D is a fat-soluble vitamin, so it takes longer to build up when levels are low and the symptom reduction will be subtle.
Seven weeks later she returned to my office. I thought M wanted a treatment, but instead she accompanied a new patient (her mother), whom she had just referred to me. M still had three weeks of vitamin D left to take, but her muscle pain and weakness had slowly decreased until she realized they had been gone for over a week.
I never found out how low her vitamin D had been and delayed submitting this article until I found out. When I reminded M I still needed the test results, she said she had changed her entire health plan due to her dissatisfaction with the overall care she'd received. Anyone who has read all three parts to this story will understand her decision.
This article series on nutrient deficiencies began late last year with a three-part series on iron deficiency, then continued with the current three-installment series on deficiencies missed by multiple doctors in the same patient. Visit Dr. Andersen's columnist page to review the entire series.
Click here for more information about G. Douglas Andersen, DC, DACBSP, CCN.