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| {{Infobox_Disease |
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| Name = Polymyalgia rheumatica |
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| Image = |
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| Caption = |
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| DiseasesDB = |
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| ICD10 = {{ICD10|M|35|3|m|30}} |
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| ICD9 = {{ICD9|725}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 000415 |
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| MeshID = |
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| }}
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| {{SI}}
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| {{EH}}
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| __NOTOC__ | | __NOTOC__ |
| {{CMG}}
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| '''Associate Editor-In-Chief:''' {{CZ}} [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
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| '''For patient information click [[Polymyalgia rheumatica (patient information)|here]]''' | | '''For patient information click [[Polymyalgia rheumatica (patient information)|here]]''' |
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| ==Overview==
| | {{Polymyalgia rheumatica}} |
| [[Image:Bodydone.GIF|thumb|200px|In polmyalgia rheumatica (PMR), pain is usually located in the [[shoulders]] and [[hips]].]]
| | {{CMG}}; {{AE}} {{CZ}}, Ujjwal Rastogi, MBBS [mailto:urastogi@perfuse.org], {{Rim}}, {{AEL}} |
| '''Polymyalgia rheumatica''' (PMR) - (in Greek meaning “pain in many muscles”) is an inflammatory condition of the [[muscles]], which causes pain or stiffness, usually in the [[neck]], shoulders, and hips. The pain can be very sudden, or can occur gradually over a period of time.
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| Most PMR sufferers wake up in the morning with pain in their [[muscles]]; however, there have been cases in which the patient has developed the pain during the evenings.<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref> Along with this disorder, there have been reports that patients who have polymyalgia rheumatica also have [[temporal arteritis]], which causes inflammation that damages large and medium size [[arteries]]. PMR usually goes away within a year or two after treatment.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| == Epidemiology and Demographics ==
| | {{SK}} Anarthritic Syndrome, Arthritic Rheumatoid Disease, Polymyalgia, PMR |
| * Mean age at onset ~ 70 (range 50-90)
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| * F:M ratio = 2:1
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| ==Causes== | | ==[[Polymyalgia rheumatica overview|Overview]]== |
| The cause of this disorder is unknown; however, studies have shown that during this disorder, the [[white blood cells]] in the body attack the lining of muscle joints, causing inflammation.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref> Recent studies have found that inherited factors also play a role in the probability that an individual will become sick with polymyalgia rheumatica. Several theories have included viral stimulation of the [[immune system]] in genetically susceptible individuals.<ref name="citation3">http://www.medicinenet.com/polymyalgia_rheumatica/article.htm Shiel, William C. MD, FACP, FACR. "Polymyalgia Rheumatica (PMR) & Giant Cell Arteritis (Temporal Arteritis)." MedicineNet. 3 Mar. 2008. 14 Mar. 2008 </ref>
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| Manifestation of [[gaintcell arteritis]] as polymyalgia rheumatica is associated with the increased frequency of [[HLA DR4]].<ref name="pmid3259885">{{cite journal |author=Cid MC, Ercilla G, Vilaseca J, ''et al.'' |title=Polymyalgia rheumatica: a syndrome associated with HLA-DR4 antigen |journal=Arthritis Rheum. |volume=31 |issue=5 |pages=678–82 |year=1988 |month=May |pmid=3259885 |doi= |url=}}</ref>.[[PMR]] and [[GCA]] also share the associated sequence polymorphism encoded by the second hypervariable region(HVR) of the [[HLA DRB1 gene]] unlike [[rheumatoid arthritis]] in which the sequence is encoded by third HVR.<ref name="pmid8147928">{{cite journal |author=Weyand CM, Hunder NN, Hicok KC, Hunder GG, Goronzy JJ |title=HLA-DRB1 alleles in polymyalgia rheumatica, giant cell arteritis, and rheumatoid arthritis |journal=Arthritis Rheum. |volume=37 |issue=4 |pages=514–20 |year=1994 |month=April |pmid=8147928 |doi= |url=}}</ref>. Isolated PMR has positive association with TNFb3, independent of HLA DRB1 association.<ref name="pmid10943865">{{cite journal |author=Mattey DL, Hajeer AH, Dababneh A, ''et al.'' |title=Association of giant cell arteritis and polymyalgia rheumatica with different tumor necrosis factor microsatellite polymorphisms |journal=Arthritis Rheum. |volume=43 |issue=8 |pages=1749–55 |year=2000 |month=August |pmid=10943865 |doi=10.1002/1529-0131(200008)43:8<1749::AID-ANR11>3.0.CO;2-K |url=}}</ref>
