Discover the symptoms, diagnosis, and treatment options for polymyalgia rheumatica. Get expert advice on Meri Sehat today!

Polymyalgia Rheumatica

Online Consultation

Ismail Munir

Overview

Polymyalgia translates to &lsquo;many muscle pains&rsquo;, while rheumatica means &lsquo;changing/influx&rsquo;. Thus, polymyalgia rheumatica (PMR) is an inflammatory condition characterized by widespread muscular pain and stiffness. 
&nbsp;

Polymyalgia rheumatica (PMR) is a disorder that causes muscle discomfort, stiffness, and inflammation in the shoulders, neck, and hips. People with PMR may be in their 80s or even older because the average age at which symptoms first appear is 70.&nbsp; Rarely does it appear in those under 50 years of age<a href="#accordion">[2]</a>. Women are somewhat more frequently affected than men.

Although all ethnicities can develop PMR, white people seem to experience it more frequently than other ethnic groups<a href="#accordion">[1].</a> In some predominantly white populations, PMR has been reported to be the second most prevalent inflammatory autoimmune rheumatic disease after<a href="https://merisehat.pk/disease/rheumatoid-arthritis"> rheumatoid arthritis</a><a href="#accordion">[3]</a>. It is substantially less common among African-American, Asian-American, and Hispanic populations<a href="#accordion">[3]</a>. Moreover, Northern European and Scandinavian people have shown a high risk of the disease<a href="#accordion">[2]</a>.

The exact cause of PMR is unknown. However, it is thought to be an autoimmune illness where the body&#39;s immune system targets healthy tissues. In 20% to 30% of those with PMR, temporal arteritis is a common development<a href="#accordion">[5]</a>. The frequency of polymyalgia rheumatica (PMR) varies geographically. In the United States, the average annual incidence in those aged 50 and older is 52.5 cases per 100,000<a href="#accordion">[4]</a>. Whereas, the prevalence ranges between 0.5% and 0.7%<a href="#accordion">[4]</a>. In the UK, the prevalence of PMR in patients aged 55 years and older ranged from 0.91% to 1.53%, depending on the diagnostic criteria utilized<a href="#">[4]</a>. 
&nbsp;

Polymyalgia rheumatica has no types. 
&nbsp;

Signs and Symptoms

Polymyalgia rheumatica (PMR) is characterized by symmetrical pain and stiffness around the shoulders, hip girdle, neck, and torso, which is worse in the morning. The onset can be sudden, even startlingly so, and appear to happen quite instantly.&nbsp; Other common clinical features include: 
&nbsp;

<ul>
	<li>Bilateral shoulder pain, which happens in 70-95% of patients, presents in the upper arms with restriction of active shoulder abduction.</li>
	<li>Neck pain occurs in 70% of patients.</li>
	<li>Hip girdle pain occurs in 50% of patients.</li>
	<li>Pelvic girdle symptoms present as pains in the groin and lateral aspects of the hips which often radiate to the posterior region. This is often &lsquo;referred pain&rsquo; from the joints and structures of the hips and shoulders.</li>
	<li>Wrists, metacarpophalangeal joints, and knees are involved in almost one-half of patients. </li>
	<li>Carpal tunnel syndrome because of wrist involvement is seen in 10-15% of patients.</li>
	<li>Morning stiffness or gelling can be severe with PMR and if left untreated it can last into the late morning or afternoon. Stiffness might return after a prolonged period of inactivity, such as a long vehicle ride. Nighttime ache is common.</li>
	<li>Proximal stiffness might make it difficult to perform daily tasks like getting dressed, putting on a bra, putting on socks and shoes, or getting up from lying down or sitting to standing. When the gelling phenomenon is severe and the proximal region is stiff, patients may need help getting dressed in the morning.</li>
	<li>Systemic signs of PMR are malaise, fatigue, <a href="https://merisehat.pk/disease/depression">depression</a>, <a href="https://merisehat.pk/disease/anorexia-nervosa">anorexia</a>, weight loss, and low-grade fever. 
	&nbsp;</li>
</ul>

The majority of people with this condition eventually fully recover.<a href="#accordion">[6]</a>

&nbsp;

Causes

Polymyalgia rheumatica (PMR) is an inflammatory disorder that causes muscle pain and stiffness in various parts of the body, most commonly the neck, shoulders, hips, and arms. Its exact cause remains unknown.

