Polymyalgia Rheumatica
Overview
Polymyalgia rheumatica (PMR) is an inflammatory condition that primarily affects adults over 50 years of age, causing widespread muscle pain and stiffness. The name literally means "many muscle pains," which accurately describes the condition's primary characteristic. PMR typically affects the muscles and tissues around the shoulders, neck, and hips, leading to significant discomfort and reduced mobility.
This condition is considered a rheumatic disease and is closely related to giant cell arteritis (GCA), with approximately 15-20% of PMR patients also developing GCA. The exact cause remains unknown, but it's believed to involve an autoimmune response where the body's immune system mistakenly attacks healthy tissues.
PMR affects approximately 700,000 people in the United States, with women being affected twice as often as men. The condition is most common in people of Northern European descent and rarely occurs before age 50. The peak incidence occurs between ages 70-80, making it an important consideration in geriatric medicine.
Symptoms
The symptoms of polymyalgia rheumatica typically develop gradually over weeks to months, though they can sometimes appear suddenly. The hallmark feature is bilateral muscle pain and stiffness, particularly pronounced in the morning or after periods of inactivity.
Primary Symptoms
Additional Symptoms
Characteristic Pattern: The pain and stiffness in PMR typically affects both sides of the body symmetrically and is most severe in the morning or after periods of rest. Patients often describe difficulty getting out of bed or raising their arms above their heads.
Causes
The exact cause of polymyalgia rheumatica remains unknown, but research suggests it results from a combination of genetic predisposition and environmental triggers that lead to an inflammatory autoimmune response.
Autoimmune Component
- Inflammatory response: The immune system attacks healthy muscle and joint tissues
- Cytokine production: Increased levels of inflammatory markers like IL-6 and TNF-alpha
- Tissue inflammation: Synovitis in joints and bursitis in surrounding tissues
Genetic Factors
- HLA associations: Certain HLA-DRB1 and HLA-DQB1 alleles increase susceptibility
- Family clustering: Higher incidence in families with autoimmune conditions
- Ethnic predisposition: More common in people of Northern European ancestry
Environmental Triggers
- Viral infections: Some studies suggest viral triggers, particularly respiratory viruses
- Seasonal patterns: Higher incidence in certain geographic regions and seasons
- Stress: Physical or emotional stress may trigger onset
- Hormonal changes: Menopause and aging-related hormonal shifts
Risk Factors
Several factors increase the likelihood of developing polymyalgia rheumatica:
Non-modifiable Risk Factors
- Age: Risk increases significantly after age 50, peak incidence at 70-80 years
- Gender: Women are affected twice as often as men
- Ethnicity: Higher prevalence in people of Northern European descent
- Genetics: Family history of autoimmune conditions
- Geographic location: Higher rates in northern latitudes
Potentially Modifiable Factors
- Infections: Recent viral or bacterial infections may trigger onset
- Stress levels: High physical or emotional stress
- Smoking: May increase inflammation and worsen symptoms
- Vitamin D deficiency: Low levels may contribute to muscle symptoms
Diagnosis
Diagnosing polymyalgia rheumatica can be challenging as there is no single definitive test. Diagnosis is primarily based on clinical criteria, laboratory findings, and response to treatment.
Clinical Criteria
- Age requirement: Patient must be over 50 years old
- Symptom duration: Symptoms present for at least 2 weeks
- Bilateral shoulder pain: Most important clinical feature
- Morning stiffness: Lasting more than 45 minutes
- Hip girdle involvement: Pain and stiffness in hip area
Laboratory Tests
- Erythrocyte Sedimentation Rate (ESR): Usually elevated above 40 mm/hour
- C-Reactive Protein (CRP): Often elevated, indicating inflammation
- Complete Blood Count: May show mild anemia
- Rheumatoid Factor: Typically negative
- Anti-CCP antibodies: Usually negative
- Creatine kinase: Normal levels help distinguish from myositis
Imaging Studies
- Ultrasound: May show bursitis and synovitis in shoulders and hips
- MRI: Can detect inflammation in joints and surrounding tissues
- PET scan: May show inflammation in large vessels (if GCA suspected)
Differential Diagnosis
- Rheumatoid arthritis
- Fibromyalgia
- Hypothyroidism
- Polymyositis/dermatomyositis
- Malignancy
- Infection
Diagnostic Response: A dramatic improvement in symptoms within 1-3 days of starting corticosteroid treatment is considered highly supportive of the diagnosis of PMR.
