Out of Scope, Out of Mind: Magnesium Deficiency & Physiotherapy
- Aleksandra Nikolovski, PT, MScPT
- Jul 25, 2023
- 6 min read
Updated: Apr 12, 2024
As physiotherapists, we are tasked with prescribing treatments based on what we identify - by way of comprehensive assessments - as the "root cause" of the problem.
Depending on the area of practice in which a physiotherapist works, clinical cases can span all systems of the body, and may even cross multiple. For example, commonly identified root causes of musculoskeletal concerns include muscle imbalances, weakness, maladaptive postures, reduced joint or tissue mobility, traumatic or repetitive strain injuries, and more.
Sometimes, physiotherapists already know the root cause of a problem. This is common in those who treat neurological conditions such as stroke, Parkinson's Disease, concussion, cerebral palsy, and more. This is also applicable to many hospital-based physiotherapists who are working on helping individuals recover from the aftermath of major surgeries or complex medical conditions.
What happens though, when the root cause gets misidentified? This is often the case with individuals experiencing magnesium deficiency, which is contributing to an ever-growing public health crisis.
What is magnesium?
Magnesium is a micronutrient that is highly abundant in both the crust of the earth, and the core of human beings. In humans, magnesium is the fourth most common cation, and approximately 25mg is naturally produced by the body. Other essential micronutrients include potassium and calcium [1].
What does magnesium do?
Magnesium is a critical component of over 300 enzyme reactions in the body, and 90% of it is found in muscles and bones. More specifically, magnesium is responsible for maintaining homeostatic flow of ion channels, supporting tissue integrity (or preventing tissue breakdown), minimizing oxidative stress, and protein synthesis. It also helps regulate nerve function, blood sugar, and blood pressure by way of supporting cardiac muscle function [1].
Magnesium is generally kept at static levels due to the role of the kidneys in excreting excess, and conserving it during a deficit. Unfortunately though, during a time of deficit, magnesium is often pulled from bones, muscles, and organs to keep serum (blood) levels of magnesium steady [1].
This last point about serum magnesium is absolutely critical to understanding the public health crisis of magnesium deficiency. Serum blood tests are the most readily available diagnostics for assessing magnesium levels, however, they do not reflect the total amount or utilization of magnesium in muscles, bones, and organs. Let us remember that only 1% of the body's magnesium is found in the blood stream. As such, the majority of individuals experiencing magnesium deficiency will have normal levels of serum magnesium, despite the fact that their bones, muscles, and organs are suffering in deficit [1-3].
In part due to the high frequency of normal blood work results, 34% of Canadians and 48% of Americans continue to live in a state of magnesium deficiency [4].
Who is most risk for magnesium deficiency? [5]
Elderly individuals, due to poorer absorptive capacity of their bones and muscles
Those with diets low in magnesium
Hydration; those with soft drinking water and low magnesium, and those who drink bottled water only
High sodium diets in cooking and pre-packaged foods
Pregnant individuals; magnesium is often lost through lactation
Those who engage in regular strenuous exercise without replenishing magnesium stores
Alcoholics or those who drink a lot of alcohol
Those with IBS or who have had intestinal surgery; reduced absorption from small intestines
Diuretic medications including proton pump inhibitors, thiazide, chemotherapeutics, phosphate-based medications
What are the signs and symptoms of magnesium deficiency?
If we cannot see magnesium deficiency through blood work, how can we see it? It can vary between individuals, however, there are some common signs & symptoms that occur with sub-clinical magnesium deficiency that are often overlooked in favor of other conditions. Some of the most common side effects include the following:
Body System | Side Effects |
Nervous system | Fatigue, exhaustion, anxiety, restlessness, headaches, migraines, shocking or shooting pains |
Musculoskeletal System | Muscle cramping, twitching, spasms, aching with or without activity, weakness despite activity, poor exercise progression |
Cardiovascular System | Heart palpitations, arrhythmias, rapid heart rate, shortness of breath, cold hands and feet with glove-stocking pattern |
Endocrine System | Stomach cramping, bloating, nausea, diarrhea, constipation |
Right away, you can see that none of these signs or symptoms would automatically point you in the direction of a magnesium deficiency. Someone may have stomach cramping because they're eating high fat foods, or they may have an allergy. Someone may have headaches because they sleep poorly or spend too much time looking at screens. Someone may have muscle cramping because they're dehydrated or lifting too heavy.
It's evident that with a combination of poor diagnostic accuracy and overlapping signs and symptoms with multiple conditions, it can be very challenging to identify if magnesium is affecting one's health.
What matters here is context - small details.
If we think back to the laundry list of processes for which magnesium is responsible, we can see that without enough of it, we start to experience impacts in muscle function, heart function, bone integrity, nerve function, and more. What we need to look at is whether or not these signs and symptoms can be explained by anything else. When things don't add up, we can begin to rule in magnesium deficiency as a potential factor.
