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A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 37 the hoped-for benefits of massage may delay their seeking help from a primary care provider). • GCA in particular is associated with some serious complications that appropriate treatment can prevent—a delay in treatment can lead to permanent damage. ETIOLOGY: WHAT HAPPENS? PMR and GCA have been painstakingly studied for many years, and we still don't completely understand how these conditions come about. It is clear they both involve inappropriate immune system activity, perhaps in reaction to a common viral trigger. They appear to have a predictable chemical profile with consistently high levels of a pro-inflammatory cytokine called IL-6. Further, IL-6 levels appear to correlate with the severity of symptoms, and this finding may help in the development of more treatment options. PMR In PMR, the inappropriate immune system activity appears to begin in the synovia of the proximal limb joints: shoulders and hips, and sometimes the neck. Inflammation may affect the joint linings, bursae, and synovial sheaths in the area. The individual often interprets this as muscle pain and weakness, but strength tests and muscle biopsies are normal. And here is more good news: the inflammation of joint capsules in the shoulders and hips is non- erosive—no permanent damage accrues. In rare cases, PMR may cause some swelling in distal tissues of the arms or legs, but this is the exception rather than the rule. Untreated PMR may persist for many months, up to a couple of years. At that time, it may spontaneously resolve with no lasting consequences, but about one-fifth of people with PMR also develop GCA. GCA In GCA, we see the accumulation of abnormal white blood cells that proliferate in the lining of medium and large arteries. These are the "giant cells" found in tissue biopsies. We don't know why this occurs, but the result of this type of vasculitis is a risk for obstruction of the artery, and tissues downstream of the damaged vessel may degenerate and die. Arteries that branch off the carotid are the most commonly affected by GCA. This condition is not limited to the arteries that supply the head, however; it can also affect the subclavian artery, and it may weaken the ascending arch of the aorta. SIGNS AND SYMPTOMS PMR Signs and symptoms of PMR look as if someone engaged in a lot of unusual activity one day, and then woke up the next feeling terribly stiff and sore. Pain centers in the lower neck, shoulders, and hips. It is worse after rest and in the morning, and it can make activities of daily living—including getting out of bed or standing up from using the toilet—extremely difficult. About half of all patients report a sudden onset, but the other half experience a slower development of symptoms. Pain may begin on one side, but eventually becomes bilateral. About one-third of all PMR patients also have unexplained fever, cough, sore throat, and other subtle signs that might suggest low-grade vasculitis. In some cases, pain spreads to affect the upper arms and thighs, and, in rare versions, patients may experience substantial swelling in the extremities, with pitting edema. GCA GCA is usually identified by long-lasting headache that is accompanied by scalp tenderness and jaw pain. Inflammation of the throat and the tongue are common. Diagnostic Criteria for PMR and GCA PMR and GCA have some diagnostic criteria in common, and many patients who have markers for one condition may have subtler markers for the other. Symptom or Sign PMR GCA Age is 50 years or older High erythrocyte sedimentation rate (a marker for inflammation) Pain for more than 1 month in 2 or more of the shoulder, neck, or pelvic girdle 1 hour or more of morning stiffness New headache, scalp, or jaw pain Abnormality of the temporal artery, including tenderness and decreased pulsation Positive biopsy of temporal artery Rapid response to steroidal anti- inflammatories Low-grade fever, weight loss, and depression may also develop. And any visual changes—dizziness, difficulty focusing, double vision or cloudy vision, or any loss of balance or coordination—need to be referred to a doctor immediately: damage to the optic nerve is irreversible, and permanent blindness is a real possibility. One final observation about PMR and GCA is that their onset appears to occur most often in the spring and summer, and falls off in the autumn and winter.