Polymyalgia Rheumatica

Polymyalgia rheumatica is an inflammatory condition that causes sudden pain and stiffness in the shoulders, neck, and hips, mainly affecting people over 50 years of age.

Table of contents

• What is Polymyalgia Rheumatica?
• Signs and Symptoms
• Causes and Risk Factors
• Diagnosis
• Treatment
• Complications and Related Conditions
• Living with Polymyalgia Rheumatica

What is Polymyalgia Rheumatica?

Polymyalgia rheumatica, often called PMR, is an inflammatory condition that causes pain and stiffness in large muscle groups around your shoulders, neck, and hips. This is a common condition among older adults, affecting about 50 out of every 100,000 people per year in the United States.^[1][2]

The condition almost always affects people over 50 years of age. It is very rare in people younger than 50. Most people who are diagnosed are over 65, and the condition is most common between ages 70 and 75.^[1][3] Women are affected more often than men.^[2]

Polymyalgia rheumatica is more common in people of certain backgrounds. It affects Caucasian people more often than any other ethnic or racial group, especially people of Northern European ancestry.^[2]

Signs and Symptoms

The main symptom of polymyalgia rheumatica is muscle pain and stiffness. These symptoms usually begin quickly, developing over several days to weeks, and sometimes even overnight.^[1][2] The pain and stiffness most often affect both sides of the body at the same time.

The aching and stiffness are usually much worse in the morning or after you haven’t moved for a while. Morning stiffness typically lasts longer than 45 minutes, and often 30 minutes or more.^[3][2] The pain can be severe, but it may improve with activity throughout the day.^[2]

Common areas affected include:^[1][2]

• Shoulders
• Neck
• Upper arms
• Hips
• Buttocks
• Thighs
• Lower back

The pain and stiffness can be so severe that people have difficulty performing ordinary daily tasks. Many people have trouble getting dressed in the morning, such as putting on a jacket or pulling on socks and shoes. Raising your arms over your shoulders may be particularly difficult, making it hard to brush your hair.^[2][6]

Other symptoms may include:^[1][2][3]

• Extreme tiredness or fatigue
• Feeling generally unwell
• Loss of appetite
• Weight loss without trying
• Mild fever
• Feeling depressed
• Swelling of hands or wrists

Causes and Risk Factors

The exact cause of polymyalgia rheumatica is not well understood. Researchers believe that a combination of genetic (inherited characteristics) and environmental factors may be responsible.^[3][4]

Some factors that may play a role include:^[2][4]

• Genetics and family history
• Environmental factors, such as infections
• The aging process
• The immune system accidentally attacking the body’s own tissues
• Inflamed sacs in the hips or shoulders

Several factors increase the risk of developing polymyalgia rheumatica:^[2][3]

Age: The condition almost always affects people over 50 years old. The risk increases with age, and rates are highest between ages 70 and 75.

Sex: Women experience the condition more often than men.

Race and ethnicity: Caucasian people, especially those of Northern European ancestry, are affected more often than any other ethnic or racial group.

Diagnosis

Diagnosing polymyalgia rheumatica can be challenging because the symptoms are similar to those of many other conditions, including rheumatoid arthritis and fibromyalgia.^[3][6] These other conditions need to be ruled out before a diagnosis of polymyalgia rheumatica can be confirmed.

You should see a doctor if you have pain and stiffness that is new, keeps you from sleeping well, makes it hard to do daily activities like getting dressed, or lasts more than a week.^[1][3]

Your healthcare professional will perform a physical exam that may include checking your joints and nervous system. During the exam, they might gently move your head and limbs to check their range of motion.^[8]

Blood tests are commonly used to help diagnose polymyalgia rheumatica. Your healthcare professional will look for signs of inflammation (irritation and swelling in the body). The two main blood tests are:^[8][6]

• Erythrocyte sedimentation rate (ESR or “sed rate”)
• C-reactive protein (CRP)

Not everyone with polymyalgia rheumatica has high levels of these proteins in their blood, but most do.^[8]

