Polymyalgia rheumatica

Complaints with polymyalgia rheumatica

The typical polymyalgia rheumatica (PMR) symptoms are widespread aching and stiffness in the upper arms, neck, lower back and thighs. The aching is always worse in the morning and improves as the day goes by. The complaints with PMR usually develop slowly, but a sudden onset is also possible. You probably have not felt completely fit for a while, were tired more often, got thinner, had mild fever, tiredness, feeling sick, losing weight, sweating at night and so on.

The main complaints with polymyalgia rheumatica are:
• a sudden severe muscle pain and stiffness in your neck, shoulders, upper arms, around the hips, thighs and in the lower back, lasting more than four weeks. By moving, the pain and stiffness that you feel, are getting worse and are most severe at night and in the morning.
• losing weight and a lack of appetite.
• a lack of energy.
• fatigue.

Characteristic is that you have the pain on both sides of your body, but the complaints may start on one side. Symptoms tend to come on quickly, over a few days or weeks, and sometimes even overnight. The involvement of the upper arms, with trouble raising them above the shoulders, is common. Sometimes, aching occurs at joints such as the hands and wrists. Yet inactivity, such as a long car ride or sitting too long in one position, may cause stiffness to return. Stiffness may be so severe that it causes any of these problems:
• Disturbed sleep.
• Trouble getting dressed in the morning (for example putting on a jacket or bending over to pull on socks and shoes).
• Problems getting up from a sofa or in and out of a car.

Most patients, in addition to complaints of painful and stiff muscles of both shoulders and the pelvic area, also have an increased sedimentation and an increased inflammation protein in the blood. Furthermore, some of the polymyalgia rheumatica patients also suffer from a vascular inflammation, called giant cell arteritis. This is a serious illness, in which patients, among other things, may have severe headaches and may even become blind if left untreated.

Since polymyalgia rheumatica (PMR) does not often cause swollen joints, it may be hard to recognize.

Diagnosis

Your doctor will base your diagnosis on a combination of the medical history, his findings and additional test results.

Anamneses
At the first visit, the doctor asks you a number of questions to get a good picture of your condition. You can think of the following questions:
– When did your complaints start?
– Can you describe your complaints?
– How are your working conditions?
– What medication do you use?
– Do rheumatic diseases occur in your family?
– What is your medical history?
– Are you under the treatment of other specialists and for what?

Polymyalgia rheumatica may be hard to diagnose. The main characteristic of polymyalgia rheumatica is the specific pattern of symptoms and the diagnosis is made on the basis of a combination of characteristics and description of your symptoms. Usually it is your family doctor who recognizes polymyalgia rheumatica and treats you. If he can not explain the diagnosis, he will refer you to an internist or rheumatologist.

Blood test
Polymyalgia rheumatica is an inflammatory form of arthritis, just like rheumatoid arthritis (RA). There is an important difference: people with polymyalgia rheumatica have no antibodies in the blood. In PMR results of blood tests to detect inflammation are most often abnormally high. One such test is the erythrocyte sedimentation rate (ESR), also called “sed rate”, in which the sedimentation rate of your blood is measured.
• Sedimentation speed. Blood tests also measure the degree of inflammation through the sedimentation rate of the red blood cells. The erythrocyte sedimentation rate (ESR) is measured by a laboratory test. The test measures the sedimentation rate of red blood cells (erythrocytes) through the speed at which the red blood cells settle, due to gravity, in an upright, narrow tube of blood. The upper part of the blood in the tube is the plasma, which becomes visible as a column of clear, yellowish liquid after the sedimentation of the red blood cells. The length of this column of plasma is measured after one hour and expressed in millimetres per hour (mm/hour). This blood test does not diagnose one specific condition. Instead, it helps your doctor to determine whether you are experiencing an inflammation. This can be the result of infections (bacteria, viruses), tumors and autoimmune diseases (such as arthritis).
• C-reactive protein (CRP). Another test is the C-reactive protein (CRP) in which the amount of C-reactive protein (CRP) in your blood and white blood cells is measured. When an inflammation is present in the body, the liver makes the substance C-reactive protein. It is possible through a blood test to measure the amount of this protein in the blood. The test is useful for the doctor when diagnosing acute and chronic conditions that cause inflammation. A wide range of inflammatory conditions causes increased levels of C-reactive protein (CRP).

