|Year : 2020 | Volume
| Issue : 1 | Page : 58-61
Assessment of musculoskeletal pain in rheumatoid arthritis patients and its relation to vitamin D levels
Alok Chandra Agrawal, J Rakshit, Harshal Sakale, Bikram K Kar
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India
|Date of Submission||17-Apr-2020|
|Date of Acceptance||20-Apr-2020|
|Date of Web Publication||26-Jun-2020|
Dr. J Rakshit
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Vitamin D is associated with musculoskeletal function in our body, and its deficiency is a common health problem all over the world. The role of Vitamin D in rheumatoid arthritis (RA) is well established due to its immunomodulatory effect. The aim of this study was to assess the musculoskeletal pain in patients with RA in relation to Vitamin D levels. We found a negative correlation and found an increase in the pain intensity among RA patients with low levels of Vitamin D.
Keywords: Rheumatoid arthritis, visual analog scale, Vitamin D
|How to cite this article:|
Agrawal AC, Rakshit J, Sakale H, Kar BK. Assessment of musculoskeletal pain in rheumatoid arthritis patients and its relation to vitamin D levels. J Orthop Traumatol Rehabil 2020;12:58-61
|How to cite this URL:|
Agrawal AC, Rakshit J, Sakale H, Kar BK. Assessment of musculoskeletal pain in rheumatoid arthritis patients and its relation to vitamin D levels. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Jul 10];12:58-61. Available from: http://www.jotr.in/text.asp?2020/12/1/58/287713
| Introduction|| |
Vitamin D, a secosteroid hormone, is involved in the metabolism of calcium and bone. It is involved in the regulation of calcium homeostasis since it regulates the absorption of calcium from the gastrointestinal tract. The major source of Vitamin D for most of the vertebrates including Homo sapiens is exposure of the skin to sunlight.
Vitamin D deficiency and insufficiency is the most common nutritional deficiency in the world. Vitamin D deficiency has been defined as a 25(OH) D as <20 ng/ml and Vitamin D insufficiency as 21–29 ng/ml. These definitions are based in part on provocative testing in healthy adults.
Rheumatoid arthritis (RA) is an inflammatory rheumatic disease with a progressive course affecting articular and extra-articular structures. This results in pain, disability, and mortality. Persistent inflammation leads to erosive joint damage and functional impairment in the vast majority of patients. The course of the disease may be different according to the absence or presence of several parameters including genetics, frequency of swollen joints, autoantibody in the serum, and the severity of inflammatory process.,
With a prevalence ranging from 0.4% to 1.3% of the population depending on both sex (women two to three times more often than men), age (frequency of new RA diagnoses peaks in the sixth decade of life), and studied patient collective (RA frequency increases from south to north and is higher in urban than rural areas),,,,, RA is one of the most prevalent chronic inflammatory diseases.
The cause of RA is unknown, both genetic and environmental factors are shown to contribute to RA development. As it is hypothesized for other autoimmune diseases, it is likely that the triggering event of RA requires two separate events: (1) genetic predisposition of the respective patient resulting in the generation of autoreactive T- and B-cells and (2) a triggering event, such as viral and bacterial infections or tissue injury, providing the activated antigen-presenting cells to activate the previously generated autoreactive lymphocytes, resulting in disrupted tolerance and subsequent tissue/organ destruction. Therefore, RA develops likely in a genetically predisposed individual due to a combination of genetic variation, epigenetic modification, and environmental factors initiated by a stochastic event (e.g., injury or infection). Risk factors for the development of RA include smoking, obesity, exposure to ultraviolet light, sex hormones, drugs, and infections.,,,,
There is a raising interest in the role of Vitamin D in the field of rheumatology as a potential treatment for a number of inflammatory diseases. Vitamin D has a broad range of roles from its biological effects ranging from the classic role as a mediator of calcium and phosphorous metabolism promoting the healthy mineralization and growth and remodeling of the bone to antimicrobial activity and modulation of cellular differentiation. In addition, Vitamin D exerts suppressive functions on cells of the adaptive immune response, i.e., those which are directly involved in the RA development.,
With this in mind, this study is conducted to assess the musculoskeletal pain in RA patients and its relation with Vitamin D levels.
| Materials and Methodology|| |
Subjects and methods
This is a cross-sectional study.
Source of data
The study was conducted in accordance with the Declaration of Helsinki. We included 77 patients who had appealed to our polyclinic and a known case of RA whose level of Vitamin D had been measured.
The data of patients between 18 and 70 years of age with a diagnosis of RA were included in the study. Patients were divided into three groups as Vitamin D deficient (Group 1) with a Vitamin D level <20 ng/mL, Vitamin D insufficient (Group 2) with levels <30, and normal (Group 3) with a value >30 ng/mL. The relationship between severity of pain and Vitamin D levels was evaluated.
