POLYMYALGIA
RHEUMATICA (PMR)
What is PMR and how does it start?
Polymyalgia Rheumatica (‘poly’ = many; ‘myalgia’ =
painful/aching muscles), hereafter referred to as PMR, is an inflammatory
rheumatic condition characterised by pain and stiffness usually in the
shoulders and thighs and also the neck.
It affects almost exclusively people aged over 50 years, with the
average age of onset being 70 years. In
some people the onset is very sudden, literally overnight. In others there is a more gradual development
over a few weeks. In an article on the
netdoctor.co.uk website, there is reference to a “flu-like illness just prior
to the onset of symptoms” being noticed by some patients, but the article goes
on to state that in most cases PMR is spontaneous.
There is no known cause of PMR as yet, but recent
studies and research are investigating the role of genetic predisposition,
immune system abnormalities and environmental factors in both PMR and Giant
Cell Arteritis (GCA) - an associated condition, described later.
PMR may simply disappear in one to several years
without treatment (please refer to section headed ‘Treatment’). With treatment, the symptoms are usually
controlled quite quickly but recurrence is likely if treatment is stopped too
early. For the majority of people it is
generally expected that treatment will be required for two or more years, but
some people may have to continue treatment for many years.
In my search for information and research on PMR, I
discovered that for many of the conditions that mimic PMR and that PMR might be
wrongly diagnosed as, such as fibromyalgia (please see section headed
‘Differential Diagnosis’), there is a great deal known and a broad range of
information available, while there is relatively little in the case of
PMR. While acknowledging that some
studies and websites are more reliable than others, perhaps this lack of
research is one of the reasons that there were some inconsistencies in the
information, such as a range in incidence in relation to gender from equality
between males and females to a ratio of 3:1 females to males.
Epidemiology
In the majority of the literature, there was
consensus on the following. Women appear
to be two times as likely as men to be affected. While PMR can affect people of any race,
there is evidence to show that PMR is significantly more common in Caucasians,
particularly in Northern Europe and Scandinavia, than Asian or Afro-Caribbean
people, e.g. annual incidence:- approximately 4 per
1,000 people affected in the UK and just under 1.5 per 1,000 affected in South
Norway (figures from: - ARC Topical Review, netdoctor website, Mayo Clinic
website, eMedicine website). There
are wide variations in incidence rates by country and this is stated as one of
the reasons that genetic factors are being investigated as a possible cause.
Signs and Symptoms
The pain and stiffness is usually worse in the
morning and can be severely debilitating.
It differs from other ‘aches and pains’ in not being eased by
painkillers; it feels different from pain experienced following unaccustomed
exercise. The stiffness may be so severe that getting out of bed in the morning
is difficult or impossible, climbing stairs may be difficult and the pain may
cause broken sleep and erratic sleep patterns developing. Prolonged rest or inactivity may increase
the stiffness but equally ‘pushing yourself too far’ can bring on the
symptoms. Stiffness usually eases during
the day. Symptoms may be unilateral
initially but become bilateral.
Other symptoms might include fever, weight loss,
fatigue, depression and generally feeling unwell. Some people may experience inflammation and
swelling in other soft tissues, for example tenosynovitis or carpal tunnel
syndrome and some joints may become slightly swollen. In later stages muscle atrophy or frozen
shoulder might develop. Muscle strength
is usually normal.
The most serious complication of PMR is the
development of another related condition – Temporal Arteritis, also known as
Giant Cell Arteritis (GCA). The exact relationship
between PMR and GCA is unclear but it is estimated that approximately 15-25% of
people with PMR also develop GCA.
Interestingly, between 40-60% of those with GCA have PMR. This condition causes the inflammation of the
lining of the arteries of the skull, mostly the temporal arteries, although any
artery may be affected (temporal, ophthalmic and vertebral most commonly). Signs and symptoms include severe headaches,
pain at temples on touch, vision problems and jaw pain. Untreated, GCA can lead to damage to the
temporal arteries, a stroke or aneurysm or loss of vision. It is important that these signs and symptoms
are noted as soon as possible; GCA may develop before or simultaneously with
the PMR or after the PMR has disappeared.
Differential Diagnosis
There is no single test available to definitely
diagnose PMR. The patient’s history is
crucial in a diagnosis of PMR: - at the top of the list must be the description
of the onset of the pain and type of pain; when and how the pain and stiffness
arises during the day (worse after inactivity or activity?). This is combined with the results of an ESR
(erythrocyte sedimentation rate) blood test that measures the rate at which the
red blood cells fall to the bottom of the tube.
In PMR, the sedimentation rate is usually high. This test also measures inflammation in the
body. Other tests may be undertaken, for
example, the CRP (C-reactive protein) test; the patient may also be tested for
the RF antibody that is often present in people with rheumatoid arthritis for
the purposes of elimination of that condition.