Imaging tests may also be used. An ultrasound can show whether you have inflammation of the joints and soft tissues. Some people may have an MRI or PET scan to look for other causes of joint pain.^[8]

If the diagnosis is strongly suspected, your doctor may prescribe a trial of low-dose corticosteroids (steroid medicine), usually in the form of prednisone. If polymyalgia rheumatica is present, the response to steroids can be dramatic, with many people experiencing improvement after only one or two doses, though sometimes the response takes longer.^[6][13]

Treatment

A steroid medicine called prednisolone or prednisone is the main treatment for polymyalgia rheumatica. It is used to help relieve the symptoms by reducing inflammation in the body.^[3][11]

Prednisolone works by blocking the effects of certain chemicals that cause inflammation inside your body. It does not cure polymyalgia rheumatica, but it can help relieve the symptoms.^[11]

When used to treat polymyalgia rheumatica, prednisolone is taken as a tablet, usually several tablets once a day. To start with, you may be prescribed a moderate dose of prednisolone, typically 10 to 15 milligrams per day.^[6][11]

Although your symptoms should improve within a few days of starting treatment, you will probably need to continue taking the medicine for a longer time. The dose will usually be reduced gradually every one to two months if you are responding well to treatment and your symptoms are well controlled.^[11]

Most people with polymyalgia rheumatica will need a course of steroid treatment that lasts for 12 months to 2 years to prevent their symptoms from returning.^[3][11] Polymyalgia rheumatica often improves on its own after this time. However, there is a chance symptoms may return after treatment stops, which is known as a relapse.^[11]

Important: Do not suddenly stop taking steroid medicine unless your doctor tells you it’s safe to stop. Suddenly stopping treatment with steroids can make you very unwell.^[11]

Sometimes other medicines may be combined with corticosteroids. Some people are prescribed immunosuppressant medicine, such as methotrexate, which works by suppressing the immune system. This may help people who have frequent relapses or do not respond to normal steroid treatment.^[11] Recently, the Food and Drug Administration also approved the use of a biologic medicine called sarilumab for this condition.^[6]

Your doctor may also recommend painkillers, such as paracetamol, to help relieve your pain and stiffness while your dose of prednisolone is reduced.^[11] Nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen or naproxen sodium, are not effective for polymyalgia rheumatica.^[6]

Side Effects of Treatment

Even low-dose corticosteroids can cause side effects, so you will need regular check-ups to watch for these problems.^[6][11] Possible side effects include:

• Increased appetite, which often leads to weight gain
• High blood pressure
• Weakening of the bones (osteoporosis)
• Stomach ulcers
• Increased risk of infection
• Changes in mental state, such as mood changes, depression, anxiety, or confusion
• Difficulty sleeping
• Bruising or thinning of skin
• Cataracts

About 1 in 20 people experience changes in their mental state when they take prednisolone. Contact your doctor as soon as possible if you experience changes to your mental state. If you have thoughts about harming yourself or ending your life, call emergency services immediately.^[11]

Older patients may need osteoporosis medications to prevent fractures.^[6] The risk of side effects should improve as your dose of prednisolone is reduced.^[11]

Follow-up Care

You will have regular follow-up appointments to check how well you are responding to treatment, if your dose needs to be adjusted, and how well you are coping with any side effects. During these appointments, you may have blood tests to check the levels of inflammation inside your body.^[11]

Follow-up appointments are usually recommended every few weeks for the first three months, and then at least every three months during the first year. Contact your doctor if your symptoms return during any part of your treatment, as your dosage may need to be adjusted.^[11]

Complications and Related Conditions

Left untreated, polymyalgia rheumatica can interfere with your ability to move. This can make it hard to perform daily activities including bathing, dressing, brushing your hair, getting up from the couch, and getting in and out of your car.^[2]

Giant Cell Arteritis

Polymyalgia rheumatica can occur along with a more serious condition called giant cell arteritis, also known as temporal arteritis.^[1][2] This form of vasculitis (inflammation of blood vessels) causes inflammation of large blood vessels, especially in the head and neck, including the arteries in the temples and the aorta (the major artery that transfers blood from your heart to the rest of your body).