In PMR, the results of blood tests to detect inflammation are usually quite high, but in some patients these tests may have normal or only slightly increased results. Both values say something about the severity of the inflammation. Blood tests do not provide a definite answer, as these findings are not specific to polymyalgia rheumatica. You can also have anemia.

Diagnosis
If no other diseases can be diagnosed, the doctor can ultimately diagnose polymyalgia rheumatica based on your age (over age 50), your symptoms and your blood count. If it turns out that the drug prednisone helps well against your symptoms, then it is absolutely certain that you have polymyalgia rheumatica.

A small proportion of patients with PMR have a more chronic (permanent) course of the disease with alternating quiet and active phases. If you are unable to stop the drug and you continue to have physical symptoms, the doctor will investigate whether you may have rheumatoid arthritis (RA) or osteoarthritis.

Treatment

Without treatment of polymyalgia rheumatica (PMR) the symptoms can also stop automatically, but that can take months to sometimes years.

Drug treatment
Drugs without a prescription
• For the pain you can get a simple painkiller with the active ingredient paracetamol without a prescription. Paracetamol helps against pain and fever, does not cause stomach problems, usually does not cause side effects and can be easily combined with other medications.
• An NSAID, an anti-inflammatory analgesic in a lower dose. The abbreviation NSAID stands for Non-Steroidal Anti-Inflammatory Drugs. These painkillers inhibit inflammation.

Do you have physical complaints? Always go to your doctor or specialist for a proper diagnosis and proper treatment.

Drugs on prescription
This is provided by your doctor or rheumatologist or internist.
• A corticosteroid (an artificial adrenal cortex hormone) is a drug that resembles the natural hormone that the body produces in the adrenal cortex. These anti-inflammatory drugs suppress the immune response in the body and inflammation. A corticosteroid drug can be quickly effective for a joint swelling that is localized (not widespread) by an injection or shot into the effected joint or tendon sheath (the membrane around a tendon).
If your doctor strongly suspects PMR, you will receive a trial of low-dose corticosteroids. Often, prednisone (Deltasone, Orasone and so on) is given. If PMR is present, the drug quickly relieves stiffness. The response to corticosteroids can be dramatic. Sometimes patients are feeling better after only one dose. But improvement can be slower. When your symptoms are under control, your doctor will slowly decrease the dose of the corticosteroid drug. The goal is to find the lowest dose that keeps you comfortable. Some people can stop taking corticosteroids within a year. Others, though, will need to use a small amount of this drug for 2 to 3 years to keep aching and stiffness under control. Symptoms can recur and because the symptoms of PMR are sensitive to even small changes in the dose of corticosteroids, your doctor should direct the gradual decrease of this drug. The long-term use of corticosteroids can also lead to bone loss (osteoporosis).
• A synthetic DMARD (Disease-Modifying Anti Rheumatic Drug) such as methotrexate (Rheumatrex, Trexall, Otrexup, Rasuvo) may be prescribed. A DMARD has different mechanisms of action and this drug can relieve symptoms and may prevent damage to the joints. When using a DMARD at an early stage of your condition, your joints will be less damaged by the inflammations. This class of drugs is helpful mainly in those with arthritis that also affects the joints of the arms and legs. In addition to the DMARD, the doctor can also prescribe an NSAID or a corticosteroid at the same time or a combination of the rheumatic inhibitors to directly combat the pain and to tackle the inflammation more effectively. It is a search for the right means or combination of resources.
• An NSAID. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin and so on) and naproxen (Naprosyn, Aleve) are not found effective in treating PMR. These drugs inhibit inflammation but do not contain corticosteroids (steroids). Anti-inflammatory painkillers are all effective against pain and inflammation. Nevertheless, one drug may work better for you than another. This is because each person responds differently to medication and because every anti-inflammatory analgesic works just a little differently in your body.

If symptoms do not disappear after two or three weeks of treatment, the diagnosis of PMR is not likely and your doctor will consider other causes of your illness.