| | ==[[Polymyalgia rheumatica historical perspective|Historical Perspective]]== |
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| Several [[viruses]] are thought to be linked to polymyalgia rheumatica,including the [[adenovirus]], which causes respiratory infections; the human parvovirus B19, an infection that affects children; and the human parainfluenza virus..<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
| | ==[[Polymyalgia rheumatica classification|Classification]]== |
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| ==Risk Factors== | | ==[[Polymyalgia rheumatica pathophysiology|Pathophysiology]]== |
| There are no certain circumstances for which an individual will get polymyalgia rheumatica, but there are a few factors that show a relationship with the disorder.
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| *Usually affects adults over the age of 50<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *The average age of a person who has PMR is about 70 years old<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *Women are twice as likely to get PMR as men<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *The vast majority of people affected are white<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *50% of people with [[temporal arteritis]] also have polymyalgia rheumatica<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| *Smoking, sun exposure, infections, nulliparity are also considered risk factors.<ref name="pmid10948749">{{cite journal |author=Cimmino MA, Zaccaria A |title=Epidemiology of polymyalgia rheumatica |journal=Clin. Exp. Rheumatol. |volume=18 |issue=4 Suppl 20 |pages=S9–11 |year=2000 |pmid=10948749 |doi= |url=}}</ref>
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| ==Diagnosis== | | ==[[Polymyalgia rheumatica causes|Causes]]== |
| There is no specific test to diagnose polymyalgia rheumatica. There are many other diseases which cause inflammation and pain in [[muscles]], but there are a few tests that can help narrow down the cause of the pain. Limitation in shoulder motion, or swelling of the joints in the wrists or hands are noted by the doctor.<ref name="citation3">http://www.medicinenet.com/polymyalgia_rheumatica/article.htm Shiel, William C. MD, FACP, FACR. "Polymyalgia Rheumatica (PMR) & Giant Cell Arteritis (Temporal Arteritis)." MedicineNet. 3 Mar. 2008. 14 Mar. 2008 </ref> The doctor will assess the patient’s pain, and may perform one of the following tests to determine if polymyalgia rheumatica is indeed the cause of the pain.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| One test that is usually performed is the [[erythrocyte sedimentation rate]] test (also known as the [[ESR]] or [[SED rate]]), which is a [[blood test]] that checks the [[erythrocyte sedimentation rate]]. This test measures how fast the patient’s red blood cells settle in a test tube. The faster the blood cells settle, the higher the SED rate, which means that there is inflammation. Because many conditions can cause an elevated SED rate, this test alone is not a good determinant if a person has with polymyalgia rheumatica.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
| | ==[[Differentiating Polymyalgia rheumatica from other diseases|Differentiating Polymyalgia Rheumatica from other Diseases]]== |
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| Another test that checks the level of [[C-reactive protein]] in the blood may also be conducted. [[C-reactive protein]] is produced by the liver in response to an injury or infection. People with polymyalgia rheumatica usually have high levels of [[C-reactive protein]], which is a response due to inflammation.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
| | ==[[Polymyalgia rheumatica epidemiology and demographics|Epidemiology and Demographics]]== |
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| Because people with polymyalgia rheumatica are sometimes associated with [[temporal arteritis]], doctors may perform a test to determine if a person has [[temporal arteritis]]. A sample from the scalp artery in the temple is taken and examined under a microscope. If a person is positive for [[temporal arteritis]], the doctor may prescribe a medicine that treats both polymyalgia rheumatica and [[temporal arteritis]].<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
| | ==[[Polymyalgia rheumatica risk factors|Risk factors]]== |
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| As a summary;
| | ==[[Polymyalgia rheumatica screening|Screening]]== |
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| * Age ≥ 50 at onset
| | ==[[Polymyalgia rheumatica natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * Symtoms in ≥ 2/3 areas (shoulder girdle, hip girdle, neck) x ≥ 1 month
