Polymyalgia Rheumatica (PMR)
1. Introduction
Polymyalgia rheumatica (PMR) is an inflammatory condition affecting the shoulders, neck, and hips. Polymyalgia means “many muscle pains”. Rheumatica means “changing” or “influx”. The cause of polymyalgia rheumatica is currently unknown (1). The condition usually affects joints on both sides of the body at the same time. This can cause pain and stiffness in the affected joints and surrounding muscles (2).
Polymyalgia rheumatica has links with another condition called temporal arteritis (giant cell arteritis). This is a problem with the arteries supplying blood to the temple region of your skull (cranium) (5). This problem can be dangerous and you should seek medical advice if you have polymyalgia rheumatica and are getting severe headaches, scalp tenderness, jaw or facial soreness (especially with chewing), or vision changes/distorted vision that is caused by decreased blood flow to the eye.
Currently, the best treatment for polymyalgia rheumatica involves a combination of medication and physical activity. This involves taking oral steroids which can help to control the inflammatory process in joints and soft tissue structures. This, combined with exercises that aim to keep joints moving and increase strength in muscles surrounding joints, will benefit people with polymyalgia rheumatica (5).
Frequently Asked Questions
- Polymyalgia rheumatica is a rare inflammatory condition affecting joints and surrounding muscles, usually affecting hips and shoulders.
- Moderately common.
- It is estimated that under 0.85% of people in the UK develop the condition every year (1).
- It carries a lifetime risk of 2.4% in females and 1.7% in males.
- Exceedingly rare in people younger than 50.
- No.
- With early diagnosis and correct therapy, patients have an excellent prognosis (1).
- With the right treatment there is no permanent damage to joints.
- It is more common in those aged 70 and over (3).
- More common in women.
- It is more common in people with Scandinavian and Northern European heritage.
- Pain and stiffness in shoulder muscles (3).
- You may also get pain in your neck and hips.
- Both sides of the body usually affected.
- Stiffness, often worse in the mornings, lasting up to 45 minutes as you become more active.
- Fatigue.
- Loss of appetite.
- Weight loss.
- Depression.
- The main treatment is oral corticosteroid treatment (prednisolone) (2).
- A combination of exercise therapy and education is recommended in the treatment of polymyalgia rheumatica (3, 5). This will reduce the risk of early functional impairment or severe disability (2).
- With treatment, symptoms usually lessen or go away within days. Without treatment, they may go away after a year but could take up to five years or more (3).
- The average length of the disease is 3 years (2).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
Polymyalgia rheumatica symptoms usually develop quickly and cause aching in the muscles. Other symptoms include:
- Stiffness.
- Weakness.
- Fatigue.
- Feeling unwell.
- Occasional fevers.
- Weight loss and loss of appetite (1).
Approximately 15% of people with polymyalgia rheumatica will also have temporal arteritis and about half of the people with temporal arteritis also have polymyalgia rheumatica. Temporal arteritis causes inflammation that damages large and medium-sized arteries. The name of the condition stems from the fact that some of the affected arteries provide blood to the head, including the temples (1, 4). Symptoms of temporal arteritis include:
- Severe headaches – the most common symptom.
- Scalp tenderness.
- Jaw or facial soreness, especially with chewing.
- Vision changes or distorted vision that is caused by decreased blood flow to the eye.
3. Causes
The cause of polymyalgia rheumatica is unknown. A combination of genetic and environmental factors is thought to be responsible. The disease has a very sudden onset and new cases occur in cycles which could suggest that infection is a cause. Inheritance of the disorder has been suggested due to patterns seen in family histories (4). However, there are no definitive studies that can confirm any of these factors are a direct cause of polymyalgia rheumatica.
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing polymyalgia rheumatica. It does not mean everyone with these risk factors will develop symptoms (1).
- Age – usually, polymyalgia rheumatica affects older adults. It most often occurs between the ages 70 and 80.
- Gender – women are about two to three times more likely to develop the disorder.
- Race – it is most common among white people whose ancestors were from Scandinavia or Northern Europe.
Taking corticosteroid is the mainstay of treating polymyalgia rheumatica. However, there are side effects of long-term steroid use. These include:
- Reduced bone health – weakening of bones.
- Increased appetite leading to weight gain.
- High blood pressure.
- Mood changes.
- Stomach ulcers.
- Increased risk of infection, e.g. chicken pox or shingles.
5. Prevalence
It is estimated that 0.83% of people, or 1 in every 1,200, in the UK develop the condition every year. It carries a lifetime risk of 2.4% in females and 1.7% in males (1). The incidence of PMR was highest in women, older age groups and those living in the South of England (4).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made.
