Polymyalgia rheumatica

Overview

Polymyalgia rheumatica is an inflammatory disorder that causes muscle pain and stiffness, especially in the shoulders and hips. Signs and symptoms of polymyalgia rheumatica (pol-e-my-AL-juh rue-MAT-ih-kuh) usually begin quickly and are worse in the morning.

Most people who develop polymyalgia rheumatica are older than 65. It rarely affects people under 50.

This condition is related to another inflammatory condition called giant cell arteritis. Giant cell arteritis can cause headaches, vision difficulties, jaw pain and scalp tenderness. It's possible to have both conditions together.

Symptoms

The signs and symptoms of polymyalgia rheumatica usually occur on both sides of the body and might include:

• Aches or pain in your shoulders
• Aches or pain in your neck, upper arms, buttocks, hips or thighs
• Stiffness in affected areas, particularly in the morning or after being inactive for a time
• Limited range of motion in affected areas
• Pain or stiffness in your wrists, elbows or knees

You might also have more-general signs and symptoms, including:

• Mild fever
• Fatigue
• A general feeling of not being well (malaise)
• Loss of appetite
• Unintended weight loss
• Depression

When to see a doctor

See your doctor if you have aches, pains or stiffness that:

• Is new
• Disrupts your sleep
• Limits your ability to do your usual activities, such as getting dressed

Causes

The exact cause of polymyalgia rheumatica is unknown. Two factors appear to be involved in the development of this condition:

• Genetics. Certain genes and gene variations might increase your susceptibility.
• An environmental exposure. New cases of polymyalgia rheumatica tend to come in cycles, possibly developing seasonally. This suggests that an environmental trigger, such as a virus, might play a role. But no specific virus has been shown to cause polymyalgia rheumatica.

Giant cell arteritis

Polymyalgia rheumatica and another disease known as giant cell arteritis share many similarities. Many people who have one of these diseases also have symptoms of the other.

Giant cell arteritis results in inflammation in the lining of the arteries, most often the arteries in the temples. Signs and symptoms include headaches, jaw pain, vision problems and scalp tenderness. If left untreated, this condition can lead to stroke or blindness.

Risk factors

Risk factors for polymyalgia rheumatica include:

• Age. Polymyalgia rheumatica affects older adults almost exclusively. It most often occurs between ages 70 and 80.
• Sex. Women are about two to three times more likely to develop the disorder.
• Race. Polymyalgia rheumatica is most common among white people whose ancestors were from Scandinavia or northern Europe.

Complications

Symptoms of polymyalgia rheumatica can greatly affect your ability to perform everyday activities, such as:

• Getting out of bed, standing up from a chair or getting out of a car
• Combing your hair or bathing
• Getting dressed

These difficulties can affect your health, social interactions, physical activity, sleep and general well-being.

Diagnosis

A physical exam, including joint and neurological exams, and test results can help your doctor determine the cause of your pain and stiffness. During the exam, he or she might gently move your head and limbs to assess your range of motion.

Your doctor might reassess your diagnosis as your treatment progresses. Some people initially given a diagnosis of polymyalgia rheumatica are later reclassified as having rheumatoid arthritis.

Tests your doctor might recommend include:

• Blood tests. Besides checking your complete blood counts, your doctor will look for two indicators of inflammation — erythrocyte sedimentation rate (sed rate) and C-reactive protein. However, in some people with polymyalgia rheumatica, these tests are normal or only slightly high.
• Imaging tests. Increasingly, ultrasound is being used to distinguish polymyalgia rheumatica from other conditions that cause similar symptoms. MRI can also identify other causes of shoulder pain, such as joint changes.

Monitoring for giant cell arteritis

Your doctor will monitor you for signs and symptoms that can indicate the onset of giant cell arteritis. Talk to your doctor immediately if you have any of the following:

• New, unusual or persistent headaches
• Jaw pain or tenderness
• Blurred or double vision or visual loss
• Scalp tenderness

If your doctor suspects you might have giant cell arteritis, he or she will likely order a biopsy of the artery in one of your temples. This procedure, performed during local anesthesia, involves removing a small sample of the artery, which is then examined for inflammation.

Treatment

Treatment usually involves medications to help ease your signs and symptoms. Relapses are common.

