Polymyalgia Rheumatica

What is Polymyalgia Rheumatica?

Polymyalgia rheumatica is an inflammatory rheumatic disease that causes pain and stiffness around the neck, shoulders and hips, and it mainly affects people older than 50.^{[1, 2]} It needs diagnosis and ongoing treatment by a physician, and it can overlap with giant cell arteritis, a condition that can threaten eyesight.^{[1, 3]}

Common symptoms

The typical picture is aching in both shoulders, often with pain in the hips or neck, and pronounced stiffness in the morning.^[4] Fatigue, fever and weight loss can also occur.^[5]

Symptoms usually develop over days to weeks. Because the disease has no single specific test, other causes of similar symptoms have to be ruled out.^[2]

Causes and risk factors

The cause is not fully known. Female sex, previous infections and genetic factors are presumed risk factors.^[6] The disease is two to three times more common in women, and it can appear as a side effect of cancer treatment with checkpoint inhibitors.^[5]

How it is diagnosed and treated conventionally

Diagnosis rests on the typical symptoms, raised inflammation markers in the blood (ESR and CRP) and exclusion of other conditions, including giant cell arteritis.^[4] Imaging such as ultrasound is increasingly used to support the diagnosis.^[2]

Glucocorticoids are the main treatment. They usually bring rapid relief, and the dose is lowered gradually, ideally over 12 months or less.^[4] Relapses are common when the dose is tapered, and side effects of long-term steroid use, such as diabetes and osteoporosis, are frequent.^{[2, 5]} For relapses, physicians may add methotrexate or interleukin-6 blockers.^[4]

Why Polymyalgia Rheumatica calls for a whole-person approach

Polymyalgia rheumatica is driven by inflammation, but the way it affects daily life also depends on pain from other conditions, treatment side effects, fitness and mood. The disease can reduce quality of life even though it does not clearly shorten survival.^[2]

A treatment plan therefore works best when the rheumatologist manages the disease and other care addresses the factors around it. Supportive care at our clinic is limited to those surrounding factors.

Inflammation and whole-body symptoms

Fatigue, fever and weight loss in this disease are thought to be driven by interleukin-6, an inflammatory signaling molecule.^[5] This is why the general feeling of being unwell can be as troubling as the muscle pain.

Other sources of pain

Pain from common conditions such as osteoarthritis and tendon problems can return as steroids are lowered. This can make it hard to tell a true flare from other pain.^[2] Your physician needs to make that distinction.

Steroid side effects and bone health

Long-term glucocorticoid use is linked to diabetes and osteoporosis in people with this disease.^[5] Following bone and blood sugar monitoring from your physician is an important part of care.

Movement and strength

For older patients with limited physical ability, exercise programs play an important role alongside medication.^[6] Your physician or physical therapist should guide what activity is suitable.

Acupuncture as supportive care in Polymyalgia Rheumatica

What the research shows

No randomized trials of acupuncture for polymyalgia rheumatica turned up in a PubMed search. A Chinese-language clinical experience report exists, but it is not controlled research. We therefore cannot say that acupuncture helps this disease.

What is known comes from other conditions. A pooled analysis of individual data from 39 high-quality trials (20,827 patients) found acupuncture reduced chronic musculoskeletal pain, osteoarthritis pain, headache and shoulder pain more than sham or no acupuncture, with effects lasting up to a year.^[7] These trials did not include people with polymyalgia rheumatica, so the result may not carry over. A Cochrane review of acupuncture for shoulder pain, which excluded polymyalgia rheumatica, found little evidence either way because the trials were few and small.^[8]

A review of 25 trials in fibromyalgia, another widespread pain condition, reported improvements in pain, fatigue, stiffness and sleep with acupuncture or dry needling in the short term.^[9]

How acupuncture may work

No studies explain how acupuncture might act in polymyalgia rheumatica. In chronic pain generally, the pooled analysis concluded that the pain relief cannot be explained by placebo effects alone.^[7] That does not show an effect on the inflammation behind this disease.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes. A course of several visits is followed by reassessment. We would aim treatment at pain, stiffness, sleep and stress, not at the disease process.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[10] Tell the practitioner first if you take blood thinners, have a bleeding disorder, are pregnant, or have a pacemaker. Tell us also about long-term steroid use, as you may bruise more easily and have fragile skin or bones.

