Generality
The polymyalgia rheumatica is an inflammation of the muscles, which starts from the shoulders, neck and hips, and then spreads, in the absence of treatment, to the rest of the body. The main symptoms experienced by patients are pain and muscle stiffness.
The precise causes of onset, at the moment, continue to remain unknown. However, it is assumed that at the origin of polymyalgia rheumatica there is a combination of genetic factors and environmental factors.
What is polymialgia rheumatica
By polymyalgia rheumatica is meant an inflammatory process that causes pain and muscle stiffness, especially in the shoulders, neck and hips. He who is affected by it encounters various difficulties in getting up from the bed, in dressing up, in entering / leaving the car, in other words, in performing the most common daily activities.
The polymyalgia rheumatica resembles, under certain points of view, different pathological conditions; when it is in its infancy, it can be confused by flu, but at a later stage, it can recall rheumatoid arthritis . However, it is distinguished from the first by the duration of symptoms and by the modalities of treatment, and from the second by the site of inflammation (articular in the case of rheumatoid arthritis).
RHEUMATIC POLYMALGIA AND HORTON ARTERITIS
Often, those suffering from polymyalgia rheumatica also suffer from Horton arteritis at the same time. The latter is an inflammation of the arteries of medium and large caliber, especially those that cross the temporal area of the head (at the temples).
Horton's arteritis is a curable pathological condition, but compared to polymyalgia rheumatica it can develop much more serious complications (especially if the diagnosis or treatment is late).
Epidemiology
Every year one person every 1, 200 suffers from polymyalgia rheumatica. The subjects affected are often elderly women (aged 65-70 and over) of women (women are twice more affected than males).
Moreover, individuals from Northern Europe, particularly from Scandinavia, are particularly predisposed to manifest the disorder.
Horton arteritis and polymyalgia rheumatica: epidemiology
Except for the incidence, the other epidemiological features just described also apply to Horton's arteritis. This confirms the similarities between the two pathological conditions.
According to some statistical data, about 15-30% of people with polymyalgia rheumatica also suffer from Horton arteritis, while about half of those who have Horton's arteritis are affected (or have been in the past) by polymyalgia rheumatica.
Causes
The exact cause of polymyalgia rheumatica still remains unknown. According to the most accepted hypothesis, the inflammatory process derives from a combination of genetic and environmental factors. Therefore, the presence of only one of the two components is not sufficient to cause the disease.
But what do we refer to when we talk about genetic and environmental factors?
- Genetic factors . There are people with a natural predisposition to develop polymyalgia rheumatic. This predisposition is written in their genes and cannot be cured.
- Environmental factors . It has been observed that, in genetically predisposed persons, polymyalgia rheumatica often makes its appearance after a viral or bacterial infection. There is no more influential organism than others, or at least it has not yet been identified.
RISK FACTORS
As anticipated, there are some conditions that favor the onset of polymyalgia rheumatica. They are:
- Advanced age . People aged 65-70 are the most affected. It can happen, but it is rare, that people around the age of 50-55 get sick.
- Female sex . In women, polymialgia rheumatica is twice as frequent as in men.
- Scandinavian origin . A greater incidence of polymyalgia rheumatica was noted in individuals from Northern Europe, particularly from Sweden, Finland and Norway. However, the reasons for this have not yet been understood.
Symptoms and Complications
To learn more: Symptoms Polymyalgia Rheumatica
Due to the symptoms it causes, polymyalgia rheumatica resembles a normal flu; however, unlike the latter, it does not resolve spontaneously without treatment.
The symptoms and signs are different, but they all lead to an inflammatory process that starts at the level of the neck, shoulder and hip muscles.
Muscle pain ( myalgia ) is the main pathological manifestation: it appears, first, on one side only of the body, then on both sides.
In addition to myalgia, the patient usually warns:
- Stiffness and soreness of the areas affected by myalgia, therefore: shoulders, neck, hips and limbs.
- Limited mobility of the muscles next to the joints
- Aching knees and wrists
- Medium-high fever (37-38 °)
- Sense of fatigue
- Feeling sick
- Loss of appetite
- Inexplicable drop in body weight
- Depression
THE MUSCULAR PAIN (MIALGIA)
As mentioned above, muscle pain is the key symptom of polymyalgia rheumatica; at the beginning, it arises in precise points of the body: neck, shoulders and also, subsequently, tends to involve the limbs (both upper and lower) and the muscles next to the joints (knees and wrists, in particular).