Medications

• Corticosteroids. Polymyalgia rheumatica is usually treated with a low dose of an oral corticosteroid, such as prednisone (Rayos). You'll likely start to feel relief from pain and stiffness within the first two or three days.

  After the first two to four weeks of treatment, your doctor might begin to gradually decrease your dosage depending on your symptoms and the results of blood tests. Because of potential side effects, the goal is to keep you on as low a dose as possible without triggering a relapse in your symptoms.

  Most people with polymyalgia rheumatica need to continue the corticosteroid treatment for a year or more. You'll need frequent follow-up visits with your doctor to monitor how the treatment is working and whether you have side effects.

  Long-term use of corticosteroids can result in serious side effects, including weight gain, loss of bone density, high blood pressure, diabetes and cataracts. Your doctor will monitor you closely for problems. He or she might adjust your dose and prescribe treatments to manage reactions to corticosteroid treatment.

• Calcium and vitamin D. Your doctor will likely prescribe daily doses of calcium and vitamin D supplements to help prevent bone loss as a result of corticosteroid treatment. The American College of Rheumatology recommends 1,000 to 1,200 milligrams of calcium supplements and 600 to 800 international units of vitamin D supplements for anyone taking corticosteroids for three months or more.
• Methotrexate. Joint guidelines from the American College of Rheumatology and the European League Against Rheumatism suggest using methotrexate (Trexall) with corticosteroids in some patients. This is an immune-suppressing medication that's taken by mouth. It might be useful early in the course of treatment or later, if you relapse or don't respond to corticosteroids.

Physical therapy

Most people who take corticosteroids for polymyalgia rheumatic return to their previous levels of activity. However, if you've had a long stretch of limited activity, you might benefit from physical therapy. Talk with your doctor about whether physical therapy is a good option for you.

Self care

Over-the-counter nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve), are not usually recommended for easing the signs and symptoms of polymyalgia rheumatica.

Healthy lifestyle choices can help you manage the side effects that corticosteroid treatment can cause:

• Eat a healthy diet. Eat a diet of fruits, vegetables, whole grains, and low-fat protein and dairy products. Limit the salt (sodium) in your diet to prevent fluid buildup and high blood pressure.
• Exercise regularly. Talk to your doctor about exercise that's appropriate for you to maintain a healthy weight and to strengthen bones and muscles.
• Get enough rest. Rest is necessary for your body to recover from exercise and activities of daily living.
• Use assistive devices. Consider using luggage and grocery carts, reaching aids, shower grab bars, and other assistive devices to help make daily tasks easier.

Coping and support

Even though you'll start to feel better soon after you begin treatment, it can be frustrating having to take medication daily, especially one that can cause such serious side effects. Ask your health care team what steps you can take to stay healthier while you're taking corticosteroids.

Your doctor might also know of local support groups in your area. Talking to others who are living with the same illness and challenges might be helpful.

Preparing for your appointment

You'll likely start by seeing your primary care doctor, who might refer you to a specialist in inflammatory disorders of muscles and the skeletal system (rheumatologist).

Here's some information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.

Make a list of:

• Your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment, and when they began
• Key personal information, including major stresses or recent life changes, and personal and family medical history
• Any medications, vitamins and other supplements you take, including doses
• Questions to ask your doctor

Ask a family member or friend to come with you, if possible, to help you remember the information you receive.

For polymyalgia rheumatica, questions to ask your doctor include:

• What's the most likely cause of my symptoms?
• What are other possible causes of my symptoms?
• What tests do I need? Do they require special preparation?
• Is this a temporary or long-lasting condition?
• What treatments are available, and which do you recommend?
• What side effects can I expect from treatment?
• What are alternatives to the primary approach that you're suggesting?
• I have other health conditions. How can I best manage them together?
• Do you have brochures or other printed material that I can have? What websites do you recommend?

What to expect from your doctor

Your doctor will likely ask you questions, such as:

• Where is your pain or stiffness?
• How would you rate your pain on a scale of 1 to 10?
• Are symptoms worse at certain times of the day or night?
• How long does stiffness last after you wake in the morning or after a period of inactivity?
• Does the pain or stiffness limit your activities?
• Have you had new or severe headaches or jaw pain?
• Have you noticed changes in your vision?