What's up doc? That pain and stiffness may be PMR

[Guest guest]

What's up doc? That pain and stiffness may be PMR

By Dr. Jeff Hersh / News Correspondent

Tuesday, January 18, 2005

QUESTION: My uncle was diagnosed with PMR. What is this and how is it

treated?

ANSWER: Polymyalgia rheumatica is a syndrome of unknown cause that

usually afflicts people over age 50. It is fairly common, with some studies

estimating it affects anywhere from 1 in 200 to 1 in 1,000 people over age

50. There may be a hereditary component to PMR, but it is not strongly

hereditary. It is more common in women and in white people of Northern

European origin, and is actually pretty rare in African Americans.

Patients with PMR usually present with symptoms of pain and stiffness.

The most commonly affected areas are the neck, shoulders, lower back, hips

and thighs. It usually affects both sides of the body the same (it is

symmetric) and is often worse in the morning. Other common symptoms include

weight loss, fatigue and low-grade fevers. Patients with PMR often have low

blood counts (anemia), and may have night sweats. PMR patients may also

develop depression.

PMR affects the muscles, not the bones and joints like arthritis. The

muscles become inflamed and this leads to the soreness and stiffness. The

pain of PMR can be severe and may awaken the patient at night.

It is believed that inflammation of the blood vessels that supply the

muscles is associated -- and may be causative -- of this disorder. There is

no weakness of the muscles per se, but the pain and stiffness may make it

seem to the patient that their muscles are not working normally, and they

often complain of feeling weak. The pain and stiffness of the hips, legs and

lower back may make it hard for them to rise up out of a chair. If the

shoulders and neck are affected it may be difficult for them to use these

muscle groups to lift things.

There is no definitive test for PMR, but sometimes your doctor will do

tests to rule out other diseases (such as other inflammatory conditions of

the muscles). A non-specific test (the ESR or erythrocyte sedimentation

rate) is almost always elevated in PMR, and is often used as a screening

test (if it is not elevated, then PMR is not usually the cause of the

symptoms). A rheumatoid factor (RF) blood test may be done to screen for

rheumatoid arthritis.

Most patients with PMR will get better within a couple of years even

without treatment. Although PMR is not life threatening, symptomatic

treatment is often required. First-line treatments may include non-steroidal

anti-inflammatory drugs such as ibuprofen or naproxen and/or exercise

regimens to improve pain and stiffness. For severely symptomatic patients

with PMR low doses of steroids (such as prednisone) are usually very

effective -- although patients may need to be treated for six months to two

years.

With treatment, even severe symptoms usually improve quickly. If

symptoms recur after treatment is stopped, another course of steroids is

usually required.

Up to 15 percent of people with PMR develop giant cell arteritis (also

called temporal arteritis since the temporal artery is involved), an

inflammation of the medium sized arteries (the inflammation causes

multi-nucleated giant sized cells in these arteries, so it is not really a

misnomer). Temporal arteritis occurs in people without PMR as well, and so,

although there is an association between these diseases, they should also be

considered as separate entities.

The symptoms of temporal arteritis typically include headache (which

can be severe pain in the temporal area), tenderness of the temporal area

(and often the entire side of the head, to the point where it may even hurt

to brush your hair), transient or even constant vision changes (blurred

vision, double vision, vision loss), jaw stiffness/soreness, neck soreness

or eyelid droop. As with PMR, fatigue, weight loss, depression or low-grade

fever are also common.

Temporal arteritis is more common in older people, especially in people

over age 70, and is twice as common in women than men.

Although PMR is usually self-limited (even if not treated it would get

better, eventually, on its own with no permanent sequelae), temporal

arteritis can cause blindness if not treated. This makes it a medical

emergency.

As with PMR, an ESR blood test is usually done as a screening test. If

it is elevated, steroid treatment (typically prednisone, but at a higher

dose than for PMR) is immediately begun. A biopsy of the temporal artery is

then done (within two weeks after treatment is started) to confirm the

diagnosis.

Thankfully, if treatment is begun before there is vision loss, then the

prognosis for complete recovery is excellent. If there is constant vision

loss before treatment is begun, then the vision loss is often permanent.

So, if you have symptoms of temporal arteritis you should seek

treatment immediately. If you have symptoms of PMR (but not temporal

arteritis) you should see your doctor for evaluation and to discuss

treatment options.

Jeff Hersh, Ph.D., M.D., F.A.A.P., F.A.C.P., F.A.A.E.P., is an

attending doctor at St. 's Hospital, director of emergency medicine

research at Worcester Medical Center and an assistant professor at the

University of Massachusetts Medical School. He can be reached at

DrHersh@....

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