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| * Erythrocyte sedimentation rate (ESR) ≥ 40 mm/hr
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| * Exclusion of alternative diagnosis
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| | ==Diagnosis== |
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| 2012 provisional criteria for Polymyalgia rheumatica by EULAR/ACR : patient ><u></u>50 years old presenting with bilateral shoulder pain, not explained by an alternative pathology can be classified as PMR in the presence of morning stiffness >45 minutes, elevated CRP and/or ESR and new hip pain.<ref name="pmid22388996">{{cite journal |author=Dasgupta B, Cimmino MA, Maradit-Kremers H, ''et al.'' |title=2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative |journal=Ann. Rheum. Dis. |volume=71 |issue=4 |pages=484–92 |year=2012 |month=April |pmid=22388996 |pmc=3298664 |doi=10.1136/annrheumdis-2011-200329 |url=}}</ref>
| | [[Polymyalgia rheumatica diagnostic study of choice|Diagnostic Study of Choice]] | [[Polymyalgia rheumatica history and symptoms|History and Symptoms]] | [[Polymyalgia rheumatica physical examination|Physical Examination]] | [[Polymyalgia rheumatica laboratory findings|Laboratory Findings]] | [[Polymyalgia rheumatica electrocardiogram|Electrocardiogram]] | [[Polymyalgia rheumatica x ray|X-ray]] | [[Polymyalgia rheumatica echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Polymyalgia rheumatica CT scan|CT scan]] | [[Polymyalgia rheumatica MRI|MRI]] | [[Polymyalgia rheumatica other imaging findings|Other Imaging Findings]] | [[Polymyalgia rheumatica other diagnostic studies|Other Diagnostic Studies]] |
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| == History and Symptoms ==
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| There are a wide range of symptoms that indicate if a person has polymyalgia rheumatica. The symptoms include pain and stiffness in the [[muscles]], usually in the [[neck]], [[shoulders]], and [[hips]]. The pain is moderate to severe, and may inhibit the activity of the person. These symptoms usually occur in the morning, or after sleeping. [[Fatigue]] and [[lack of appetite]] are also signs of polymyalgia rheumatica. [[Lack of appetite]] could lead to unintentional [[weight loss]]. [[Anemia]] is another sign of polymyalgia rheumatica. An overall [[feeling of illness]] and a slight [[fever]] are also signs of this disorder.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| Studies have shown that about 15% of people who are diagnosed with polymyalgia rheumatica also have [[temporal arteritis]], and about 50% of people with [[temporal arteritis]] have polymyalgia rheumatica. Some symptoms of [[temporal arteritis]] include severe [[headaches]], scalp tenderness, [[jaw]] or facial soreness, distorted vision or aching in the limbs caused by decreased blood flow, and [[fatigue]].<ref name="multiple">http://arthritis.webmd.com/polymyalgia-rheumatica-temporal-arteritis Gelfand, Jonathan L MD. "Polymyalgia Rheumatica and Temporal Arteritis." WedMD. 17 Nov. 2007. Cleveland Clinic. 16 Mar. 2008 </ref>
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| * Symmetric aching/stiffness of axial & proximal limb musculature
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| *:* Shoulder girdle, neck, hip girdle
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| *:* Morning stiffness, gelling
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| * Muscle strength intact, though may be limited by pain
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| * [[Synovitis]] in knees, wrists, sterno-clavicular (SC) joints, hips/shoulders
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| * Distal extremity swelling ([[tenosynovitis]])
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| * [[Malaise]], [[fatigue]], [[weight loss]] in > 50%
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| ==== Relation to Giant Cell Arteritis (GCA) ====
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| * 25% of patients with GCA have PMR as presenting symptom
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| * 40-60% of patients with GCA have PMR during disease course
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| * 10-15% of patients with PMR have GCA by temporal artery (TA) biopsy
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| <br>
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| {|
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| |-style="background:silver; color:black"
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| | '''''Symptoms GCA''''' || || '''''Signs GCA''''' ||
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| |-style="background:silver; color:black"
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| | '''Headache''' || '''68%''' || '''Decreased TA pulsations''' || '''46%'''
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| |- style="background:silver; color:black"
