Definition

Polymyalgia rheumatica is an inflammatory condition characterized by muscle pain and stiffness, particularly in the shoulders and hips. Symptoms typically manifest rapidly and are most severe in the morning. 

This condition predominantly affects individuals over 65, with occurrences being rare in those younger than 50. 

Additionally, polymyalgia rheumatica is closely associated with another inflammatory condition known as giant cell arteritis, which involves inflammation of the arterial blood vessel walls. Notably, individuals with polymyalgia rheumatica may also develop giant cell arteritis simultaneously, highlighting the interconnected nature of these inflammatory conditions.

Causes

The precise cause of polymyalgia rheumatica remains unclear. However, two factors are thought to contribute to the onset of this condition:

• Genetic factors: Certain genes and genetic variations may predispose individuals to develop polymyalgia rheumatica. Research suggests that inherited traits may increase susceptibility to the condition.
• Environmental exposure: The occurrence of new cases of polymyalgia rheumatica often follows certain cycles, such as seasonal patterns. This suggests that environmental factors, such as viral infections, may trigger the condition. However, no specific virus has been definitively linked to the development of polymyalgia rheumatica.

Giant cell arteritis

Polymyalgia rheumatica and giant cell arteritis often coexist and share many similarities. Individuals with one of these conditions may also experience symptoms of the other.

Giant cell arteritis involves inflammation of the lining of blood vessels, typically affecting arteries in the temples. Common signs and symptoms include headaches, jaw pain, vision disturbances, and scalp tenderness. Left untreated, giant cell arteritis can lead to serious complications such as stroke or blindness.

Risk factor

Several factors can elevate the risk of developing polymyalgia rheumatica:

• Age: Polymyalgia rheumatica predominantly affects older individuals, with the highest incidence occurring between the ages of 70 and 80.
• Gender: Women are at a 2-3 times higher risk of developing this condition compared to men.
• Race: Polymyalgia rheumatica is most frequently diagnosed in individuals of white ethnicity, particularly those with ancestry from Scandinavia or Northern Europe.

Symptoms

Signs and symptoms of polymyalgia rheumatica typically manifest on both sides of the body and may include:

• Pain or stiffness in the shoulders
• Pain or stiffness in the neck, upper arms, buttocks, hips, or thighs
• Stiffness in the affected areas, particularly noticeable in the morning or after periods of inactivity
• Limited range of motion in the affected areas
• Pain or stiffness in the wrists, elbows, or knees

In addition to these localized symptoms, individuals with polymyalgia rheumatica may also experience more general signs such as:

• Mild fever
• Fatigue
• Malaise (a general feeling of discomfort or unease)
• Loss of appetite
• Unintended weight loss
• Depression

Diagnosis

Physical examination, which includes joint and nerve assessments, along with diagnostic tests, is instrumental in identifying the underlying cause of the pain and stiffness associated with your symptoms. During the examination, your doctor will carefully manipulate your head and limbs to evaluate your range of motion.

Your healthcare provider may reevaluate your diagnosis throughout the diagnostic process, particularly during therapy. It's worth noting that some individuals initially diagnosed with polymyalgia rheumatica may change their diagnosis to rheumatoid arthritis over time. 

Diagnostic tests

The doctor may recommend several examinations to aid in the diagnosis of polymyalgia rheumatica:

• Blood tests: In addition to a complete blood count, the doctor will assess two inflammation markers: erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). While these markers are often elevated in polymyalgia rheumatica, they may be within the normal range or only slightly elevated in some individuals.
• Radiology examinations: Ultrasonography (USG) is increasingly used to evaluate polymyalgia rheumatica, helping differentiate it from other conditions with similar symptoms. Additionally, MRI scans can identify potential causes of shoulder pain, such as joint abnormalities.

Giant cell arteritis

In addition to monitoring for polymyalgia rheumatica, healthcare providers will also remain vigilant for signs and symptoms suggestive of giant cell arteritis. If there is suspicion of giant cell arteritis, your doctor may recommend a biopsy of the blood vessels in one of your temples. This procedure, conducted under local anesthesia, involves obtaining a small sample of blood vessels from the temple area for examination to detect any signs of inflammation. This biopsy is an essential diagnostic tool for confirming the presence of giant cell arteritis and guiding appropriate treatment interventions. 

Management

Treatment for polymyalgia rheumatica typically involves medications aimed at alleviating symptoms, particularly pain and stiffness. Here are the commonly used medications:

• Steroids

Polymyalgia rheumatica is typically managed with low-dose oral corticosteroids, such as prednisone. Pain and stiffness can often be relieved within the first 2-3 days of starting medication. The dose is gradually tapered over 2-4 weeks based on symptoms and blood test results. 

The treatment goal is to use the lowest effective dose to control symptoms while minimizing the risk of side effects. Many individuals with polymyalgia rheumatica require corticosteroid therapy for 1 year or longer, with regular follow-up visits to monitor treatment success and side effects.

Closely monitoring your response to corticosteroid therapy, your doctor may adjust the dose or prescribe additional therapies to manage side effects. Long-term use of corticosteroids can lead to serious side effects, including weight gain, decreased bone density, high blood pressure, diabetes, and cataracts. 

While most individuals can resume activities at their previous intensity, those with long-term activity restrictions may benefit from physical therapy. Discussing suitable physical therapy options with your doctor can help improve mobility and overall quality of life.

• Calcium and Vitamin D

Daily calcium and vitamin D supplements may be prescribed to help prevent bone density loss associated with corticosteroid therapy. For individuals taking corticosteroids for 3 months or longer, the recommended doses are typically 1000-1200 mg of calcium and 600-800 IU of vitamin D daily.

• Methotrexate

Sometimes, methotrexate, an immunosuppressant taken orally, may be combined with corticosteroids. This medication may be considered if symptoms relapse or the response to corticosteroid therapy is inadequate.

Complications

Here are some tips for preventing complications and managing the condition effectively:

• Getting out of bed, standing up from a seated position, or exiting a car
• Completing personal grooming tasks such as combing your hair or taking a shower
• Dressing oneself

These challenges can significantly impact various aspects of life, including physical health, social interactions, level of physical activity, quality of sleep, and overall well-being. 

Prevention

There's no specific prevention for polymyalgia rheumatica itself. However, prevention efforts primarily focus on minimizing the risk and managing the side effects of treatments used for polymyalgia rheumatica therapy.

Here are some tips for preventing complications and managing the condition effectively:

• Healthy diet: Embrace a balanced diet rich in fruits, vegetables, whole grains, lean protein, and low-fat dairy products. Limiting salt intake can help prevent fluid retention and reduce the risk of high blood pressure.
• Regular exercise: Consult with your healthcare provider to determine suitable exercises to help you maintain an ideal weight and strengthen your bones and muscles.
• Adequate rest: Prioritize getting enough rest and sleep, as sufficient rest is crucial for the body's recovery from physical activity and daily tasks.
• Use of assistive devices: Consider utilizing assistive devices or tools to make daily activities easier and reduce strain on your joints and muscles.

When to see a doctor?

It's essential to consult a doctor if you experience stiffness, pain, or soreness that:

• Is newly felt
• Disrupts your sleep
• Causes limitations in your daily activities, such as dressing

Moreover, prompt medical attention is necessary if you notice symptoms indicative of giant cell arteritis, including:

• New, unusual, or persistent headaches
• Pain or tenderness in the jaw
• Blurred or double vision or decreased vision
• Pain in the scalp

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