The presence of elevated inflammatory markers reveals it to be an immune-mediated disorder. Another theory points to the role of genes and gene variation in increasing one&rsquo;s risk of the disease. Moreover, polymyalgia rheumatica is typically seasonal and is frequently diagnosed in cycles. This shows that the illness may be brought on by an environmental trigger, such as a viral infection. The rapid onset of symptoms also points to being brought on by an infection. However, no such connection has been discovered.

In addition, the incidence of PMR increases with age, affecting older people more often.<a href="#accordion">[1]</a> <a href="#accordion">[2]</a> 
&nbsp;

Temporal arteritis, also called giant cell arteritis (GCA), can often affect people with polymyalgia rheumatica. It is characterized by an inflammation of arteries, particularly those on each side of the head, the scalp, and the aorta and its main branches. Giant cell arteritis frequently manifests as jaw discomfort, tenderness in the scalp, and headaches. Visual issues like temporary or permanent vision loss or double vision may occur if the blood vessels that nourish the eyes are harmed. If you experience vision problems, it&#39;s critical to get medical attention right away because, if untreated, they can result in total blindness. 15% of patients with GCA develop permanent visual loss<a href="#accordion">[5]</a>.

Many medical professionals believe that PMR and GCA represent different points on a continuum of a particular systemic inflammatory disease syndrome, with PMR expressing a milder type of disease and GCA indicating a more severe disease<a href="#accordion">[5]</a>. Corticosteroids must be used at higher dosages in GCA than in polymyalgia rheumatica. Your doctor will probably request a temporal artery biopsy if they suspect giant cell arteritis. 
&nbsp;

There are currently no screening tests for polymyalgia rheumatica. However, a clinical history and physical examination can help doctors suspect the disease. Thus, leading them to order additional tests. 
&nbsp;

Diagnosis

To make an accurate diagnosis, your doctor will first perform a physical exam. During the examination, the neck, arms, and legs are gently moved to assess their range of motion. The doctor also assesses tenderness over the shoulders. However, muscle strength will likely remain intact during the examination.

The doctor may order the following tests to help confirm the diagnosis: 
&nbsp;

<ul>
	<li>Erythrocyte Sedimentation Rate (ESR) And C-Reactive Protein (CRP) Levels: Abnormally high levels are suggestive of inflammation which is a common feature of PMR. CRP can be a better indicator of disease activity, whereas ESR is a good indicator of relapse.</li>
	<li>Complete Blood Count (CBC): This is required to detect normocytic, normochromic anemia. White blood cells are normal or mildly elevated and platelet count is increased indicating inflammation<a href="#accordion">[4]</a>.</li>
	<li>Liver Function Tests (LFTs): Alkaline phosphatase might be slightly increased in around one-third of patients, and serum albumin levels might be decreased slightly<a href="#accordion">[4]</a>.</li>
	<li>Ultrasound: To check for inflammation in your joints and tissues, your doctor might also arrange an ultrasound. An ultrasound makes precise images of the soft tissue in various areas of your body using high-frequency sound waves.</li>
	<li>Magnetic Resonance Imaging (MRI): MRI helps detect inflammation just as an ultrasound, but it is particularly more sensitive for hip and pelvic girdle findings. Moreover, an MRI scan can also detect other causes of shoulder pain, such as joint changes.</li>
	<li>Biopsy: Your doctor might conduct a temporal artery biopsy since polymyalgia rheumatica and temporal arteritis can occur together. 
	&nbsp;</li>
</ul>