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| | '''Jaw claudication''' || '''45%''' || '''Fever''' || '''42%'''
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| |-style="background:silver; color:black"
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| | '''Transient visual symptoms''' || '''16%''' || '''Tenderness over temporal artery''' || '''27%'''
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| |-style="background:silver; color:black"
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| | '''Fixed visual loss''' || '''14%''' || '''Nodular or swollen scalp arteries''' || '''23%'''
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| |-style="background:silver; color:black"
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| | '''Dysphagia ''' || '''8%''' || '''Large artery bruits ''' || '''21%'''
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| |-style="background:silver; color:black"
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| | '''Tongue claudication''' || '''6%''' || '''Ophthalmoscopic abnormalities''' || '''18%'''
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| |-style="background:silver; color:black"
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| | || || '''Visual loss''' || '''14%'''
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| |}
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| == Laboratory Findings ==
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| * Mild normochromic, normocytic anemia (during active phase)
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| * [[White blood cell]] ([[WBC]]) normal, [[platelets]] often increased
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| * Markedly elevated [[ESR]]
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| * [[Antinuclear antibody]] (ANA), [[rheumatoid factor]] (RF) usually negative
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| * [[Creatine kinase]] (CK), aldolase, [[electromyogram]] (EMG), [[muscle biopsy]] all normal
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| === Other Diagnostic Studies ===
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| ==== Temporal Artery Biopsy ====
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| * Not indicated if no symptoms suggestive of GCA
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| * Negative predictors of GCA
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| *:* Age < 70
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| *:* Absence of headache or jaw claudication
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| *:* Clinically normal temporal arteries
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| *:* 3 negative predictors--1.7% risk GCA
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| *:* If ≤ 2 negative predictors--55% risk GCA
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| * Can still demonstrates arteritis after 2-4 weeks of steroid treatment
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| == Differential Diagnosis ==
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| * [[Rheumatoid arthritis]]
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| * [[Polymyositis]]
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| * Malignancy ([[myeloma]], others)
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| * Chronic infection ([[subacute bacterial endocarditis]] ([[SBE]]))
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| * [[Hypothyroidism]]
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| ==Treatment and Medication==
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| Anti-inflammatory medicine such as [[aspirin]] or [[ibuprofen]] is typically prescribed to treat mild cases of polymyalgia rheumatica. For more serious cases, with extreme pain and discomfort, [[steroids]] are prescribed to patients. [[Prednisone]] is the typical [[steroid]] used to treat polymyalgia rheumatica. The [[steroids]] are normally distributed in low doses (10-15 mg per day), and results are usually seen within the first few days of taking the medication.<ref name="citation4">http://www.rheumatology.org/public/factsheets/pmr_new2.asp "POLYMYALGIA RHEUMATICA." American College of Rheumatology. June 2006. American College of Rheumatology. 11 Mar. 2008 </ref> The patient's SED rate is monitored throughout the medication process, and other [[blood tests]] are conducted to make sure the patient does not experience any side effects from the treatment. Once the SED rate is back to normal, the patient will receive lower doses of the [[steroids]] in order to avoid any long term health effects from the [[steroids]].<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| Some side effects from the [[steroids]] may occur. Studies have shown that [[steroids]] increase the patient’s [[blood pressure]]. For this reason, the patient’s [[blood pressure]] is monitored throughout the treatment process. Also, the [[steroids]] lower the patient’s [[immune system]], making them more susceptible to [[infection]]. The doctor should be notified of any signs of sickness.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| Along with medical treatment, patients can increase their chances of recovery by exercising and eating healthy foods. [[Exercise]] will help strengthen the weak [[muscles]], and help to prevent weight gain. A healthy diet will help to keep a strong [[immune system]], and also help build strong muscles and bones.<ref name="citation2">http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=1 "Polymyalgia Rhuematica." MayoClinic. 17 May 2006. 15 Mar. 2008 </ref>
