Muscle Pain in Older Adults
Polymyalgia Rheumatica and Temporal Arteritis are Common Disorders
Dec 31, 2008
Polymyalgia rheumatica (PMR) is an inflammatory condition that commonly affects older adults, causing severe pain and stiffness in the muscles of the pelvic and shoulder girdles. PMR is frequently associated with temporal arteritis (TA; also known as giant cell arteritis).
Approximately 10% of patients with PMR develop temporal arteritis, while 50 to 60% of patients who have TA also suffer from PMR. The cause of these conditions is unknown, but both disorders elicit a similar syndrome of systemic inflammation.
Because there is so much clinical and pathophysiologic overlap between PMR and TA (similar immune-cell reactivity and serologic markers), many authorities consider these two conditions to be different phases of the same disorder. (The Merck Manual, 18th Edition 2006:278-279)
In PMR, the systemic inflammatory response is the prominent clinical feature; in temporal artertitis, systemic inflammation is present, but blood vessel involvement causes the predominant symptoms. It is important to distinguish between PMR and TA, as the latter can lead to permanent blindness and requires higher doses of medication. Both of these conditions, if left untreated, can lead to significant disability.
One in 133 people over the age of 50 is affected by PMR; women are twice as likely to be affected as men. Temporal arteritis isn’t as common, affecting 18-20 persons per 100,000 in the same age group. Interestingly, diagnosis of both conditions is more common in northern latitudes. (Salvarani C, et al. Polymyalgia rheumatica and giant-cell arteritis. N Engl J Med 2002;347:261-71)
Signs and Symptoms of Polymyalgia Rheumatica
- Aching, pain, and stiffness (worse in the morning or after inactivity) in the shoulders, upper arms, hips, thighs, neck, and/or torso. (While pain may limit muscle use, strength remains undiminished)
- Loss of appetite
- Night sweats
- Fever
- Depression
- Weight loss
- Elevated erythrocyte sedimentation rate (ESR); usually > 50 mm per hour
- Mild anemia
- Less commonly, asymmetrical arthritis of the knees or wrists, carpal tunnel syndrome, or swelling of the hands and feet
Signs and Symptoms of Temporal Arteritis
Same as for PMR, plus:
- Headache, either temporal or occipital
- Tenderness over temporal artery
- Jaw claudication (pain, heaviness, or other discomfort in jaw, tongue, or sinuses; worse with chewing)
- Visual symptoms: partially obscured visual field, double vision, blindness, transient blindness (amaurosis fugax)
- Arthralgias (joint pain)
- Transient ischemic attacks (TIAs), neuropathies, or stroke (rare)
- Giant cell arteritis may affect vessels in other areas of the body
(From Unwin B, et al. Polymyalgia rheumatica and giant cell arteritis.Am Fam Physician 2006;74:1547-54, 1557-8)
Diagnosis of Polymyalgia Rheumatica and Temporal Arteritis
PMR and TA are diagnosed clinically. Blood tests (i.e., ESR, CBC, CRP, metabolic panel, etc.) and physical examination might be sufficient to begin treatment.
In some cases, biopsy of the temporal artery or, perhaps, muscle biopsy may be necessary to clarify the diagnosis.
Treatment of Polymyalgia Rheumatica and Temporal Arteritis
- Low-dose prednisone (15 to 20 mg daily) usually brings dramatic improvement of PMR symptoms within days.
- Temporal arteritis requires higher doses (40 to 60 mg daily); for people who present with visual symptoms, therapy may be started intravenously.
- Prednisone may be tapered within two to four weeks, depending on individual response.
- Prednisone dosage is adjusted to prevent the return of symptoms; normalization of the ESR is not necessary in order for prednisone taper to begin.
- Once PMR or TA are stabilized and prednisone has been tapered to low dose (5 to 10 mg daily), therapy is usually continued for two to three years, at which time prednisone is again tapered and eventually discontinued.
When treated, most patients with either PMR or temporal arteritis have a good prognosis.