It is important to for physiotherapists, amongst other healthcare providers to enhance their screening skills in this area, because we are often seeing individuals before they experience medical crises. With excellent screening skills and communication with primary care teams, we can work to prevent some of the following health conditions and crises, which have been identified as highly correlated with (not caused by) magnesium deficiency [5]:
Type 2 diabetes Mellitus
Metabolic syndrome
Ischemic heart disease & myocardial infarction
Hypertension
Muscle weakness
Osteoporosis
Fatigue
Numbness & tingling in the limbs
Muscle spasms, cramps, or tetany
Fibromyalgia
Depression
Stroke
Colorectal cancer
Asthma
Chronic low grade inflammation
I want to look a little closer at osteoporosis, because I feel it is extremely relevant to the aging population in Canada. Over 2.3 million Canadians live with osteoporosis, and 80% of ALL fractures in individuals over age 50 are due to osteoporosis [6].
Below is an image extracted from Castiglioni et al., (2013) [7], illustrating the direct and indirect effects of magnesium deficiency on bones, and how they contribute to osteoporosis. In simple terms, magnesium deficiency directly reduces the number of cells that build bones, and increases the cells that destroy bone. Indirectly, it leads to reduced hormones that create bone-building cells, low vitamin D, and increased oxidative stress and inflammation.
Now let us look at the large-scale impacts of this single condition, and why magnesium deficiency should be classified as a public health crisis. Fractures are one of the most common health events caused by osteoporosis. As of 2016, osteoporosis cost the Canadian healthcare system a whopping $4.6 billion per year [8]. Below is a portion of a chart that I've extracted from Hopkins et al., (2018), that illustrates the costs of an osteoporotic fracture of both the hip and the spine for the year following the injury in Canada:
Cost Component | Hip | Vertebral |
Acute Care | $22,759 | $8073 |
Rehab beds | $6419 | $1773 |
Rehab Clinics | $119 | $124 |
Complex Continuing Care | $8200 | $3353 |
Long Term Care | $15,816 | $8501 |
Home Care | $4018 | $2166 |
Outpatient Physician Services | $2510 | $1298 |
Mobility Devices | $1700 | $678 |
Total Direct Medical Cost | $63, 649 | $26,960 |
You can refer to reference #8 in the list below for a more comprehensive overview of this chart, and compare these costs to wrist, humerus, and other types of fractures along with additional cost analyses.
How could we otherwise reallocate these funds within the healthcare system to alleviate the strain on primary care providers, reduce wait times in hospitals, eliminate overflow statuses, and promote aging in place for our elderly?
Physiotherapy Has Entered the Chat
As physiotherapists, we have the privilege of spending more time on average with patients than most other healthcare practitioners. As such, we have the opportunity to dig much deeper into a clinical case and identify minute details that may often be missed during shorter visits where primary care providers are addressing a number of issues at once.
While physiotherapists cannot communicate medical diagnoses in Canada, it is very much within our scope to screen for them, and to educate individuals on risk factors, signs, and symptoms of such conditions. It has often been deemed taboo for physiotherapists to discuss nutrition with patients, and I've had many classmates and colleagues tell me that it's "out of our scope".
Prescribing diets is out of our scope. Educating patients about natural elements found in their body, and how it can impact their health is most certainly within it. And, while we will likely never be prescribers of diets, supplements, or medications, we are - and should be - educators of such topics.
If we keep preaching that it is out of our scope, it will remain out of our minds. It will remain out of our curricula, and it will remain out of our practice.
Perhaps it is worth considering introducing more nutrition education for physiotherapy students, or offering collaborative placements in the realm of dietetics or pharmacology to better learn about how physiotherapists can contribute.
Perhaps it is worth rethinking the barriers of our scope of practice, and welcoming the idea that nutrition screening and education is very much within our scope.
Perhaps it is worth advocating for physiotherapists to get more seats at the public health tables to inform policy leaders and funders of our impact.
For a much more brief and visually appealing summary about magnesium, please check this infographic I've created:
Next week, I will be releasing a second post highlighting 3 recent clinical cases where I have used my physiotherapy skills and expertise around nutrition. Stay tuned!
References:
[1] DiNicolantonio JJ, O’Keefe JH, Wilson W. Subclinical magnesium deficiency: a principal driver of cardiovascular disease and a public health crisis. Open heart. 2018 Jan 1;5(1):e000668.
[5] Ismail AA, Ismail Y, Ismail AA. Chronic magnesium deficiency and human disease; time for reappraisal?. QJM: An International Journal of Medicine. 2018 Nov 1;111(11):759-63.
[7] Castiglioni S, Cazzaniga A, Albisetti W, Maier JA. Magnesium and osteoporosis: current state of knowledge and future research directions. Nutrients. 2013 Jul 31;5(8):3022-33. doi: 10.3390/nu5083022. PMID: 23912329; PMCID: PMC3775240.
[8] Hopkins RB, Burke N, Von Keyserlingk C, Leslie WD, Morin SN, Adachi JD, Papaioannou A, Bessette L, Brown JP, Pericleous L, Tarride J. The current economic burden of illness of osteoporosis in Canada. Osteoporos Int. 2016 Oct;27(10):3023-32. doi: 10.1007/s00198-016-3631-6. Epub 2016 May 11. PMID: 27166680; PMCID: PMC5104559.
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