What is polymyalgia rheumatica?
Polymyalgia rheumatica is an inflammatory disease that appears after age 50, generally in older people and often around age 70.
It is more common in women, although it can also occur in men.
Symptoms of polymyalgia rheumatica: severe pain and stiffness
The disease causes very significant pain and bodily stiffness, especially in:
- The neck.
- The shoulders.
- The pelvic girdle and hips.
Involvement is usually bilateral. The person may have enormous difficulty raising the arms, getting dressed, rising from a chair or getting out of bed.
Despite the intensity of symptoms, visibly swollen joints are not necessarily found. The person may feel almost completely disabled, but the main problem is pain and stiffness in the affected regions.
It can be confused with fibromyalgia
Because of widespread pain and stiffness, polymyalgia rheumatica may be confused with fibromyalgia.
Age helps guide the distinction. Fibromyalgia usually begins in young women, while polymyalgia appears after age 50.
There is another extraordinarily important difference: the response to treatment.
A spectacular response to treatment
The response of polymyalgia rheumatica to steroids can be spectacular, almost magical.
A person who had enormous difficulty moving, raising the arms or getting out of bed may improve extraordinarily after starting treatment.
This contrasts with fibromyalgia, which does not show such a spectacular response to steroids.
The way the patient responds also provides important information supporting the clinical diagnosis.
Diagnosis begins by listening to the patient
In polymyalgia rheumatica, much of the diagnosis comes from listening.
I have always said that diagnosing it may be 80% letting the patient speak.
Age, how the condition began, the bilateral distribution of pain, the intensity of stiffness and difficulty performing simple activities build the clinical suspicion.
Tests help, but they do not replace the patient's history.
Erythrocyte sedimentation rate and C-reactive protein
The erythrocyte sedimentation rate and C-reactive protein may be elevated, but they may also be normal.
Normal inflammatory markers therefore do not automatically exclude polymyalgia rheumatica when the history is characteristic.
In my experience with Latin American patients, these tests may also provide prognostic information. When they remain elevated, they can suggest a more chronic course.
Treatment should not always stop at two years
There is an idea that treatment can be withdrawn after approximately two years. Not everyone, however, follows the same course.
If inflammatory markers and disease behavior suggest a more prolonged course, treatment should not be stopped solely because a particular date has been reached.
Management should adapt to each patient's progress. Forcing withdrawal while the disease remains active may cause a relapse.
Relationship with giant cell arteritis
Polymyalgia rheumatica is related to temporal arteritis, also known as giant cell arteritis.
This disease can cause headache, and one of its most serious complications is loss of vision.
When a person with polymyalgia develops a new headache or visual symptoms, possible giant cell arteritis must be assessed. Not every headache in a person with polymyalgia is automatically due to this complication; the patient must be evaluated and examined.
A difference between populations
The association with giant cell arteritis is described much more frequently in the United States and Europe.
In my experience, it is considerably less common in Latin America. I believe this difference may relate to the genetic characteristics of our populations.
Figures from European or US populations therefore cannot always be transferred automatically to Latin American patients.
The prognosis is usually excellent
In general, the prognosis of polymyalgia rheumatica is excellent.
The key is to recognize it, distinguish it from other causes of widespread pain and begin the correct treatment. Improvement can be extraordinary.
The duration of disease is not identical in everyone. Some patients can gradually withdraw treatment, while others have a more chronic course and need longer follow-up.
The objective is not to meet an arbitrary deadline. It is to keep the disease controlled and adjust treatment according to each patient's actual course.