Diagnosing polymyalgia rheumatica can be a lengthy process as its symptoms are common in other inflammatory conditions. For example, rheumatoid arthritis shares many symptoms with polymyalgia rheumatica, so ruling out these types of conditions is important. There is no specific test for polymyalgia rheumatica. It is likely that a blood test will be done to check inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). If these are normal it is unlikely polymyalgia rheumatica will be diagnosed.
As inflammation is common in many conditions, above normal levels of inflammatory markers do not mean you have polymyalgia rheumatica. Further tests will be done to rule out other causes, e.g. a test for rheumatoid factor or anti-CCP antibodies to rule out rheumatoid arthritis.
Polymyalgia rheumatica can be confidently diagnosed if you meet all the following criteria:
- Over 50 years of age.
- Pain in both shoulders and/or hips.
- Stiffness lasting longer than 45 minutes.
- Symptoms lasting longer than 2 weeks.
- Blood tests showing raised inflammation.
- Symptoms rapidly improve with corticosteroids.
7. Self-Management
With treatment, polymyalgia rheumatica symptoms usually lessen or go away within days. Without treatment, they may go away after a year but could take up to five years or more. Proper nutrition, activity, rest and following medication regimens are important for managing the condition. Once stiffness goes away, a person can return to daily activities, including exercise, as tolerated. Treatment includes anti-inflammatory medication and exercise (5, 6).
8. Rehabilitation
Polymyalgia rheumatica treatment focuses on reducing pain and inflammation, and easing stiffness, achiness, fatigue and fever.
A combination of exercise and education for polymyalgia rheumatica is recommended as this will reduce the risk of functional impairment and disability. Your physiotherapist will work with you to form a bespoke rehabilitation plan to help improve strength and mobility. This is vital for the long-term management of polymyalgia rheumatica in terms of managing pain and stiffness, and can help slow down, or in some cases help reverse some symptoms.
Exercise and keeping active are essential parts of this, but you may have to modify how you do things a little. Your musculoskeletal physiotherapist can instruct you on how this can be achieved by implementing a bespoke home exercise and self-management plan. In the meantime, the below exercise programme can provide a good starting point for this condition.
9. Polymyalgia Rheumatica (PMR)
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
The exercises in this programme provide some basic exercises that can help to maintain function and reduce stiffness often associated with the condition. This should not exceed any more than 5/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and to establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
The typical medication for polymyalgia rheumatica is corticosteroid treatment, usually in the form of prednisolone. This works by blocking the effects of chemicals that cause inflammation; it is not a cure but helps to relieve symptoms. The corticosteroid is taken in tablet form and you will be started on a moderate dose to begin with; the dose will be gradually reduced every 1-2 months. Symptoms usually improve within a few days, but you will need to continue taking prednisolone for about 2 years. Do not suddenly stop taking your medication until your doctor says it is safe to do so. This is due to the potential side effects of stopping treatment abruptly. Polymyalgia rheumatica often resolves in time on its own, however, there is a chance of the symptoms returning; this is called a relapse.
Your doctor will prescribe daily doses of calcium and vitamin D supplements to help prevent bone loss because of corticosteroid treatment (5).
Treatment options include (5,6):
- Medications.
- Lifestyle changes:
- Diet.
- Exercise.
- Getting enough rest.
- Using assistive devices, e.g. grab rail to help with use of shower.
References
- LeGrove L. (2009). Polymyalgia rheumatica: management guidelines. Practice Nurse. MA. Accessed April 4, 2011. 37, 33-37
- Goodman CC, Fuller KS. (2009). Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis: Saunders Elsevier.
- Toby Helliwell, Samantha Lara Hider, Christian David Mallen. (2013). Polymyalgia rheumatica: diagnosis, prescribing, and monitoring in general practice. British Journal of General Practice. DOI: 10.3399/bjgp13X667231. 63, e361-e366.
- Mayo Clinic: Polymyalgia rheumatica.http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441. Accessed March 31, 2011.
- El Chami, S., & Springer, J. M. (2021). Update on the Treatment of Giant Cell Arteritis and Polymyalgia Rheumatica. Medical Clinics.
- Ricardo Munir Nahas, Vivianne Horsti Dos Santos and Silvio Lopes Alabarse. (2019). Physical Exercise Improves Quality of Life in Patients with Connective Tissue Disease. Submitted: April 2nd 2018 Reviewed: December 7th DOI: 10.5772/intechopen.83388
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Adult Acquired Flatfoot
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