Doctors may order further tests to rule out other diseases that cause similar symptoms. For example, tests for rheumatoid factor and anti-CCP antibodies can help rule out rheumatoid arthritis. 
&nbsp;

As per the new criteria developed by the American College of Rheumatology and The European League Against Rheumatism, patients aged 50 years and above can be classified as having PMR if they meet the conditions below<a href="#accordion">[7]</a>:

<ul>
	<li>Bilateral shoulder pain</li>
	<li>Morning stiffness lasting at least 45 minutes</li>
	<li>Blood tests reveal a high level of inflammation</li>
	<li>Hip pain</li>
	<li>Blood tests for rheumatoid arthritis are negative</li>
	<li>No swelling present in the small joints of the feet and hands 
	&nbsp;</li>
</ul>

Some other illness that can be confused with PMR are<a href="#accordion">[7]:</a>

<ul>
	<li>Infections</li>
	<li>Rheumatoid arthritis</li>
	<li>Inflammation of blood vessels (vasculitis)</li>
	<li>Hormonal and chemical abnormalities</li>
	<li>Cancer</li>
	<li>Several other muscle diseases 
	&nbsp;</li>
</ul>

Treatment

Polymyalgia rheumatica is incurable. However, symptoms can get better in as short as 24 to 48 hours with the right care. To aid in reducing inflammation, your doctor may prescribe a low-dose oral glucocorticoid, such as prednisone. If your symptoms, including any signs of inflammation, improve after 3 or 4 weeks of treatment, your doctor may lower your dosage. The objective is to determine the lowest dose at which you remain comfortable. Within a year, some patients are able to discontinue using corticosteroids. While others will only use&nbsp;a small dose of this medication for two to three years to keep pain and stiffness under control.

If medication dosage is lowered too rapidly, symptoms may return, and frequently do. Your doctor should prescribe a gradual reduction in the dosage of corticosteroids because PMR symptoms can be affected by even slight variations in the dose. 
&nbsp;

In Case Of Relapse: Increase oral prednisone to the pre-relapse dose and gradually reduce it (within 4 to 8 weeks) to the dose at which the relapse occurred in order to treat relapses<a href="#accordion">[3]</a>. 
&nbsp;

Side Effects Of Glucocorticoids

Although steroids are a successful treatment of PMR symptoms, they may increase your risk of the following diseases if used long-term:

<ul>
	<li>High cholesterol</li>
	<li>High blood pressure</li>
	<li>Depression</li>
	<li><a href="https://merisehat.pk/disease/diabetes-type-1-and-2">Diabetes</a></li>
	<li>Weight gain</li>
	<li><a href="https://merisehat.pk/disease/osteoporosis-80">Osteoporosis </a>(loss of bone density)</li>
	<li>Cataracts 
	&nbsp;</li>
</ul>

To Reduce Side Effects

<ul>
	<li>The American College of Rheumatology recommends 1,000 to 1,200 milligrams of calcium supplements and 600 to 800 international units of <a href="https://merisehat.pk/disease/vitamin-d">vitamin D </a>supplements for anyone using corticosteroids for three months or more<a href="#accordion">[9]</a>.</li>
	<li>Physical therapy can help increase your range of motion.</li>
	<li>Maintain a healthy lifestyle with a balanced diet and low consumption of salt to prevent <a href="https://merisehat.pk/disease/hypertension-57">high blood pressure</a>. 
	&nbsp;</li>
</ul>

Monitoring During Treatment

To monitor your health during treatment, your doctor will:

<ul>
	<li>Order cholesterol and blood sugar level tests</li>
	<li>Recommend eye exams annually</li>
	<li>Order a bone density test to keep a check on osteoporosis</li>
</ul>

Non-steroidal anti-inflammatory drugs (NSAIDs) which are over-the-counter pain relievers are frequently used to reduce pain. 
&nbsp;

