A Common Problem, Often Misunderstood
By Ruth Werner
A Common Problem, Often Misunderstood
By Ruth Werner
As promised, this article looks at a surprisingly common problem that is poorly understood. Polymyalgia rheumatica (PMR) is a condition of unknown cause or etiology ("idiopathic") that affects mostly Caucasian women between 50 and 80 years of age. It usually is self-limiting, which means symptoms tend to spontaneously subside within several months or a couple of years following onset. In the meantime, however, PMR can be a severe problem that substantially interferes with a person's quality of life.
Here is a comment that came in from one reader, Karen, about her client with PMR:
"I do have one client who was diagnosed with polymyalgia a few years ago. Peripheral neuropathy, pain in her neck and shoulder areas, specific "hot" spots in her legs and feet are some of her issues. She had a trauma that affected her neck about six months before she was diagnosed. She was medically treated with varying doses of a steroid. She is an insulin-dependant diabetic. I used positional release, energy and other gentle modalities. Later I was able to use deeper work and neuromuscular work. Though she is much better, she still has pain and energy issues."
The client Karen describes presents a complex picture, because some of her symptoms (especially peripheral neuropathy and hot spots in her distal legs and feet) might be related to her diabetes rather than her PMR. Furthermore, the side effects of PMR treatment can interfere with diabetes management, which complicates things even further!
What Is Polymyalgia Rheumatica?
PMR literally means "many muscle and joint pains," It is a mysterious condition that involves a specific onset of extreme morning stiffness and muscle pain, often concentrated around the neck, trunk, shoulders, upper arms, hips and thighs. One person described it as feeling as if they'd worked hard in the garden or gone on a very demanding hike every single day for about two years.
Those of northern European descent have the highest incidence. Women with PMR outnumber men by about 2 to 1. The incidence among people over age 50 is fairly high. It's estimated to affect between 0.5 percent and 0.7 percent of this population. The average age at onset is 72 years, but anyone over age 50 who describes these signs and symptoms should think about getting tested for PMR. It's rare among African-Americans or Asians. This predictable racial distribution points to a genetic component for the disease.
The exact causes or etiology of PMR are unknown, but when people with this condition are compared to people without it, some differences are strongly predictable. Many (but not all) people with PMR are positive for a specific genetic marker called HLA-DR4. Evidence of past infection with several common viruses is typical. Certain kinds of white blood cells are present in the synovial capsules, tenosynovial sheaths and bursae of many people with PMR. Levels of C-reactive protein and the erythrocyte sedimentation rate (ESR or "sed rate") of people with PMR both tend to be higher than that of the general population. These tests are not definitive for PMR specifically, but they do point toward a possibility of inflammation and immune-system hyperactivity.
Signs and Symptoms of PMR
As described above, PMR most often is defined by a specific onset of pain and stiffness focused around the trunk and proximal aspects of the arms and legs. It might start unilaterally, but most people develop bilateral symptoms.
Magnetic resonance and ultrasound imaging of specific soft-tissue structures show that bursae, tenosynovial sheaths and joint capsules in the shoulders and hips may be inflamed with PMR, but no erosion or bony adaptation is present. Many specialists suggest this inflammation contributes to the sensation of stiffness and pain in the muscles that cross these joints.
PMR also might show systemic symptoms including low fever, weight loss, weakness, fatigue and depression. While it's not a dangerous disorder and the life expectancy of a person with PMR is the same as the general population, this condition certainly can interfere with the quality of a person's life. Fortunately, it's self-limiting and symptoms usually subside within two years of onset.
Complications of PMR
PMR by itself doesn't carry a lot of potential complications, but about 15 percent of people with the condition have another immune-system hypersensitivity reaction called temporal arteritis or giant cell arteritis (GCA). This condition does have some serious consequences including a high risk of permanent visual loss and some blood vessel damage. We will look more closely at GCA in the July column.
Treatment for PMR
The good news about PMR is that it's highly treatable. This chronic, low-grade inflammatory condition responds well to steroidal anti-inflammatories and most people report a significant reduction in symptoms within a few days of initiating treatment.
The bad news, of course, is that steroidal anti-inflammatories carry a long list of serious side effects including bone thinning (patients are counseled to supplement vitamin D and calcium), insulin disruption (this has implications for patients such as Karen's client, who uses insulin to control her diabetes), edema, liver and kidney problems, and other risks. Patients who take steroids must aim for the lowest possible dose for the shortest possible period of time, and they must be vigilant about scanning for side effects that can be prevented or treated.
PMR Versus FMS
Careful readers may now be wondering about differentiating between PMR and another common, poorly understood condition, fibromyalgia syndrome (FMS). Because they are both more common in women than in men, and both involve non-injury related muscle tenderness and debilitating fatigue, the potential for confusion is large. A few delineations can help sort out these conditions:
- PMR has observable markers in blood tests.
- PMR is limited to proximal joints and nearby muscles.
- PMR spontaneously resolves.
- PMR responds to steroidal anti-inflammatories.
None of those things is true for fibromyalgia syndrome. If a mature Caucasian female client reports a new onset of morning stiffness and muscle pain, it's very much worth their time to get tested for PMR, which has a different treatment protocol than fibromyalgia syndrome.
Massage for PMR
As always, judgments about massage and bodywork for clients with PMR boil down to potential risks and benefits. The risks of working with a client who has PMR include the fact that this is a demonstrably inflammatory condition, and some types of massage promote inflammation: We don't want to attract new fluid to areas like shoulders or hips that are already packed and busy. Other risks center around treatment: Does the client have any side effects related to steroid use that might interfere with the ability to deliver massage safely? These can include bone thinning, diabetes-management challenges and other complications. Remember, too, that anti-inflammatories quell pain symptoms, which makes clients easier to overtreat.
Benefits of massage and bodywork for clients with PMR can be significant if we are careful. If we can reduce muscle stiffness and fatigue without exacerbating local inflammation, what a gift for a person who always feels sore! Massage is unlikely to undo the immune system hyperactivity we observe with this condition, but it certainly can contribute to the coping skills of the client waiting for the problem to resolve.
In my next column, I will discuss the companion to PMR, giant cell arteritis (GCA). In the meantime, I'd love to hear from some of you who work with clients who have PMR, GCA or both. What's the best outcome you've seen? What will you do differently next time? This column is a place for you to share with your colleagues: What's on Your Table?
- Giant Cell Arteritis and Polymyalgia Rheumatica. http://familydoctor.org/online/famdocen/home/ common/pain/disorders/567.printerview.html.
- Saad E. Polymyalgia Rheumatica. www.emedicine.com/med/TOPIC1871.HTM.
- Mayo Foundation for Medical Education and Research. Polymyalgia Rheumatica. www.mayoclinic.com/health/ polymyalgia-rheumatica/DS00441.
- Egland A. Temporal Arteritis. www.emedicine.com/emerg/TOPIC568.HTM.