Figure: the red areas highlight the anatomical areas, where pain and muscle stiffness are perceived. . From the site: //pdg.molig.com
The patient, if not treated, complains of pain when he has to perform the most normal daily activities, such as getting out of bed or from a chair, getting in or out of the car, getting dressed, combing, etc.
SENSE OF STIFFNESS?
In the same areas of the body affected by myalgia, the patient also experiences a feeling of muscle stiffness . This is the second important signal of polymyalgia rheumatica.
This rigidity is perceived above all in the first hours after awakening; over time (in the absence of appropriate care) it tends to spread to other parts of the body.
DEPRESSION
One will wonder why the patient with polymyalgia rheumatica sometimes suffers from depression . The reason is simple: in just a few days, sick people find it difficult to carry out even the simplest daily operations. This fact, in particular on an elderly subject with other ailments, can have serious psychological repercussions.
WHEN TO REFER TO THE DOCTOR?
In the beginning, polymyalgia rheumatica remembers a common influence and can be mistaken for this. However, in a few days the symptoms, instead of improving, drastically worsen: this is the signal that you should contact your doctor for a thorough visit.
In general, the following events should not be overlooked:
- Appearance of new muscle pains
- Appearance of rigidity where there was already pain
- Difficulty performing simple daily activities
- Limited joint mobility
COMPLICATIONS
The complications of polymyalgia rheumatica arise due to the patient's neglect of the symptoms he feels.
This leads, in less severe cases, to a worsening of health conditions and the degree of motor impediment, while in the most unfortunate situations Horton's arteritis can appear. It is not yet clear how the latter develops from polymyalgia rheumatica, however this happens in a fair number of patients.
How to recognize a Horton arteritis?
Horton's arteritis can cause serious consequences, such as complete blindness . Therefore, it is essential to recognize the main symptoms promptly: persistent headache (especially at the temples), sudden loss of sight, double vision and pain in the jaw or neck.
With early diagnosis and timely therapeutic intervention, Horton's arteritis can be cured, avoiding the danger of the aforementioned complications.
Diagnosis
Figure: a classic sign of Horton's arteritis: the swelling of the artery affected by inflammation . From the site: www.medibird.com
Due to the similarity with other diseases, polymyalgia rheumatica requires a scrupulous diagnosis, consisting of an objective examination and various instrumental and laboratory tests on the blood of patients.
In some cases, if doubts persist, it may be useful to implement the so-called differential diagnosis, through which pathologies with similar symptoms are excluded.
Knowing the exact reason of muscle pain is essential for setting the most appropriate therapy.
EXAMINATION OBJECTIVE
During the physical examination, the doctor asks the patient how the symptoms occurred and when he warns them. After that, he assesses firsthand what pain means to the patient, making him perform some movements of the neck, shoulders and limbs.
Evaluating the state of motor impediment is a source of much information, very useful for a correct diagnosis.
BLOOD TESTS
If there is a suspicion of a polymyalgia rheumatica, the erythrocyte sedimentation test performed on the patient's blood can provide significant information. This is based on the evaluation of the speed with which the red blood cells sediment at the bottom of the tube that contains them. The faster this movement (high ESR), the more probable is the presence of an ongoing inflammation.
Another blood parameter, detectable during an inflammatory state, is the high presence of a particular protein, produced by the liver, known as the C-reactive protein .
Both tests, both sedimentation and C-reactive, are rapid and non-invasive.
Blood tests also evaluate:
- The presence of infectious agents, such as viruses or bacteria
- Renal function (creatinine levels)
- Thyroid function (amount of thyroid hormones)
INSTRUMENTAL TESTS
Instrumental tests are particularly useful, because they provide in-depth images of internal tissues (muscles, joints, bones, etc.) and clarify the precise cause of myalgia (if doubts remain). In fact, if there is an inflammation, this is recognized, as well as an eventual other cause triggering the painful sensation.
The instrumental diagnostics consists of: nuclear magnetic resonance (NMR) and ultrasound.