About 10% to 20% of people with polymyalgia rheumatica may develop giant cell arteritis. Alternatively, 40% to 60% of people with giant cell arteritis may have polymyalgia rheumatica.^[2][3] Some researchers consider giant cell arteritis an extreme form of the same disease process as polymyalgia rheumatica.^[4]

Symptoms of giant cell arteritis can include:^[3][8]

• New or frequent headaches that usually develop suddenly
• Tender scalp
• Pain in the jaw muscles or tongue when eating or talking
• Blurred vision, double vision, or loss of vision in one or both eyes

If you have any of these symptoms, contact your doctor immediately or call emergency services. Unlike polymyalgia rheumatica, giant cell arteritis requires immediate medical attention. It can lead to serious problems like stroke or blindness if not treated quickly.^[3][8]

Living with Polymyalgia Rheumatica

If muscle aches and stiffness respond well to treatment, people with polymyalgia rheumatica can get back to a normal lifestyle and regular activities.^[6] There are several strategies that can help you manage pain and stiffness without taking additional medication.

Simplify Daily Activities

Use devices that help simplify your daily activities, so you can avoid strenuous joint movement:^[18][21]

• A walker or rollator to help you get out of bed and walk around when hips are painful and stiff
• Long-handled bath brushes and hair brushes to help you avoid repeated bending, raising, and moving arms
• A rolling laundry cart to carry clothes, avoiding heavy lifting
• A reaching aid or grabber tool to help you reach high shelves or grab clothes from the dryer
• Buttoned shirts or blouses instead of clothes that require raising your arms over your head
• Elastic shoelaces that don’t need tying

Stay Active

Being sedentary can make polymyalgia rheumatica stiffness worse. Physical activities and hobbies are a great way to keep you active. Rotate activities to ensure that different muscles and joints get used but not over-strained.^[18][15]

Activities that may help include:^[18][21]

• Gardening and walking outdoors
• Swimming and cycling to help loosen stiff muscles and joints
• Yoga and tai chi to provide flexibility and improve joint and muscle symptoms

Set practical goals. A good physical activity routine can include 10 minutes of daily exercise, gradually adding 5 minutes every other week. It is important to perform stretches slowly and advance only if you feel comfortable without pain. Start slow and easy.^[18][21]

Manage Stress and Pain

Stress can make inflammatory conditions worse. Here are a few tips to help you focus, calm down, and relax:^[18][21]

• Meditation and relaxation techniques can improve concentration, release feel-good hormones (endorphins), and decrease anxiety and stress
• Simple breathing exercises, such as taking 10 deep, slow breaths in a row
• Less strenuous activities like reading, listening to music, crafting, and watching favorite movies
• Sharing your feelings with a close friend or loved one
• Getting enough sleep—a minimum of 7 to 9 hours per night allows your body to rest, heal, and repair

Heat and Cold Therapy

Applying heat, such as warm baths or heating pads, can help ease muscle stiffness by increasing blood flow. Cold packs may help reduce inflammation, swelling, and provide pain relief.^[2]

Healthy Diet

Maintain a balanced and nutritious diet to support overall health. Some people find that reducing intake of inflammatory foods, such as processed and sugary foods, can help manage symptoms. Foods rich in omega-3 fatty acids, such as salmon, tuna, nuts, and walnuts, may be beneficial.^[15]

It is particularly important to include calcium and vitamin D in your diet to maintain good bone health, especially when taking corticosteroids.^[15]

Work with Your Healthcare Team

It is important to work closely with your rheumatologist or healthcare team, follow your doctor’s treatment plan, and take medications exactly as directed. Be sure to have an open conversation with your doctor about any possible side effects or concerns.^[15]

If any questions or concerns arise, do not hesitate to contact your healthcare team. Your health and well-being is their primary focus.^[15]