Polymyalgia rheumatica and how it can affect daily life

Polymyalgia rheumatica (PMR) manifests in uncomfortable symptoms that if left untreated can potentially lead to disability and, in rare cases, serious complications.

We speak to highly experienced, leading consultant rheumatologist Mr Vijay Hajela, all about this condition, how it can affect patient’s daily lives and the effectiveness of available treatment in this informative article.

What causes polymyalgia rheumatica and how is it diagnosed?

Polymyalgia is a condition that can be difficult to diagnose and it can mimic many other things. It's a condition caused by inflammation in the body, that particularly affects the area where tendons attach to the bones around the shoulders, particularly the shoulders and the neck, and also around the pelvis. This causes very characteristic symptoms that people describe as feeling very stiff and achy, particularly first thing in the morning. They feel generally quite unwell with this condition. 

It comes on when people age, so over the age of 60 is the most common time and it really shouldn't be diagnosed under the age of 50. If someone's under 50 and they have these symptoms, then there's another diagnosis. 

It's slightly more common in women; about twice as common in women. We think smoking is a slight risk factor, and it's also important because it can cause polymyalgia progress towards a more serious condition that's linked, called giant cell arteritis. We know that in patients with polymyalgia, the arteries are also slightly inflamed. This can be much more severe with this more dangerous condition. Other people might know it as temporal arteritis. It can lead to:

• Loss of vision
• Double vision
• Blindness
• Problems chewing food, and more severe illness. 

About one in four people with polymyalgia can go on to get more serious conditions like these, and smoking is a risk factor to that. 

Overall:

• It’s a painful, stiff condition that comes on, for reasons we don't know fully why;
• usually over the age of 60, and;
• causes stiffness and pain in the hips and shoulders.

It's associated with a high level of inflammation in the blood when the doctor takes a blood sample. 

How is polymyalgia rheumatica treated and what medications are used?

The treatment for this condition is to try and reduce inflammation in the blood quickly. Really the only thing that we have that works quickly and effectively as possible, is steroids. We know that of course, steroids can lead to long-term problems, but in this condition, they are incredibly helpful. In fact, within one week of treatment with steroids, patients will often say they've had a miraculous improvement.

If they haven't had an improvement of more than 70 per cent, the diagnosis should be questioned. Improvement is rapid and very profound. The problem is, you need to start with steroids at a dose of 15 milligrams, and then taper very gradually. In fact, over about a course of a year or 18 months, even. 

It's a bit like throwing water on a fire. Initially, you need to throw a big bucket of water on it but if you then walk away, it will catch fire again. You need to keep throwing smaller and smaller amounts of water on it, until maybe you're only throwing a little thimble of water on it, to make sure the embers are completely out. Otherwise, they'll catch fire again and it's a little bit like snakes and ladders; you have to go all the way back to the beginning and start on a higher dose.

Some patients really find this difficult to think about; being on treatment for a year or 18 months, particularly with steroids and all the problems they can cause. But really there is very little choice in the early stages. We do know about side effects of steroids and we try to mitigate against the side effects by giving people medicines to protect the bones from osteoporosis, monitor blood pressure and blood sugar to make sure that doesn't go too high; we give advice about diet and exercise, and we give people medicines to try and prevent their stomach from being sore from the steroids.

We know about the side effects of steroids, but this condition untreated causes great disability and problems, so there's not a lot of choice, I'm afraid. 

What are the common symptoms of polymyalgia rheumatica and how do they affect daily life of patients? 

The symptoms are really very classic: Pain and stiffness are worse, first thing in the morning. 

If you ask someone, "When are the symptoms worse?", they'll always say in the morning. Often the second half of the night is also disturbed, and that's when inflammation always shows itself. If people say "I'm generally okay in the morning, and better as the day goes on", then it isn't polymyalgia.

It's usually across both shoulders and neck, and often the hips. It can be either, or, but usually it's both sides. The pain has to have been there for at least two weeks. Stiffness in the morning tends to slightly ease as you get going, so it needs to be a minimum of 45 minutes. Although often it's hours. Generally, people feel better as the day goes on, so towards the afternoon they say "I feel reasonably good, but the morning after I feel dreadful." 

The important thing is to rule out things that mimic this condition. So, things like:

• certain hormonal conditions;
• other rheumatological conditions such as rheumatoid arthritis, or;
• other types of arthritis.

There are some metabolic conditions that can do this.

Some patients have very chronic pain that can present in a very similar way, but the key thing is to identify the level of inflammation in the blood, which the doctor can do with a blood test. They can put together the symptoms and rule out other things. It can be complicated.

Once diagnosis is made and the treatment's given, a week later you will know for sure because the improvement will have been so dramatic. 

Can polymyalgia rheumatica lead to other health complications? And what are the risk factors? 

Polymyalgia itself is an inflammatory condition which, as I say, can affect the blood vessels. If people smoke, the arteries can firm up a bit more quickly so people could be more prone to developing heart disease or strokes. 

There are also side effects through treatment, from the steroids and things like:

• high blood pressure;
• diabetes;
• risk of infection;
• thinning of the bones.

We try to help people by giving them preventative treatment for this. 

As I say, a small percentage of patients will go on to develop a more serious condition called giant cell arteritis, or temporal arteritis. This tends to present with classic symptoms such as:

• headache on the side of the head;
• change of vision;
• double vision;
• difficulty chewing food, or;
• loss of use of the hands. 

It's in a minority of patients but this can be a complication. 

In general, polymyalgia itself, if treated well, isn't associated with an increased-risk of mortality and the majority of patients can get off their treatment within about 18 months, and then go on to live a normal life. 

If you’re experiencing the symptoms outlined in this article and would like an expert consultation for polymyalgia rheumatica, arrange an appointment with Mr Hajela via his Top Doctors profile.