Use of drugs and adherence

• It is important that you take the drugs as prescribed. In order to get your illness under control, it is very important that you take your drugs on a regular basis every day. If you do not, there is no good concentration of the drug in your blood and therefore the drug will work less well.
• Do you have trouble remembering when and how many of your drugs you should take on a daily basis and at what time of the day? Then buy a drug dispenser, in which you can sort your drugs per day.
• Do you have difficulty or objection to taking the drug prescribed to you, for example because of possible side-effects? Then that can lead to you no longer taking the drug regularly. Discuss this with your doctor!

Deterioration of your illness and/or complications
The doctor will look at:
• The dosage and amount of drugs you use.
• Switching to another drug in the same type or a completely new type of drug.
• Combining different drugs at the same time.

Your doctor can tell you
• whether the drug can work for you.
• how you can best use the drug.
• how much and how often you can use the drug.
• how you can best reduce the drug.

You should always tell your doctor or specialist
• if you use other drugs (bought or prescribed by another doctor).
• if you have another medical condition.
• whether you will be operated on soon.
• if you have previously been prescribed an anti-inflammatory analgesic that has caused side effects.
• whether you want to become pregnant or are pregnant.
• if you are breast-feeding.
This is important because your doctor or specialist has to make a careful choice between different drugs.

Side-effects
• All drugs may have side-effects when used, so ask your doctor or pharmacist what side-effects you can expect or read the leaflet.

Reduce or stop
• If you stop using a drug yourself or reduce the number of drugs yourself, your symptoms may worsen. Always consult your doctor or specialist first, if you want to use less drugs or want to stop.

Alternative treatments

There are many types of alternative treatments. This refers to all treatments that fall outside normal scientific medical care. No scientific evidence has been provided for the operation of these treatments. The alternative treatments are also called ‘complementary‘ because they can supplement the regular medical treatment by your doctor.
Many people choose an alternative treatment in addition to their regular medical treatment. They hope that this helps extra against their complaints or better helps to deal with the complaints.

Can an alternative treatment be a replacement for your regular medical treatment?
No, if you opt for an alternative treatment method, it is always a supplement to your regular medical treatment. You should not stop your regular treatment, because otherwise you run unnecessary health risks. Always consult your attending doctor before you start an alternative treatment.

What alternative treatments are there for example?
There are many different alternative treatment methods available, which can also be combined. Some examples are:
• Chinese medicine (acupuncture, pressure point massage, nutrition and tai chi).
• homeopathy (products made from plants and minerals).
• Bowen therapy.
• Ayurveda.
• Bach flower treatment.
• shiatsu, foot-sole and classic massage.
• Touch for Health.
• Reiki.
• dietary supplements.

What do you have to pay attention to?
• Many alternative treatments have not shown that they actually work. If you choose to try alternative treatment, make sure that your complaints do not increase. Stop an alternative treatment as soon as your symptoms increase.
• Always consider first why you want to follow an alternative treatment.
• Prepare yourself by looking up and reading information about the alternative treatment. Consult with your attending doctor, because certain complaints may be reduced by some alternative treatment methods.
• Determine yourself in which alternative method you trust for the relief of your complaints and whether you want to start.

What can you do best when choosing an alternative treatment?
• Always consult your doctor about the alternative treatment method you want to follow.
• Consult with your attending doctor and with the alternative therapist if they want to discuss your treatment with each other.
• Choose an alternative therapist who has followed a recognized vocational training and is affiliated to a professional organization.
• Ask your alternative therapist in advance about the purpose, duration, costs and risks of the treatment. How much money you spend depends on which treatment you choose and how long it takes.
• Do not stop your regular medical treatment, as this may worsen your symptoms.
• Weigh during treatment whether you want to continue or stop if your symptoms get worse, if you do not notice any effect of the alternative treatment or if you get side effects.

Why is your food important?

• Healthy nutrition is important to get the vitamins and minerals and other nutrients that your body needs.
• Obesity creates risks for your health and disease progression. In the case of arthritis and obesity, for example, obesity plays an important role in overburdening and osteoarthritis in the knees, hips and ankles. The pressure on your joints is then simply too great. Healthy eating and exercise (exercising a sport and active in the home and outdoors) can help to reduce or prevent excess weight.
• A healthy diet is always important and the dietitian can support you with the right dietary advice.

What is a healthy diet?
With a healthy diet your body gets the right amount of good nutrients, which it needs. You eat the quantities that your body needs. The dietitian can support you with the right nutritional advice.
The 5 courses to choose from are:
• Vegetables and fruit
• Bread, cereal products and potatoes
• Fish, legumes, meat, egg, nuts and dairy
• Lubrication and preparation fats
• Drinks.