Treatment Options
Treatment of polymyalgia rheumatica focuses on reducing inflammation, controlling symptoms, and preventing complications. The mainstay of treatment is corticosteroid therapy.
First-line Treatment
- Corticosteroids: Prednisolone 15-20mg daily is the standard initial treatment
- Gradual tapering: Slow reduction over 12-24 months to minimum effective dose
- Symptom monitoring: Regular assessment of pain and stiffness levels
- Laboratory monitoring: Regular ESR and CRP measurements
Steroid Management
- Initial response: Dramatic improvement expected within 1-3 days
- Tapering schedule: Reduce by 2.5mg every 2-4 weeks initially
- Maintenance dose: Aim for lowest dose that controls symptoms
- Duration: Most patients require treatment for 1-2 years
Adjunctive Treatments
- Methotrexate: May be added as steroid-sparing agent
- Calcium and Vitamin D: Bone protection during steroid therapy
- Bisphosphonates: Prevent steroid-induced osteoporosis
- Proton pump inhibitors: Gastric protection if indicated
Non-pharmacological Management
- Physical therapy: Maintain range of motion and strength
- Regular exercise: Low-impact activities like swimming or walking
- Heat therapy: Warm baths or heating pads for symptom relief
- Occupational therapy: Adaptive strategies for daily activities
- Stress management: Relaxation techniques and counseling
Prevention
While polymyalgia rheumatica cannot be completely prevented due to its unknown exact cause, certain strategies may help reduce risk or severity:
General Health Measures
- Regular exercise: Maintain muscle strength and joint flexibility
- Healthy diet: Anti-inflammatory foods rich in omega-3 fatty acids
- Stress management: Techniques to reduce physical and emotional stress
- Adequate sleep: 7-9 hours of quality sleep per night
- Smoking cessation: Reduces overall inflammation
Immune System Support
- Vaccination: Stay current with recommended vaccines
- Infection prevention: Good hygiene practices
- Vitamin D supplementation: Maintain adequate levels
- Moderate sun exposure: For natural vitamin D synthesis
Monitoring and Early Detection
- Regular check-ups: Especially for those with family history
- Symptom awareness: Know early signs and seek prompt evaluation
- Laboratory screening: Annual inflammatory marker assessment if at risk
When to See a Doctor
Seek Medical Attention Promptly If:
- Persistent muscle pain and stiffness, especially in shoulders and hips
- Morning stiffness lasting more than 1 hour
- Fatigue and malaise with muscle symptoms
- Unexplained weight loss with muscle pain
- Low-grade fever with widespread muscle discomfort
Giant Cell Arteritis Warning Signs: Seek immediate medical attention if you experience severe headache, vision changes, jaw pain while chewing, or scalp tenderness, as these may indicate associated giant cell arteritis.
Regular Medical Consultation
Schedule routine appointments for:
- Symptom monitoring: Regular assessment during treatment
- Medication management: Steroid dose adjustments
- Side effect monitoring: Screening for steroid-related complications
- Bone health assessment: Regular bone density screening
- Giant cell arteritis screening: Watch for symptoms of associated condition
Related Conditions
References
- Dasgupta B, Cimmino MA, Kremers HM, et al. 2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheum. 2012;64(4):943-954.
- Dejaco C, Singh YP, Perel P, et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheumatol. 2015;67(10):2569-2580.
- González-Gay MA, Matteson EL, Castañeda S. Polymyalgia rheumatica. Lancet. 2017;390(10103):1700-1712.
- Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. Lancet. 2008;372(9634):234-245.
- Mackie SL, Mallen CD. Polymyalgia rheumatica. BMJ. 2013;347:f6937.
Medical Disclaimer
This information is for educational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.
Polymyalgia rheumatica requires professional medical management, particularly for corticosteroid therapy and monitoring for associated conditions like giant cell arteritis. The information provided here is general in nature and may not apply to every individual case.
If you suspect you may have polymyalgia rheumatica, especially if you are over 50 and experiencing persistent muscle pain and stiffness, consult with a healthcare professional for proper evaluation and treatment.