Polymyalgia rheumatica: is your muscle stiffness age or immuno-related?

For many elderly individuals, aches and muscle stiffness are a common, even daily, occurrence. However, whilst this can be a normal sign of ageing, sudden stiffness can be indicative of immune-musculoskeletal conditions like polymyalgia rheumatica.

Dr Rod Hughes, highly esteemed rheumatologist, offers a comprehensive insight into polymyalgia rheumatica, explaining how the condition is caused, diagnosed and treated.

Can you detail what polymyalgia rheumatica is?

Polymyalgia rheumatica is an inflammatory disorder that causes pain and stiffness in the muscles around the neck, shoulders, pelvis, hips and upper legs. Generally, it presents as an autoimmune disease that is triggered by one of several stimuli in the environment.

Polymyalgia rheumatica is an age-related condition that mainly affects people over the age of 70 (it is rare in people younger than 50 years old.) It is also more common in women than in men.

It is estimated that 1 in every 1,200 people develop this inflammatory disorder in the UK every year. In some cases, however, it is not recognised as polymyalgia rheumatica. The condition is thought to be one of the effects of ageing, but these come on slowly. Polymyalgia rheumatica, on the other hand, can develop in a matter of days or over a few weeks.

What are the main causes and symptoms?

Whilst the cause of polymyalgia rheumatica is unknown, it is believed that the disorder develops due to a combination of genetic and environmental factors.

Worldwide, the highest rates of polymyalgia rheumatica are among people who are Caucasian and come from Northern European countries (especially Scandinavia). This is because the Vikings’ ancestry is associated with an increased risk for this disorder, marked by migration from Scandinavia to Western European lands. Polymyalgia rheumatica is uncommon in India.

Infections, traumatic injuries or sudden shocks such as bereavement or a period of high stress can trigger the onset of polymyalgia rheumatica. There have now been reported cases of polymyalgia rheumatica occurring after a COVID-19 infection or, in some cases, after a COVID-19 vaccination. Despite this, polymyalgia rheumatica will usually arise without a clear trigger being identifiable.

The symptoms of polymyalgia rheumatica are, in most cases, so typical that they have led to the development of diagnostic criteria. Common symptoms of polymyalgia rheumatica include:

• Early morning or late-night stiffness, that lasts for more than 60 minutes. This pain is felt in the muscles around the neck, shoulders, pelvis, low back and hips (generalised musculoskeletal pain is not a manifestation of polymyalgia rheumatica.) During the day, the stiffness can reoccur after a period of immobility. In extreme cases, musculoskeletal stiffness may cause even a daylong immobilisation.

• Pain, that may overwhelm symptoms of stiffness, especially morning stiffness that lasts for more than one hour. Morning stiffness is more specific to polymyalgia rheumatica, but pain is more frequently reported.

• Limitations of upper limb elevation can make it harder for a patient to comb his/her hair or wash it in the morning. Patients will often report limb weakness with limitation of motion due to stiffness and pain. Actions like getting out of bed or getting out of a chair may be difficult. However, after overcoming the morning stiffness, people with polymyalgia rheumatica will usually perform their daily activities very well.

• In rare cases, there is small joints involvement.

• Shoulder girdle involvement, that usually starts first and then gradually extends to the neck area and the hip girdle.

• Symmetrical involvement, which is a common sign of polymyalgia rheumatica. Worse at night, the pain will usually disturb a person’s sleep sometime between 04:00 and 06:00 AM.

• Muscles which may be tender if squeezed.

• Fatigue, loss of appetite, weight loss and sometimes, fevers.

What can happen to the shoulders, neck and hips if polymyalgia rheumatica is left untreated?

Polymyalgia rheumatica is very often a self-limiting condition and symptoms can take up to two to three years to settle without causing damaging side effects. Most people will prefer not to have symptoms for so long without seeking treatment.

Around 15 to 20 per cent of people with polymyalgia rheumatica will also develop a blood vessel inflammation condition known as giant cell arteritis (GCA). In most cases, GCA is recognised by symptoms such as a headache, jaw pain after chewing, scalp tenderness or sometimes, vision disturbance. In these instances, treatment is urgent, to prevent damage to blood vessels that can lead to strokes, heart attacks and blood vessel wall damage.

In a small number of cases, polymyalgia rheumatica may then become typical rheumatoid arthritis with symmetrical small joint inflammation, pain and swelling in the hands and feet.

How is it diagnosed and what should I avoid doing if I have polymyalgia rheumatica?

The diagnosis of polymyalgia rheumatica relies on the recognition of its usual symptoms. This means taking a careful history of symptoms and their onset from the patient. Most people will show raised markers of inflammation (erythrocyte sedimentation rate or C-reactive protein), but these markers are not reliable proof for a polymyalgia rheumatica diagnosis. In my experience, up to 10 per cent of people with polymyalgia rheumatica will be diagnosed with normal blood tests.

In particular, it is important to exclude other conditions that may mimic polymyalgia rheumatica such as thyroid under or over activity, statin-associated stiffness, low cortisol levels and – in some cases – underlying cancer. An ultrasound examination of shoulders and hips can help to prove the presence of soft tissue inflammation either in or around the joints.

Above all, the clearest way of diagnosing polymyalgia rheumatica is to see how well symptoms disappear after steroid treatment. The response can be miraculous; at least 80 per cent of symptoms disappear within two weeks after steroid treatment.

If you have polymyalgia rheumatica, it is important to ensure regular and steady exercise – predominantly stretching and gentle aerobic exercise to keep the muscles and the soft tissues toned and healthy. This may only be possible after steroid treatment.

How is polymyalgia rheumatica treated? What are the best home remedies?

If polymyalgia rheumatica is suspected, treatment should involve steroid tablets such as prednisolone 15mg daily for two weeks, to prove the diagnosis. If at least 80 per cent of symptoms resolve, then the diagnosis is proven. In some singular cases of polymyalgia rheumatica and if GCA is also suspected, doses of steroids may be higher (up to 40 steroids daily.)

After the diagnosis is proven, steroid doses are slowly reduced over time and eventually, after 12 to 18 months, treatment may be stopped. In proven polymyalgia rheumatica, it is also helpful to prescribe patients with medication to protect their bones, as steroid treatment can lead to thin brittle bones. As well as bone thinning, patients should always be warned about the possible side effects of steroids including weight gain, easy bruising and the development of latent diabetes.

Home remedies like low-dose anti-inflammatory drugs (for example, ibuprofen) may sometimes reduce symptoms of polymyalgia rheumatica, but they are not strong enough to treat the condition effectively. Plant-based remedies such as turmeric or rose hip supplements may provide anti-inflammatory relief for some people with polymyalgia rheumatica.

If you have symptoms of polymyalgia rheumatica and would like to seek expert assessment and management, don’t hesitate to visit Dr Hughes’ Top Doctors profile today to receive the utmost quality rheumatology care.