Where can you get advice for a healthy diet?
• You can request advice from your doctor or a dietitian. The doctor can refer you to a dietitian. Some diets may possibly help against your symptoms. Consult with your doctor or dietitian if you want to try a certain diet. And make sure that you do not omit important foods from your daily diet.

What can you do with a painful or dry mouth?
Sometimes you can suffer from a dry or painful mouth for various reasons, also due to your illness. Tips:
• by chewing (for example piece of cucumber, sugar-free candy or chewing gum) and sucking (ice cube) the salivary glands are stimulated to produce saliva.
• good oral care is important: good tooth brushing, flossing and the use of mouthwash.
• rinse your mouth regularly, drink small amounts of water and use a mouth sprayer if necessary.
• let hot drinks cool down first.
• use ice or cold dishes, because the cold numbs the pain.
• do not use sharp herbs and spices, fruit juice, carbonated soft drinks, alcoholic beverages, very salty foods and sour food.
• food with hard crusts, nuts, bones and bones can cause injuries.
• use soup, gravy or sauce with the hot meal to make the food smoother.
• spreadable cheese, spreadable paté or salad, jam or honey on bread, porridge, drinking breakfast and custard, for example, swallows easier than dry spreads.
• if you need to use ground or liquid food, you can use a mixer to grind your meal with some extra moisture.

In some forms of arthritis or use of certain drugs intestinal complaints can occur. The intestinal complaints can arise from the influence of certain drugs on food intake. Conversely, the food you eat can have an effect on the way your drugs work.

Dietary supplements, fish fatty acids, glucosamine and vitamin D?
• Dietary supplements are available as pills, powders, drops, capsules or drinks and are intended as a supplement to inadequate daily nutrition. They contain vitamins, minerals or bio-active substances. These synthetic or isolated vitamins, minerals or bio-active substances have the same effect as the vitamins and minerals that are already naturally in your food and drink.
Many people choose an additional supplement, in addition to their daily diet. The users of dietary supplements indicate that they experience positive effects of the use of certain herbs, vitamins and minerals. The body absorbs the nutrients in pills more easily than the nutrients in food. But if you eat healthy and varied, you do not need additional nutritional supplements, because you already get enough nutrients, minerals and vitamins. Always report to your doctor and pharmacist that you are using dietary supplements.
• Fish fatty acids appear to have a mild anti-inflammatory effect with a high intake. Research has been done especially in rheumatoid arthritis. The advice is to eat oily fish twice a week.
• Glucosamine can act as a mild painkiller for osteoarthritis in the knee, but does not stop arthritis.
• Our body naturally makes vitamin D under the influence of outdoor sunlight. Vitamin D may have a beneficial effect in inflammatory arthritis, but that has not yet been proven sufficiently. People with Lupus erythematosus get vitamin D prescribed as they are not often outside, because sun exposure can lead to lupus flares and skin problems. Vitamine D is given with calcium tablets to ensure a good intake in the body, when you have osteoporosis or osteoarthritis.

Living with polymyalgia rheumatica (PMR)

You can resume all normal activities once the stiffness has disappeared, including exercise. But you can have side-effects from the use of corticosteroids. These include higher blood sugar, weight gain, sleeplessness, osteoporosis (bone loss), cataracts, thinning of the skin and bruising. Checking for these problems, including bone density testing, is an important part of follow-up visits with your doctor.
As PMR can occur with a more serious condition, giant cell arteritis, see your doctor right away if you have PMR and you get symptoms of headache, changes in vision or fever.

To get the disease under control, you can do the following yourself:
• exercising and keeping the muscles warm or cooled can sometimes help to relieve the symptoms.
• physical therapy is necessary to treat stiffness and movement limitation of joints.
• take your drugs consistently, otherwise it has no effect.
• consult with your doctor if you get side-effects or your symptoms get worse.
• never stop on your own with taking prednisone, always consult your doctor first.

Patient Education Library
Polymyalgia Rheumatica and Giant cell arteritis
https://www.ypo.education/rheumatology/polymyalgia-rheumatica-and-giant-cell-arteritis-t146/video/