Method of collection of data
- Pain has been defined
- Pain level has been determined by the visual analog scale (VAS)
- Vitamin D levels have been determined in ng/mL.
- Patients who have missing demographic or study data
- Trauma, infection, and endocrinologic, neurological, and rheumatologic patients diagnosed with diseases, tumors, and depression
- Patients who are followed up with osteomalacia diagnosis
- Patients with advanced osteoporosis and compression fracture in X-ray were excluded from the screening.
As a result of the screening, 77 patients were eligible to be included and participated in the present study. Patients' demographic data including age, gender, and occupation were recorded.
Pain level was evaluated as nominal data determined by 10-cm VAS. VAS is resulted from marking on a horizontal line where patients have no pain shown as “0” and where the pain is the most severe shown as “10.”
All the analyses were carried out by means of Windows SPSS software (IBM Corp., Released 2013. IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). The appropriateness of variables was investigated with visual and analytical methods. Descriptive statistical data were presented as mean, standard deviation (SD), numbers, and percentage. There was no difference between the normally distributed group and the nonnormally distributed group in terms of Vitamin D levels.
| Results|| |
The study included 77 patients who were diagnosed with RA according to the 2010 American College of Rheumatology and European League against Rheumatism criteria. Patients were mostly female (56 of 77), with a mean (SD) age of 45 ± 12 years and median disease duration (SD) of 24 ± 13 weeks.
Sociodemographic data of the groups are as follows. The mean age of the groups (44 vs. 45 ± 12.3 years vs. 46.78 ± 17.6 years), sex, and occupation were compared, but there was no statistically significant difference between the results (P > 0.05).
The mean Vitamin D levels calculated were lower in men (12.8 ± 7 ng/ml) than in women (17.88 ± 6.2 ng/ml). The mean of various parameters recorded is depicted in [Table 1].
Visual analog score calculated in Group 1 was 5 in 16.21% of the patients and was not elicitable in 45% of the patients; in Group 2, it was 7 in 25% of the patients and was not elicitable in 50% of the patients; and it was 5 in 66% patients of Group 3, which is depicted in the charts [Chart 1], [Chart 2], [Chart 3], [Chart 4], [Chart 5], [Chart 6], [Chart 7].
While a negative correlation was found between Vitamin D level and VAS score, no correlation was found between body mass index (BMI), age, education level, marital status, and working status (P > 0.05).
| Discussion|| |
In our study, we investigated the relationship between the severity of pain and the level of Vitamin D in patients with RA. Data we obtained showed that patients with RA had a deficiency of Vitamin D and there was a negative correlation between the level of Vitamin D and pain severity.
We also found that Vitamin D levels in male patients were lower than female patients but were statistically insignificant. This could be because in this particular region, females are more exposed to sunlight which is the main source of Vitamin D.
In a review study that supports our study partially, the relationship between Vitamin D and RA has been investigated, and it has been found that patients with RA have lower serum 25(OH)D levels and more common in younger women. The mean age of the groups (44 ± 12.3 years vs. 45 ± 17.6 years), sex, and working conditions were compared, and any statistically significant differences were not found.
On the literature review, there were few studies investigating the relationship between D Vitamin and pain severity. In those studies, there was a significant correlation between serum 25(OH)D and pain severity. However, in some studies, serum 25(OH)D and pain severity were not significantly correlated. Considering these conflicting findings, careful evaluation of Vitamin D supplementation is required.
Gheita et al. found that decreased 25(OH) Vitamin D levels in RA patients compared with controls, and, among RA patients, Vitamin D was considerably lower in patients with fibromyalgia syndrome in addition to RA.
The synthesis of > 90% of Vitamin D in the body occurs under the influence of sunlight. Vitamin D, taken parenterally, does not have a significant contribution, especially after a supplement is not taken.,, The average prevalence in Vitamin D deficiency prevalence studies in the USA is reported as 41.6%, which is 82.1% in dark people and 69.2% in Hispanics. Gokcek et al. reported a 50.8% prevalence of Vitamin D deficiency in the young adult population.
Patients with RA are prone to osteoporosis and suffer from pain when the disease is in a flare. Vitamin D supplementation has been proposed for patients with RA for the prevention and treatment of osteoporosis as well as for its possible effects on disease activity.
Vitamin D has also an effect on the recurrence rate of RA. A study by Yang et al. stated that the recurrence rate was less in patients supplemented with Vitamin D.
| Conclusion|| |
In conclusion, it appears that Vitamin D deficiency is highly prevalent in patients with RA, and Vitamin D deficiency may be linked to disease severity in RA. Vitamin D-deficient patients are more prone to musculoskeletal pain. Vitamin D supplementation may be needed for the prevention of osteoporosis and for pain relief in patients with RA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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