A variety of conditions can present with polymyalgic
symptoms and it is important that these are excluded before a diagnosis of PMR
is made, they include:- Rheumatoid arthritis, osteoarthritis (in neck,
shoulders and back), polymyositis (muscle inflammation), cervical spondylosis,
bilateral shoulder conditions (e.g. adhesive capsulitis), underactive thyroid,
depression, Parkinsonism, myeloma (cancer of bone marrow) and fibromyalgia. The articles in the eMedicine and ARC
websites suggested that an MRI scan of the shoulders might reveal subdeltoid,
subacromial and bicipital bursitis.
In summary, a diagnosis of PMR can only be made after
taking a comprehensive medical history, the patient’s own account and
experience of the condition, physical examination and blood tests. If the patient is under 50 years, the
condition has chronic onset, there is no inflammatory stiffness and ESR and CRP
results are normal, these provide important clues to a non-PMR diagnosis. The possibility of other conditions
developing at a later stage has to be taken into account and there should be
consideration of signs and symptoms of GCA.
Treatment Issues
The treatment currently favoured for PMR is
corticosteroids, with prednisolone the most commonly prescribed drug. The initial daily dose, usually oral, begins
at about 15mg, depending on the severity of the condition. The dose is reduced gradually over time on
the basis of blood test results. In most
of the articles that I read, it was recommended that patients with PMR who are
prescribed with corticosteroids should also take calcium and vitamin D. Because it is known that both inflammation
and the side effects of steroid treatment can affect bone density, those ‘at
risk’ may also be prescribed medications to prevent bone loss. In mild cases, the initial treatment may be
NSAIDs (non-steroidal anti-inflammatory drugs) but these tend not to ease the
symptoms of many PMR sufferers; and in some prolonged cases, ‘steroid sparing’
drugs such as methotrexate might be used.
An intramuscular depot injection may be used as this “has the
advantage of much lower cumulative dose compared with oral prednisolone and
translates into lower steroid-related toxicity” (ARC Topical Review). Treatment is often required for two
years or longer and occasionally some people remain on small doses of steroids
for many years.
The many variables involved in reaching a diagnosis
of PMR and the very individualistic nature of the condition underlines the
absolute importance of taking a comprehensive history and adopting a holistic
approach to treatment.
While there is no literature providing structured
research evidence on the effects and possible benefits of massage therapy for
PMR, that I can find, I am aware of two cases of PMR, one of which reportedly
responded well to the relaxation effects of massage and the other where massage
appeared to trigger the pain and stiffness symptoms. Through the case of a family member who has
PMR I know that at the time of dose reduction, there is period of adjustment to
a lower dose and the reaction is sometimes a recurrence of the symptoms. Throughout the course of the condition, like
other inflammatory conditions, there can be ‘flare-ups’ and therefore periods
of acute inflammation, when massage would be contra-indicated. It is therefore vitally important that the
therapist develops a good relationship with the client and understanding of how
the condition affects them and is in this way aware of when massage might be
indicated and when it is not the most appropriate treatment. Considerations for the remedial massage
therapist therefore include:-
·
Client without
diagnosis but with pain that has come on suddenly, especially in the shoulders:
– at first the client might put the aches and pains down to having ‘overdone’
the gardening or ‘just getting older’.
The description of the onset and type of pain, location of pain and
stiffness (shoulders, thighs and/or neck), age of the client, no relief from painkillers,
severe morning stiffness (30 minutes to over 1 hour) that eases as the day goes
on, pain and stiffness after rest or inactivity, together these are possible
indicators of PMR and referral to the GP for blood tests is advisable. It is important to reiterate that many other
conditions mimic PMR symptoms.
·
Client with PMR
who begins to experience severe headaches, pain at temples or over scalp,
blurred vision and/or jaw pain – it is extremely important that they see the GP
as soon as possible, to check for giant cell arteritis (temporal
arteritis).
·
Given what we
know about the benefits of massage therapy in chronic conditions, it would seem
that there are many aspects of PMR that might be improved with Advanced
Remedial Massage, e.g. releasing muscle spasm; reducing pain; reducing
inflammation; restoring structural balance; affecting the nervous system to
encourage production of endorphins and stimulating the parasympathetic nervous
system to encourage rest and repair; boosting the immune system; improving
circulatory and respiratory systems to ensure a good supply of oxygen- and
nutrient-rich blood to the cells, efficient venous return and lymphatic
transportation of excess fluid, protein and waste products; improving joint
mobility, and so on. As mentioned
before, it is thought that environmental factors might be part of the cause and
stress is an obvious example, so the relaxation effects of massage in general
and increased awareness of the client should be of assistance in addressing the
effects of stress on the condition.
There are however reasons to be cautious:-
·
There is a wide
variation in the severity of the condition and there may be many or few
recurring episodes of the inflammatory symptoms, when massage would not be
appropriate.
