Robert Greenwald, M.D.

COULD YOUR PAIN BE POLYMYALGIA RHEUMATICA? Robert Greenwald, M.D. An often-overlooked cause of muscular and arthritic pain in senior citizens goes by the funny name of polymyalgia rheumatica, abbreviated PMR. It is a mysterious condition with which many physicians are not familiar. When properly diagnosed and treated, immediate and substantial relief can be given to its suffers.

PMR is very rare under the age of 60 and is seen mostly in Caucasians. It usually starts suddenly. Patients often report that they went to bed fine and woke up sore all over. It affects the muscles of the upper arms and upper legs. Symptoms include difficulty putting on a sweater or coat, trouble standing up from a chair, tossing and turning at night, and severe morning stiffness. The pains are usually symmetrical, and the hallmark is pain – not weakness. In some cases there is swelling on the back of the hands and wrists.PMR occurs in clusters – a specialist will see a few cases in a month and then it may disappear for several months at a time.

It is important to diagnose PMR not only because it can easily be treated, but also because there is a rare complication called temporal arteritis. This is inflammation of an artery that runs on the side of the forehead. Temporal arteritis, also called giant cell arteritis, can cause permanent vision loss that is devastating and irreversible. Symptoms include headache, pain on chewing food, and fever. Since the consequences of temporal arteritis are so serious, we often recommend a temporal artery biopsy whenever we even think it might be present. I would rather have ten negative biopsies than one patient go blind!

The key to diagnosis is first suspicion and second, a blood test called ESR (erythrocyte sedimentation rate.) Most cases have an elevated ESR (up to 30 is normal, 50 or more is highly suspicious, 100 is almost certain.) However, some cases have a normal ESR. Polymyalgia is not the same as fibromyalgia. Fibromyalgia is a psychosomatic disorder of younger people (mostly women), but both conditions cause diffuse pain with poor sleep and morning exacerbation.

The only effective treatment for PMR is with steroids, which of course is not without risk. Fortunately, almost all patients will get dramatically better within a few days on a very low dose. Anti-inflammatory drugs, such as Aleve or Advil, are uniformly ineffective. Prednisone (a steroid that is commonly used) is a 12-hour drug so it should be given half in the morning and half at night. Patients with diabetes or osteoporosis must be very careful as this drug can worsen these conditions. After 3 to 6 weeks on 10 mg, the dose is reduced in very small decrements – 9 mg/day for 3 weeks, then 8, etc. If I suspect PMR and give the patient 10 mg of Prednisone, and they call 3 days later using the word “miracle,” then I know my diagnosis was correct!