Health Beat: What to know about PMR
In 1983, I was a rheumatology fellow (in training) and was called to see an old preacher who was being seen in the urology clinic at North Carolina Baptist Hospital.
He told me, “Doc, I’m hurting all over.” I asked him to sit up on the exam table but he couldn’t do it without assistance. He was stiff and sore with muscle pain in his shoulders, upper arms, hips and upper legs. He received a steroid injection, prompting a dramatic improvement in his pain within a few hours. He later told me that the Lord had healed him.
That was the first time that I saw, diagnosed and treated polymyalgia rheumatica.
Polymyalgia rheumatica (PMR) is an inflammatory disease associated with widespread aching, pain and stiffness in the shoulders, hip girdle and neck. It is virtually never seen in patients less than 55, with peak incidence over 70, and is more common in women, Caucasians and those of Northern European descent. Only rheumatoid arthritis is a more common inflammatory systemic disease.
Extensive evaluations have not shown inflamed muscles but some imaging shows inflammation in the tendons and bursae around the shoulder, neck, hip and back. Blood tests usually show non-specific elevation of inflammation levels, but there are no blood tests or imaging studies that prove the diagnosis. That is made on clinical grounds by the physician.
Most patients present with symmetrical aching and stiffness in the shoulders, hips, neck and torso, which is worse in the morning or after inactivity and usually sudden in onset. On occasion, patients have low-grade fever, fatigue, depression, and weight loss, but pain is the most common presentation.
The cause of PMR remains unknown. It is associated with giant cell arteritis (GCA), an inflammatory arterial disease, in about 10% of cases. GCA adds a particular risk and complication when seen with PMR, where headaches, jaw pain, prominent scalp arteries and a risk of stroke, including blindness, prompts more aggressive treatment.
It can be difficult to diagnose PMR, which sometimes gets confused with rheumatoid arthritis or other inflammatory diseases, such as myositis, hypothyroidism, a widespread pain syndrome, fibromyalgia, or even recurrent bursitis and tendonitis. Again, when GCA is associated, the combined disorders present greater risk. And GCA typically requires a temporal artery biopsy to diagnose.
The treatment of PMR initially involves low dose steroids, typically prednisone, with a starting dosage of around 15mg. A dramatic response is typical with marked resolution of pain and stiffness in the great majority. A gradual taper over 1-3 years is also typical with attempts to discontinue. Most cases of PMR run a self-limited course, but I have had a few patients that required 10 years of low dose prednisone before the medicine could be stopped. If GCA complicates the disease, more aggressive treatment is necessary, often 60 mg of prednisone or more. In particular patients, where the steroids are not tolerated well, or cannot be tapered easily, other immunosuppressive drugs may be used, such as methotrexate. Somewhat surprisingly, anti-inflammatory drugs, such as naproxen or ibuprofen, and physical therapy do not help in most cases.
Thankfully, PMR has a favorable prognosis, without expected crippling or premature death. Unlike arthritis such as rheumatoid, no deformity or structural damage is seen. Investigations continue for alternative therapies, and a precise cause, but even now, with proper assessment and treatment, most patients will do well and be off therapy in less than 5 years.
Dr. Randal White is a physician with Vidant Rheumatology.