Note: It&#39;s possible that polymyalgia rheumatica is not the true cause of your pain and stiffness if your symptoms don&#39;t get better with glucocorticoids. In this situation, additional exams to rule out other rheumatic diseases will be performed by your doctor, including:

<ul>
	<li>Rheumatoid arthritis</li>
	<li>Osteoarthritis</li>
	<li>Rheumatic fever 
	&nbsp;</li>
</ul>

Most patients with polymyalgia rheumatica have a normal life expectancy and can lead a normal life with careful monitoring and the right therapy. 
&nbsp;

PMR symptoms can make it difficult for people to do everyday tasks, such as getting dressed, walking, or bathing. The lack of treatment can severely reduce one&rsquo;s range of motion. Moreover, some people may also experience a temporary loss of function of a joint. This predisposes them to join problems, like a frozen shoulder. 

Polymyalgia is oftentimes accompanied by temporal arteritis which has severe consequences if left untreated. Other common complications are: 
&nbsp;

<ul>
	<li>According to various research, people with polymyalgia rheumatica have a 1.15 to 2.70 times higher chance of developing cardiovascular illnesses<a href="#accordion">[3]</a>.</li>
	<li>PMR patients have higher chances of developing inflammatory arthritis<a href="#accordion">[3]</a>. 
	&nbsp;</li>
</ul>

Risk factors of polymyalgia rheumatica include:<a href="#accordion">[9]</a> 
&nbsp;

<ul>
	<li>Age: Older adults are almost exclusively affected. </li>
	<li>Sex: Women are 2 to 3 times more likely to develop this disease</li>
	<li>Race: White people of Scandinavian or northern European ancestry are most commonly affected 
	&nbsp;</li>
</ul>

Unfortunately, there are no known preventive measures for polymyalgia rheumatica. 
&nbsp;

<ul>
	<li>Deflazacort, a corticosteroid, is being investigated as a potential treatment for polymyalgia rheumatica. Deflazacort may be an effective alternative to prednisone with lesser side effects.&nbsp;To ascertain the long-term safety and efficacy of this medication for the treatment of polymyalgia rheumatica, more research is required. </li>
	<li>Researchers are also investigating immunosuppressants like methotrexate for the treatment of PMR. To ascertain the long-term security and efficacy of this possible therapy for sufferers of polymyalgia rheumatica, further clinical trials are required. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>Polymyalgia rheumatica is an inflammatory condition characterized by widespread muscular pain and stiffness.</li>
	<li>Polymyalgia rheumatica (PMR) is characterized by symmetrical pain and stiffness around the shoulders, hip girdle, neck, and torso, which is worse in the morning.</li>
	<li>People who have PMR may be in their 80s or even older because the average age at which symptoms first appear is 70.</li>
	<li>Women are somewhat more frequently affected by the condition than men.</li>
	<li>People with PMR are also likely to develop temporal arteritis. It is characterized by inflammation of the blood vessels in the neck, scalp, and arms. The condition results in headaches, jaw pain, and vision problems.</li>
	<li>The exact cause of polymyalgia rheumatica is unknown. However, researchers believe it might be an autoimmune condition.</li>
	<li>Some other illnesses that can be confused with PMR are infections, rheumatoid arthritis, vasculitis, hormonal and chemical abnormalities, cancer,&nbsp; and several other muscle diseases.</li>
	<li>Polymyalgia rheumatica is incurable. However, symptoms can get better in as short as 24 to 48 hours with the right care.</li>
	<li>Steroids are typically preferred for the treatment of polymyalgia rheumatica. Dosage is tapered gradually because of the risk of relapse and side effects. 
	&nbsp;</li>
</ul>

[1] Polymyalgia Rheumatica - American college of rheumatology.

[2] Higuera V. Polymyalgia Rheumatica. Healthline.

[3] Acharya S, Musa R. Polymyalgia Rheumatica. [Updated 2022 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.