Ayurvedic medicine as supportive care in Polymyalgia Rheumatica

The Ayurvedic view

Ayurveda has no classical diagnosis that matches polymyalgia rheumatica. Some practitioners compare it to Amavata, a pattern of stiffness and aching said to involve Vata imbalance and ama, a term for poorly processed material in the body. This comparison is an interpretation, not a medical equivalence.

Therapies that may be used

Care is individualized and traditionally includes:

• Diet and daily routine aimed at regular meals, steady sleep and gentle morning movement
• Warm oil massage over stiff areas, where skin and bones can tolerate it
• Herbs chosen and prescribed individually by a qualified practitioner
• Yoga or breathing practices for stress and sleep, adjusted to your strength and balance

Panchakarma is a traditional set of cleansing procedures. It is not appropriate during pregnancy, acute illness or frailty, which can apply to someone in a flare. Talk with your physician before considering it for this condition.

What the research shows

A PubMed search found no clinical trials of Ayurvedic treatment for polymyalgia rheumatica, so the evidence for the disease is none.

Some herbs have been studied for symptoms. A meta-analysis of 12 trials found ashwagandha reduced anxiety and stress compared with placebo, but rated the certainty of the evidence as low.^[11] A meta-analysis of five trials (400 participants) found a small improvement in sleep, and noted that long-term safety data are limited.^[12] None of these trials studied polymyalgia rheumatica.

Herbal medicine as supportive care in Polymyalgia Rheumatica

Herbs and formulas that have been studied

The only controlled study found for this disease tested Yanghe Decoction, a traditional Chinese formula, taken with prednisone.^[13] Turmeric (curcumin) has been studied in other autoimmune and inflammatory diseases, but not in polymyalgia rheumatica.^[14]

What the research shows

The evidence for polymyalgia rheumatica is limited to a single small trial. In a 2007 Chinese trial of 61 patients, those given the formula plus prednisone had a faster fall in ESR and a faster prednisone reduction than those given prednisone alone.^[13] The trial was small, and the abstract does not describe blinding or a placebo, so it cannot be relied on.

A meta-analysis of 31 trials across 10 autoimmune diseases found curcumin improved results in several, including rheumatoid arthritis, but the authors said trials were small and more high-quality studies are needed.^[14] A separate meta-analysis of six trials (539 patients) in rheumatoid arthritis reported lower inflammation markers and joint counts.^[15] Rheumatoid arthritis is a different disease, so these findings cannot be assumed to apply here.

Safety and herb-drug interactions

Herbs can interact with the medicines used in this disease, and a review of herb-drug interactions found that serious consequences can occur.^[16] Case reports describe bleeding when warfarin is combined with herbs including dan shen, dang gui, ginger, ginseng and Boswellia.^[17] Tell us about all prescribed medicines, including steroids, methotrexate, blood thinners and diabetes drugs, before any herb is considered.

Herbal and dietary supplements account for about 20% of cases of liver injury from drugs and supplements in the United States, so tell your physician about any herb if you take methotrexate or other medicines that affect the liver.^[18] About one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic, so products must come from tested sources.^[19] Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

This section is interpretation, not equivalence. Chinese medicine may describe stiffness and aching in the shoulders and hips as obstruction of qi and blood, often with cold and dampness. Ayurveda may describe it as Vata with ama. Modern researchers study inflammation, pain processing and sleep, which may loosely parallel these ideas.

In polymyalgia rheumatica, the biological process is immune-driven inflammation involving interleukin-6.^[5] No study shows that a pattern, a dosha or an acupuncture point corresponds to that process.

How this care fits with your medical care

Supportive care here sits alongside your physician's treatment. Polymyalgia rheumatica needs a physician, usually a rheumatologist, and international recommendations cover its investigation, steroid dosing and tapering.^[20] Never stop, lower or skip prednisone or any other prescribed medicine on your own, because abrupt changes can be dangerous.

For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. Please bring your diagnosis, your current steroid dose and taper plan, a full list of medicines and supplements, and recent blood test results.

When to seek urgent medical care

Polymyalgia rheumatica can occur together with giant cell arteritis, which needs urgent treatment to protect eyesight.^[3]

• New headache, especially at the temples, or scalp tenderness
• Pain in the jaw when chewing
• Sudden blurred or double vision, or loss of vision in one eye
• Fever with severe new weakness or illness while on steroids
• Signs of a serious steroid side effect, such as extreme thirst and urination, or severe stomach pain or black stools

If you have any of these, call 911 or go to the nearest emergency department.