A client is tapering off her prednisone to treat her polymyalgia rheumatica. She still has persistent pain in her shoulders. Is there anything her massage therapist can safely do to help her?
Polymyalgia rheumatica sounds dire. The good news is, it’s highly treatable, and massage—with respect for pain and medications—is a great choice for people who are recovering.
ABMP Pocket Pathology: abmp.com/abmp-pocket-pathology-app
Nancy Garrick, D.D. (2017) Polymyalgia Rheumatica, National Institute of Arthritis and Musculoskeletal and Skin Diseases. Available at: www.niams.nih.gov/health-topics/polymyalgia-rheumatica
‘Polymyalgia Rheumatica’ (no date). NORD (National Organization for Rare Disorders). Available at: rarediseases.org/rare-diseases/polymyalgia-rheumatica (Accessed: 16 November 2021).
‘Polymyalgia Rheumatica: Practice Essentials, Pathophysiology, Etiology’ (2021). Medscape. Available at: emedicine.medscape.com/article/330815-overview#a7 (Accessed: 16 November 2021).
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0:00:00.0 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology, is a highly regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this ground-breaking resource serves up a comprehensive review of the pathophysiology signs, symptoms and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.
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0:01:15.4 Speaker 3: Hi, and welcome to I have a client who pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I am Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice. And sometimes, as we have all learned, that is harder than it looks.
0:02:00.3 S3: Today's episode of I have a client who comes from a massage therapist in Alberta who shares this terrific story. So, I have treated this client two times before her diagnosis. When she told me she had polymyalgia rheumatica, I was completely honest in saying I wasn't familiar with this condition. I actually used your app right there in the room to help me navigate. Side note, the app she refers to here is Pocket Pathology, that's a quick reference guide that I created with ABMP and it is a member benefit. I'll put a link in the show notes, of course. After reading the information on your pathology app, I decide it seemed like I could proceed with massage and just be cautious with my pressure as not to exacerbate her symptoms like it said. We've just done a nice relaxation massage for her.
0:02:51.4 S3: She has a couple of other health conditions and is taking a couple of other medications as well. Her pain is in her shoulders and it's worse at night. She is seeing a rheumatologist for the PMR who prescribed prednisone, she's slowly being weaned down. She started with three milligrams, is now at 20 milligrams, and by December should be at 1 milligram. The massage went well, and I referred her for some physio, I work in a physiotherapy clinic. The physio gave her some exercises and she seemed to get relief from the acupuncture that she had with them as well. I just saw her today for another massage and she seems happy with massage and physio. We got talking more about how she's coping, and she just seems confused about her diagnosis. I immediately thought of you and asked her if I could write to you about her condition. I've been at my clinic for 10 years and I have never come across this, so I thought there might be other people who could benefit from this experience.
0:03:52.3 S3: I would also love anything that might help her feel better. I was wondering if some lovely diaphragmatic breathing or progressive relaxation techniques would be helpful considering how challenging living with this pain seems to be. Well, this is the kind of message I love to receive. Thank you so much. And I'm happy to talk about polymyalgia rheumatica, which is indeed a weird and confusion condition. It sometimes has a dangerous associated condition, although that does not seem to be the case for this client, and usually it's very treatable, and so it almost always has a good outcome. So, here we go. Here's a brief overview of polymyalgia rheumatica or PMR. As always, let's start with the name polymyalgia, pain in many muscles, rheumatica, and also joints. So, that's descriptive, muscle and joint pain all over the body, but it doesn't tell us much about what this condition really is.
0:04:56.6 S3: PMR is an idiopathic disease that is probably multifactorial. It may involve a combination of genetic predisposition, exposure to some kind of environmental trigger and some abnormal white blood cell activity. It also appears to involve several cytokines that promote and prolong the presence of inflammation. Lots of people with PMR show signs of a recent infection with a virus, so this might be a version of a post-viral syndrome. The typical pattern with polymyalgia rheumatica is that a person who is usually a Caucasian woman somewhere between 50 and 80 years old, has a sudden onset of extremely painful, aching, stiff, sore muscles and joints. I've heard people describe it like the pain they might have after having worked out really hard, but it just keeps coming and getting worse day after day after day. And this painful episode can last for many months or even years if it's not treated and then some day it just begins to subside.
0:06:07.9 S3: The symptoms of PMR resemble what we see with fibromyalgia in many ways, but its pathophysiology is clearly different, because it has some easily identified inflammatory markers that we don't see with fibro. When a person has an episode of polymyalgia rheumatica, their muscles are painful and the fascia, the bursa, and the synovial capsules may also become inflamed and red and hurt. The good news is that joint inflammation in this condition appears to be non-erosive, that is to say, this isn't like osteoarthritis or rheumatoid arthritis where the cartilage or the synovia inside joint capsules might sustain permanent damage. Most people with PMR do not experience significant permanent loss of function in their muscles or their joints. The main signs and symptoms include deep aching pain of the neck, shoulders and hips. It usually has a short onset, it develops over a few days, and it is really bad after periods of inactivity.