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| Treatment lasts as long as needed; however, it normally takes patients several years to get off of the steroids. The symptoms may come back when the dosage is lowered.<ref name="citation3">http://www.medicinenet.com/polymyalgia_rheumatica/page2.htm#6whatis Shiel, William C. MD, FACP, FACR. "Polymyalgia Rheumatica (PMR) & Giant Cell Arteritis (Temporal Arteritis)." MedicineNet. 3 Mar. 2008. 14 Mar. 2008 </ref>
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| === Acute Pharmacotherapies ===
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| * [[NSAID]]s helpful in mild disease
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| * [[Glucocorticoids]] if no response to [[non-steriod anti inflammatory drug]]s ([[NSAID]]s)
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| *:* [[Prednisone]] 5-20 mg every day--rapid improvement in symptoms
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| *:* Start taper after symptoms remit and ESR returns to normal (2-4 weeks)
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| *:* Gradual dose reduction (eg, by 2.5 mg) q 1-4 weeks until dose = 5-10 mg every day
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| *:* Even ''slower'' taper once dose < 5-10 mg (reduce dose by 1 mg q month)
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| * Monitor for relapse--occurs in 25-50%, usually because taper too rapid
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| * Careful observation for signs of [[arteritis]]
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| EULAR response criteria for PMR comprise a set of core markers for monitoring theurapeutic response which include :
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| *[[ESR]]
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| *[[CRP]]
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| *Visual analogue scale of patient's pain
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| *[[Physician's global assessment]]
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| *[[Morning stiffness]]
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| *Ability to elevate the [[upper limbs]].
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| A disease activity score <7 indicates low activity, 7-17 suggest medium disease activity, >17 indicates high disease activity.<ref name="pmid16823992">{{cite journal |author=Nothnagl T, Leeb BF |title=Diagnosis, differential diagnosis and treatment of polymyalgia rheumatica |journal=Drugs Aging |volume=23 |issue=5 |pages=391–402 |year=2006 |pmid=16823992 |doi= |url=}}</ref>
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| ==References==
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| <references />
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| ==External links==
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| * [http://www.webmd.com/content/article/78/95605.htm?z=2953_00483_6501_00_29 Polymyalgia Rheumatica] - WebMD.com
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| * [http://www.arthritis.ca/types%20of%20arthritis/polymyalgia%20rheumatica/default.asp?s=1 Polymyalgia Rheumatica] - The Arthritis Society
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| * [http://www.rheumatology.org/public/factsheets/pmr_new2.asp Patient Education - Polymyalgia Rheumatica] - American College of Rheumatology
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| * [http://nmrfoundation.blogspot.com/ National Medical Research Foundation] Support groups for people with polymyalgia rheumatica
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| | ==Treatment== |
| | [[Polymyalgia rheumatica medical therapy|Medical Therapy]] | [[Polymyalgia rheumatica surgery|Surgery]] | [[Polymyalgia rheumatica primary prevention|Primary Prevention]] | [[Polymyalgia rheumatica secondary prevention|Secondary Prevention]] | [[Polymyalgia rheumatica cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Polymyalgia rheumatica future or investigational therapies|Future or Investigational Therapies]] |
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| {{Diseases of the musculoskeletal system and connective tissue}}
| | ==Case Studies== |
| {{SIB}}
| | [[Polymyalgia rheumatica case study #1|Case Study #1]] |
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