·
Prolonged use
of corticosteroids carries the
possibility of many side-effects, including weight increase, osteoporosis, easy
bruising, indigestion, blood sugar level changes, muscle wasting, rounding of
face, fluid retention and others. Also,
while the dose is mainly administered orally, steroid injections are given to
some PMR patients, this of course is a local contra-indication to massage. If giant cell arteritis is diagnosed, the
treatment is a high dose of corticosteroids.
There are more details of the side effects and adverse outcomes of
steroid treatment for PMR and GCA on the Arthritis Research Campaign (ARC)
website: - “Risks of diabetes mellitus, vertebral, femoral neck and hip
fractures are reported to be 2-5 times greater in patients with PMR on steroids…”
(ARC Topical Review). The
combination of the effects of the symptoms of PMR, e.g. the effects of lack of
mobility and inflammation on joints and bones and the osteoporotic side effects
of corticosteroids is just one area for concern. In the book ‘Mosby’s Fundamentals of
Therapeutic Massage, it notes as a caution [about steroids and massage]
that because some massage techniques set up the inflammatory response and
changes are caused in stress levels, this may have an effect on the dose and
there are therefore implications for careful monitoring (and working with the
client’s GP) if regular massage is to be used.
In the ARC Information Booklet on ‘Complementary Therapies and
Arthritis’, it notes, “It is difficult to compare conventional medicine and
complementary therapies. Most medical
and other healthcare training institutions in the
·
Any chronic
condition where there is pain (and sleep patterns are broken), has
psychological and emotional effects on an individual and careful thought and
discussion with the client in relation to pain management will be
required. In the family member case
previously referred to, I know that breathing techniques, visualisation and
relaxation techniques have proved to be effective in easing the pain of acute
exacerbations of the condition. In
managing the condition, the following have also proved to be beneficial in that
case:- adequate exercise, adequate rest, pacing
yourself, reorganising when and how activities are undertaken (e.g. instead of
doing an activity in the morning when it takes a lot of energy and causes pain,
reschedule to a later time when the stiffness has eased), maintaining a healthy
diet (e.g. eliminating foods that can have an inflammatory effect). Other
therapies such as reflexology, Alexander Technique, Bowen Technique,
Aromatherapy, etc. may be beneficial. In
letters to the ARC quarterly magazine “Arthritis Today”, there were two
about PMR: - both recommended homeopathy as an effective treatment for PMR and
GCA.
In conclusion, PMR is a more common condition that
many might imagine. As I have described,
it can be severely debilitating physically, mentally and emotionally. There is relatively little literature
available, but new research is being undertaken into the possible causes. The diagnosis is difficult because of the
similarity of symptoms of PMR and other conditions and this must be kept in
mind. The lack of any solid research and
evidence (including the Touch Research Institute, to whom I wrote) on PMR and
touch therapies places extra emphasis on the necessity for the relationship and
trust between therapist and client (and the client’s GP) to be good; any
treatment plan must be holistic, tailored to the individual’s needs and
condition and be directed by the nature, stage and progression of the condition
as it affects that individual client at different times. It is clear however that there are many
potentially beneficial courses of action and therapies that might be used to
alleviate the symptoms of PMR and help to prevent or keep to a minimum the
long-term damaging effects of the condition and the steroid treatment.
Bibliography
Arthritis
Research Campaign (ARC) ‘An Information Booklet’ Polymyalgia Rheumatica
(PMR); ARC ‘Topical Review’ Polymylagia Rheumatica and Giant Cell
Arteritis – www.arc.org.uk/about_arth/med_reports/series4/tr/6602/6602.htm;
ARC ‘News and Features’ Complementary Therapies & Food Supplements – www.arc.org.uk/newsviews/hints/compfood.htm;
ARC ‘An Information Booklet’ Complementary Therapies And Arthritis (available
to download from site); National Institute of Arthritis and Musculoskeletal and
Skin Diseases ‘Health Topics’ Questions and Answers About Polymyalgia
rheumatica and Giant Cell Arteritis – www.niams.nih.gov/hi/topics/polymyalgia/index.htm;
eMedicine ‘Polymyalgia’ – author Ehab R Saad MD – www.emedicine.com/med/topic1871.htm;
‘Health Information at your fingertips’ Polymyalgia Rheumatica’ – www.patient.co.uk; ‘Polymyalgia
Rheumatica’ www.mayoclinic.com; ‘PMR’ www.netdoctor.co.uk/diseases/facts/polymyalgia.htm;
Oxford Concise Medical Dictionary; ‘Mosby’s Fundamentals of Therapeutic
Massage’ – Sandy Fritz; SMS Dip Advanced Remedial Therapy course notes;
Touch Research Institute www.miami.edu/touch-research/index.html
Essay
written for Advanced Remedial Massage Course (Scottish Massage Schools)