A Complementary and Integrative Medicine Approach to Polymyalgia Rheumatica: Testing and Treatment Options

Polymyalgia rheumatica (PMR) is a chronic inflammatory disease that causes widespread aching, pain, stiffness, and flu-like symptoms. The pain and stiffness are most common in the shoulders, upper arms, hips, and neck and can be worse in the morning upon waking. In about 15% of people with PMR, arteries on each side of the head at the temples (temporal arteritis), scalp, and the aorta and its main branches can also become inflamed, resulting in a condition known as giant cell arteritis. This can cause headaches, jaw pain, and vision changes.

Polymyalgia rheumatica is most common in older adults and rarely seen in those under 50 years of age. It affects women more frequently than men and is more common in Caucasians than other races, especially those whose ancestors were from Scandinavia or northern Europe.

While still being studied, the inflammation in polymyalgia rheumatica seems to be a result of autoimmunity, where the body's immune system attacks healthy tissues with genetic and environmental factors such as infections also contributing. Functional medicine provides a whole-person approach that can uncover underlying contributing factors and address the needs of those with this rheumatic disease to promote well-being.

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What is Polymyalgia Rheumatica?

Polymyalgia rheumatica (PMR) is a chronic inflammatory disease that causes muscles to become stiff, tender, and very sore. It most commonly presents with sudden pain and stiffness in the muscles of the shoulders, upper arms, hips, and neck, which is sometimes accompanied by flu-like symptoms. The name polymyalgia rheumatica derives from the Greek words' poly' for 'many,' 'my' for 'muscle,' and 'algia' for 'pain' combined with 'rheumatica' which refers to 'muscle and soft tissue.'

While there can be significant pain and stiffness in the affected muscles, especially in the morning upon waking or after not moving for a period of time, there is generally no significant weakness, and the bones at the joints are not impacted.

In some people with PMR, arteries on each side of the head at the temples (temporal arteritis), scalp, and the aorta and its main branches can also become inflamed, resulting in a condition known as giant cell arteritis. This can cause headaches, jaw pain, and vision changes such as fleeting or permanent vision loss or double vision.

These rheumatic conditions are common in adults over 50 and affect women 2-3 times more frequently than men. Both PMR and giant cell arteritis occur almost exclusively in individuals older than age 50, typically in the late 60s and 70s. PMR is more common in Caucasians than in other races.

What Causes Polymyalgia Rheumatica?

The exact cause(s) of polymyalgia rheumatica is still under study, but the inflammation involved seems to be a result of autoimmunity, where the body's own immune system attacks healthy tissues with genetic and environmental factors such as infections also contributing. Genetic predispositions such as changes in genes involved in the regulation of inflammatory cytokines like interleukin-6 (IL-6) have been reported.

Since many patients rapidly respond to glucocorticoids, one hypothesis of an underlying cause of PMR is that the age-related decline of dehydroepiandrosterone (DHEA) or androstenedione (ASD) disrupts the hypothalamic-pituitary-gonadal axis, changing the responsiveness to inflammatory stimuli such as IL-6 during chronic disease.

Other factors that increase inflammation in the body, like an imbalance in the microbes in the gut, may also contribute. An imbalance in the health of the microorganisms in the gastrointestinal tract, or dysbiosis, is associated with rheumatic diseases like PMR.

What Triggers Polymyalgia Rheumatica?

Since new cases of PMR tend to come in cycles, often developing seasonally, an environmental trigger such as a virus is suspected of playing a role. The incidence of PMR peaks in correspondence with epidemics of M. pneumoniae, C. pneumoniae, Parvovirus B19, adenovirus (AdV), and respiratory syncytial virus.

Polymyalgia Rheumatica Symptoms

The inflammation found in polymyalgia rheumatica causes the muscles to become stiff and sore and may also contribute to flu-like symptoms due to widespread inflammation in the body. The symptoms of PMR often come on quickly, in a matter of a few days, or, in some cases, even overnight, with pain and stiffness upon waking.

The most common symptoms of PMR include:

• pain in the shoulders, neck, upper arms, and hip area
• stiffness in the affected muscles, especially after not moving or upon waking in the morning
• limited range of motion in the impacted areas
• flu-like symptoms, such as low-grade fever, loss of appetite, weakness, and weight loss
• occasional swelling of the wrists or other joints in the hands

People with PMR often have worsening pain and stiffness upon waking in the morning or after resting and not moving much. The muscle pain usually lasts an hour or more and may make it difficult to get up from the bed or chair, get dressed, brush your hair or do other tasks requiring lifting your arms above the shoulders, or carry out other daily activities. Further decline in functioning can result if the pain and stiffness lead to a lack of use of some body parts and resulting muscle weakness.

If PMR is accompanied by giant cell arteritis, additional symptoms may develop, such as:

• new, persistent headaches, especially on the side of the head near the temples
• scalp tenderness
• vision changes such as fleeting or permanent vision loss or double vision
• jaw pain when eating
• cramping or aching pain in the legs or arms with activity

Complications of Polymyalgia Rheumatica

This rheumatic disease can be associated with giant cell arteritis, diverticular disease, and vascular damage that can increase the risk of cardiovascular disease.

People with PMR sometimes also have inflammation in the arteries, especially those on each side of the head at the temples (sometimes called temporal arteritis), the scalp, and the large artery that carries blood from the heart (called the aorta) and its main branches. This condition, known as giant cell arteritis, causes headaches, jaw pain, scalp tenderness, and impaired vision. Due to the inflammation of the lining of the arteries, this condition can lead to blindness if left untreated. While around 10 percent of people with PMR have giant cell arteritis, almost 50 percent of those with giant cell arteritis have PMR.