Nuclear magnetic resonance provides images of an individual's bone and joint structures. Helps distinguish rheumatoid arthritis, which attacks the joints, from polymyalgia rheumatica, which involves the muscles.
The ultrasound shows, instead, the state of health of muscles and soft tissues in general.
In both cases, the patient is not subjected to any harmful radiation.
DIAGNOSIS OF HORTON ARTERITIS
If the Horton arteritis is added to the polymyalgia rheumatica, the latter must be diagnosed as soon as possible, to avoid unpleasant consequences.
In these cases, in addition to the recognition of symptoms and blood tests (the same as for polymyalgia rheumatica), the ecodoppler and PET ( positron emission tomography ) are fundamental.
THE FUNDAMENTAL CRITERIA FOR A CORRECT DIAGNOSIS
In summary, in order not to confuse polymyalgia rheumatica with another pathology (for example, rheumatoid arthritis or influenza), it is essential to remember the following diagnostic criteria:
- Age over 55 years
- Feeling of pain in the shoulders and / or hips
- Sensation of muscle stiffness, especially in the morning upon waking up
- Persistent symptomatology and which shows no signs of improving within two weeks
- Blood tests that show an internal inflammatory state
- Rapid improvement in symptoms with the initiation of corticosteroid therapy (see the chapter on therapy).
Treatment
The only way to effectively cure polymyalgia rheumatica is to give the patient powerful anti-inflammatory drugs: corticosteroids .
The other existing pharmacological treatments are, rather than alternatives to corticosteroids, medicinal products to be taken in combination.
From a therapeutic point of view, a balanced diet, vitamin integration and the regular practice of physical exercise (commensurate with the patient's age) play an essential role.
The healing times, even after an early diagnosis and a scrupulous cure, are very long: from one to two years .
THE CORTICOSTEROIDS
Side effects of corticosteroid treatment:
- Osteoporosis
- Hypertension (high blood pressure)
- Muscle weakness
- Glaucoma
- Cataract
- Weight gain
- Diabetes (blood glucose levels increase)
- Sensitive skin and easy appearance of hematomas
- Weakening of the immune system
In subjects with polymyalgia rheumatica, the first choice corticosteroid administered is prednisolone .
The beneficial effects are immediate, but the treatment should be maintained until the doctor considers the inflammation exhausted.
The drug is taken orally and daily. At the beginning, the doses are high, but after a few weeks they can be reduced to the minimum quantity capable of controlling the inflammatory state.
The only real problem, linked to prednisolone (and to all corticosteroids) is the side effects: these are numerous and, if not carefully controlled, can become very dangerous.
TREATMENTS TO BE ASSOCIATED
The doctor may prescribe some medicines to be associated with corticosteroids, to lower the doses of the latter and alleviate the side effects. These are drugs that can fight inflammation and its triggering agents.
- Methotrexate (or methotrexate ). Reduces the action of the immune system (immunosuppressive action), thus moderating the inflammatory state. It allows to limit the doses of corticosteroids.
- Anti-TNF . TNF is a molecule with a central role in inflammation. Anti-TNF acts against TNF, reducing the inflammatory state.
To learn more: Medicines for the Treatment of Polymyalgia Rheumatica »
SOME TIPS TO FOLLOW
Below are some useful medical tips to follow if you want to limit the side effects of corticosteroids.
First of all, it is good to correct the diet, so as not to favor the raising of blood pressure and blood sugar (glucose in the blood). Therefore, added cooking salt should be avoided and fatty foods, sweets, sugars and alcohol should be limited, in favor of fruit, vegetables, whole grains, lean meat and fish.
Secondly, calcium and vitamin D supplements against osteoporosis are recommended.
For further information: Diet for Polymyalgia Rheumatica »
Finally, if age allows it, it is important to stay active, as physical exercise (even moderate) allows bone turnover, maintenance of muscle tone and stability of body weight.
Prognosis
For patients with polymyalgia rheumatica, the prognosis depends essentially on the earliness of the diagnosis and the appropriateness of the treatment.
Early diagnosis allows therapy to be started early, at a time when polymyalgia is still limited to a few areas of the body. Conversely, a late diagnosis delays the start of the therapeutic treatment, increasing the possibility that the typical complications of polymyalgia rheumatica arise.