0:07:08.9 S3: Morning stiffness is a big issue. Sometimes it begins on only one side, but eventually it becomes bilateral. It usually starts at the shoulders and hips, but may move more distally and eventually the range of motion can be severely limited. Some people may also experience low grade fever, malaise, anemia, weight loss, distal edema and fatigue when it all begins. So, here is this very strange sort of free-standing inflammatory disorder that just appears to crop up. We see it mostly among mature women of northern European descent, the average age at onset is 72 to 74, depending on who you read, and it is rare in people under 50, but it is not entirely sex or ethnicity-specific, we do see it in other populations as well, just not as often. We don't know why it happens, it seems to have some autoimmune features, but unlike other autoimmune diseases, it does not appear in a pattern of flare and remission.
0:08:17.7 S3: It seems to be like one long flare, and then it just goes away, hopefully without leaving any tissue damage behind. But as I said before, there's another condition that appears alongside PMR called giant cell arteritis or GCA, and GCA happens often enough that it is considered to be related in some way, the exact sequelae is just not understood, and GCA, giant cell arteritis has some really serious possible consequences. About 15% to 20% of all people with polymyalgia rheumatica develop giant cell arteritis. And about half of all people with giant cell arteritis had polymyalgia rheumatica first. So, these two conditions are clearly connected somehow, and people diagnosed with PMR are typically told to be on the look out for signs of GCA, in giant cell arteritis, which is sometimes called temporal arteritis or cranial arteritis. What we see is that the medium-sized blood vessels in the head and the face become inflamed, they may harbor clots and interrupt blood flow, and this is really serious, because it carries the possibility of permanent vision loss or stroke.
0:09:40.2 S3: Right, so I'm gonna put aside any more discussion of giant cell arteritis until we get an I have a client who story with that topic. Let's return to our client who thankfully is not reporting an issue with GCA, and let's talk about her treatment options. We know from the therapist's description that this person is currently being tapered off her prednisone and that's really great. I have to say, I am a big, big fan of prednisone. It's an incredibly effective anti-inflammatory. It's also an immune system suppressant. So for people who have inflammation with an immune system component, prednisone makes a lot of sense and it works. Great. But this drug comes with a big sack full of side effects, it can cause edema and mood changes, and bone thinning and kidney damage, and that's just the short list. These problems are usually connected with long-term steroid use, right? But the people who have PMR might have to use prednisone on and off for many, many months.
0:10:44.5 S3: So, this is one of those drugs where it is really important to find the lowest possible dose to be effective and to use it for the shortest possible time to manage signs and symptoms. And most people don't respond well to rapid changes in prednisone doses, so people will have to work up to the required dose and then taper off as we see in this case. And if it's tapered off too quickly, then the symptoms of PMR return. PMR tends to respond really well to prednisone and for most people, this drug regimen essentially solves the problem and shortens what could be a two or three-year episode of deep aching, debilitating muscle and joint pain to a kind of unpleasant several weeks or maybe a few months. In addition, and this is really important for massage therapists to know about clients with PMR, patients are usually encouraged to stay as active as possible. They might be limited by pain and stiffness, but this condition, again, outside of the risk of giant cell arteritis is not associated with permanent tissue damage.
0:11:53.9 S3: And generally, when people are encouraged to exercise, it's a safe bet that most types of massage therapy will be safe as well. I'm not saying that this is the time to break out elbows and go deeply without respect for the client's tolerance, not at all, but there's no reason people with polymyalgia rheumatica need to be especially cautious about receiving massage that is within their limits of comfort. It sounds like this client is under supervision with her steroid use and she's getting massage, physiotherapy and acupuncture at this multi-disciplinary clinic. She seems to especially appreciate her massage and she is still having pain in her shoulders at night. So her therapist asks, I would love to know anything that might help her feel better. I was wondering if some lovely diaphragmatic breathing or progressive relaxation techniques would be helpful considering how challenging living with this pain seems to be?
0:12:49.4 S3: Well, I make no secret of the fact that I am not in practice and I seldom give any more than super basic guidance about specific hands-on techniques. I think working with the breath is a great idea for almost everyone, but that's obviously informed by my own biases. If this lady has persistent shoulder pain, especially at night, then coordinating with her physiotherapist for some stretching and gentle exercises she can do at home, seems like a good plan. And progressive relaxation and breath work may also help with her sleep, if that's a problem for her. Another as yet unanswered question that will weigh into clinical decisions is about what other conditions this client currently has and what medications she's using to treat them and we didn't get any information on that in the description. But let's put that aside for the moment and just realize that this client has a mysterious, painful, long lasting condition, but she also has the benefit of effective treatment and a curious and compassionate massage therapist who wants to do her best for her, and we should all be so lucky.
0:13:57.9 S3: Hey everybody, thanks for listening to I have a client who pathology conversations with Ruth Werner. Remember, you can send me your I have a client who stories to firstname.lastname@example.org. That's ihaveaclientwho, all one word, all lower case @abmp.com. I can't wait to see what you send me and I'll see you next time.