Polymyalgia Rheumatica
Jill C. Cash and Julie Barnes
Definition
A.Polymyalgia rheumatica (PMR) is an inflammatory condition, with an insidious or abrupt onset, that causes morning muscle stiffness, pain, and decreased range of motion (ROM), primarily in the hips, shoulders, and neck.
Incidence
A.PMR occurs in all racial groups; however, it is rarely seen in the African American and Latino populations.
B.It is commonly seen in adults older than 50 years, with an increased incidence in the 70- to 80-year-old population.
C.Women are affected two to three times more often than men.
D.PMR is occasionally associated with giant cell arteritis (GCA). Approximately 15% of diagnosed patients with PMR will also have GCA. Approximately half of patients diagnosed with GCA will be diagnosed with PMR.
Pathogenesis
A.The cause of PMR is unknown. Environmental and genetic factors have been shown to play a role in PMR. Studies speculate that environmental triggers, such as viruses, may cause the onset of symptoms.
B.There are common similarities between PMR and GCA.
Predisposing Factors
A.Age (older than 50 years).
B.Gender (women are affected two to three times more often than men).
C.Ethnicity (those of Northern European origin have a higher rate of PMR).
Common Complaints
A.Early morning joint stiffness and pain, lasting for approximately 20 to 30 minutes after waking for at least 2 weeks.
B.Stiffness and pain commonly occur in the shoulders, hips, and neck.
C.Decreased ROM of joints.
D.Muscle pain.
E.Weakness of joints and muscles.
Other Signs and Symptoms
A.Fever.
B.Fatigue.
C.Malaise.
Potential Complications
A.Difficulty performing daily activities, such as getting up out of a chair, dressing, and bathing.
B.Decreased activity.
C.Overall a decrease in general health because of limitations.
Subjective Data
A.Ask the patient if there was an activity that brought about or preceded the episode of joint pain.
B.Has the patient had any recent illness or injury?
C.Ask the patient to describe the onset, duration, and intensity of pain, noting what particular joints are involved.
D.How long does pain and stiffness last in the morning?
E.Does the patient notice a decrease in ROM? Are there activities that the patient is not able to perform?
F.Ask the patient to list all medications currently being taken, particularly substances not prescribed and OTC products. What medications improve pain?
G.Has the patient noticed a problem with sleeping since the symptoms began?
Physical Examination
A.Vital signs: Check temperature, pulse, respirations, and blood pressure (BP).
B.Inspect:
1.Hands, wrists, elbows, shoulders, hips, and neck for erythema and synovitis.
C.Palpate:
1.Palpate joints for swelling and pain. Marked swelling is not usually seen in patients with PMR.
2.Assess ROM of the shoulders, hips, back, and neck. Perform passive ROM of the shoulders and hips.
3.Assess trigger points for tenderness, assessing for symptoms of fibromyalgia.
4.Assess muscle strength of upper and lower extremities and neck.
5.Assess temporal arteries for signs of inflammation.
D.Auscultate:
1.Heart.
2.Lungs.
Diagnostic Tests
A.Complete blood count (CBC)—normocytic anemia common.
B.Erythrocyte sedimentation rate (ESR)—elevation.
C.C-reactive protein (CRP), noncardiac—elevation.
D.Rheumatoid factor (RF)—negative.
E.X-rays or MRI of the affected joints.
Differential Diagnoses
A.PMR.
B.Rheumatoid arthritis (RA).
C.GCA.
D.Fibromyalgia (symptoms will have been present for years).
Plan
A.General interventions:
1.Treat the patient with steroid therapy to improve symptoms, starting at an adequate dose to resolve symptoms. Treatment will include slowly tapering the steroids over a period of weeks/months to keep the patient symptom free until off of steroids.
B.Patient teaching:
1. 
See Section III: Patient Teaching Guide Polymyalgia Rheumatica.
2.Educate the patient and family that PMR is primarily a self-limiting condition that will improve slowly over time.
3.Treatment will include several weeks/months of low-dose prednisone therapy, tapering slowly until completion of steroid therapy. Tapering slowly and patience will prevent recurrent attacks and rebound flares.
C.Pharmaceutical therapy:
1.Low-dose prednisone is used to treat the symptoms. Steroids should be given to relieve symptoms (starting dose may be 10–20 mg orally [PO] daily) and then will be tapered slowly over the next 6 months. Gradually decreasing the steroid dose by very small increments over time has the best results, minimizing the possibility of relapse.
Follow-Up
A.A follow-up appointment is recommended 2 weeks after the initial appointment.
B.If symptoms are improving with the steroid therapy, a follow-up appointment is recommended every 1 to 2 months until there are not any flares of symptoms and the patient has completed the steroid therapy. This treatment may take several months and even up to greater than 1 year.
C.Another condition to consider with the symptoms is remitting seronegative symmetrical synovitis
with pitting edema. This condition presents with hand and distal extremity swelling, noting marked pitting edema in extremities. It is commonly seen in patients older than 50 years of age with an acute onset of swelling and pain. Symptoms respond quickly to the use of low-dose steroids. Laboratory testing for RA is negative.
D.Patients on long-term steroids should have a bone mass density (BMD) performed to evaluate for osteoporosis.
Individual Considerations
A.Geriatrics:
1.American college of Rheumatology (ACR) classification criteria for PMR for older adults are as follows:
a.Age ≥50 years, bilateral shoulder pain, and abnormal CRP/ESR.
b.Morning stiffness that lasts ≥45 minutes = 2 points.
c.Limited hip ROM and pain = 1 point.
d.Absent RA factor and/or antinucear antibody (ANA) = 2 points.
e.No peripheral joint pain = 1 point. A total of ≥4 points has a great sensitivity for discriminating RA from PMR.