Intended for healthcare professionals

Rapid response to:

Clinical Review

Low back pain

BMJ 2004; 328 doi: (Published 06 May 2004) Cite this as: BMJ 2004;328:1119

Rapid Response:

ABC...D of low back pain

EDITOR – Cathy Speed’s ‘ABC of rheumatology: Low back pain’ review
(1), fails to highlight the important, but frequently overlooked, role
that vitamin D deficiency may play.

A study of 360 patients attending spinal and internal medicine
clinics (in Saudi Arabia) over a 6-year period who had chronic low back
pain that had no obvious cause, found that 83% had an abnormally low level
of vitamin D. After treatment with vitamin D supplements, clinical
improvement was seen in all those that had a low level of vitamin D, and
in 95% of all the patients. The study authors concluded that vitamin D is
a major contributor to chronic low back pain, and that screening for
vitamin D deficiency and treatment with supplements should be mandatory.

An Australian report described two patients with chronic low back
pain who, subsequent to failed spinal surgery, were found to have severe
vitamin D deficiency (3). These patients were much improved after
treatment with vitamin D supplementation.

In a US study of primary care outpatients with persistent, non-
specific musculoskeletal pain syndromes refractory to standard therapies,
93% had deficient levels of vitamin D (4). The authors of the study
concluded that, because osteomalacia is a known cause of non-specific
musculoskeletal pain, screening of all patients with such pain for
hypovitaminosis D should be standard practice in clinical care.

In an accompanying editorial to the above study, Michael Holick
emphasises that physicians should be alert to vitamin D deficiency, and
recommends that all patients should have their vitamin D status tested
once a year (5).

Failure to recognise and treat vitamin D deficiency in patients with
low back pain may result in a great deal of unnecessary suffering, as well
as substantial direct and indirect costs. Vitamin D deficiency is readily
identified by measuring 25-hydroxy vitamin D levels (< 50 nmol/L =
deficiency; 50-100 nmol/L = insufficiency; 100-150 nmol/L = optimal), and
is easily and cheaply corrected with appropriate vitamin D supplementation
(which may typically require treatment with 6,000 IU (150 mcg) or more
daily, followed by maintenance doses of 2-3,000 IU (50-75 mcg) daily
and/or adequate exposure to sunlight).


1. Speed, C. ABC of rheumatology: Low back pain. BMJ 2004;328:1119-

2. Al Faraj S, Al Mutairi K. Vitamin D defiency and chronic low back
pain in Saudi Arabia. Spine 2003;28(2):177-9.

3. Spinal surgery and severe vitamin D deficiency. Plehwe W, Carey
RPL. MJA 2002;176(9):438-439.

4. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D
in patients with persistent, non-specific musculoskeletal pain. Mayo Clin
Proc 2003;78:1463-1470.

5. Holick MF. Vitamin D deficiency: what a pain it is. Mayo Clin Proc

Competing interests:
None declared

Competing interests: No competing interests

20 May 2004
Peter J Lewis
Integrative Physician
15 South Steyne, Manly, NSW 2095, Australia