Studies suggest that people with PMR have an increased risk of cardiovascular disease due to vascular damage. These include heart attacks, strokes, and peripheral vascular events.

Functional Medicine Labs to Test That Can Help Individualize Treatment for Patients With Polymyalgia Rheumatica

A functional medicine approach works to uncover factors that contribute to overall inflammation that impacts polymyalgia rheumatica. Functional medicine laboratory tests can help to determine the root causes of PMR and monitor inflammation over time as well as rule out conditions that cause symptoms like PMR, such as rheumatoid arthritis and lupus.

Indicators of Inflammation

Inflammatory markers like C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) help to assess inflammation throughout the body. Since rheumatic conditions like PMR are associated with increased inflammation, these markers can support the diagnosis and indicate the effectiveness of the treatment when repeated over time.

Comprehensive Blood Testing

Evaluating overall health and the markers of infections, like an elevated white blood cell count with a comprehensive metabolic profile (CMP) and a complete blood count (CBC), can help with determining a diagnosis of PMR and monitoring treatment. If signs of infection are identified, further blood testing may be performed to help identify the specific microorganism.

Gut Health

The GI-MAP assesses relative amounts of healthy and unbalanced gut bacteria, inflammation, and leaky gut markers helping to uncover imbalances that can trigger autoimmunity and perpetuate the cycle of inflammation. Detecting and treating gut infections and imbalances is essential for managing inflammatory conditions like PMR.

Food sensitivities can also contribute to increased intestinal permeability, inflammation, and autoimmunity. Foods to which an individual is sensitive can be detected with ELISA testing.

Ruling Out Other Rheumatic Conditions

Laboratory testing can detect auto-antibodies associated with conditions that cause symptoms similar to PMR, such as rheumatoid arthritis and lupus. This testing can help rule out other causes of joint and muscle pain and stiffness when evaluating for a diagnosis of PMR.

Antinuclear antibody (ANA) autoantibodies mistakenly attack the body's own cells. They can be detected in the blood to screen for autoimmune rheumatic conditions, such as lupus as well as other autoimmune diseases, such as Hashimoto's thyroiditis.  

Rheumatoid factor (RF) is an antibody that can be measured via a blood test and is associated with rheumatic conditions, including rheumatoid arthritis and lupus.

Additional Labs to Check  

The diagnosis of PMR is based on clinical symptoms and physical exam as well as the laboratory work-up that shows elevated markers of systemic inflammation. Provisional diagnostic criteria for the diagnosis of PMR have been proposed for people aged 50 years or older, including assessing new-onset bilateral shoulder pain along with abnormal inflammatory laboratory markers like C-reactive protein (CRP) levels and/or erythrocyte sedimentation rate (ESR).

Magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) scans can be used to assess arterial inflammation in cases where systemic vasculitis is suspected.

Conventional Treatment for Polymyalgia Rheumatica

A conventional treatment approach generally uses a low dose of an oral corticosteroid, like prednisone, to treat PMR. Guidelines for treating PMR with glucocorticoids suggest using the minimum effective dose, starting with 12.5-25 mg prednisone equivalent daily, with slow tapering to reach an oral dose of 10 mg per day prednisone equivalent within 4-8 weeks. If glucocorticoids are contraindicated or not successful in bringing about remission, methotrexate (MTX) may be considered.

Complementary and Integrative Medicine Treatment for Polymyalgia Rheumatica

Complementary and integrative medicine can be used to help balance the inflammation involved in PMR, manage pain, and improve quality of life. Diet and lifestyle approaches like an anti-inflammatory diet and balanced exercise can help treat this rheumatic condition.

Integrative Nutrition Options For Polymyalgia Rheumatica Patients

Diet has a significant impact on the levels of inflammation and pain in the body. Dietary patterns high in ultra-processed foods and low in nutrient-dense foods like fruits, vegetables, whole grains, legumes, olive oil, and oily fish tend to promote low-grade chronic inflammation that leads to disease development and conditions like PMR. On the other hand, an anti-inflammatory diet like the Mediterranean diet eliminates foods that can promote inflammation and focus on foods that can prevent, reduce, or resolve it.

The Mediterranean diet improves blood sugar control, the balance of microbes in the gut, immune system function, and oxidative stress. Overall, this way of eating can reduce levels of inflammatory biomarkers like interleukin-6 (IL-6), which are involved with the disease process in PMR.

Food sensitivities also increase inflammation in the body. So it is important to tailor an individualized anti-inflammatory diet to one's unique needs, sensitivities, and allergies.

Supplements and Herbs for Polymyalgia Rheumatica

Low intake of omega-3 fatty acids is associated with chronic pain. Omega-3 fatty acids from supplements or found in salmon, walnuts, flax seeds, chia seeds, and leafy greens can help balance immune system responses to inflammation, improve pain levels, and protect against a recurrence of PMR.

Although additional studies are still needed, curcumin (turmeric), devil's claw, methyl-sulfonyl-methane (MSM), Boswellia (frankincense), and rosehip have been shown to have pain-relieving properties in similar conditions like arthritis and fibromyalgia.

Curcumin found in turmeric has extensive anti-inflammatory activity and has been studied for its effectiveness in reducing inflammation and autoimmune disorders. The bioavailability of curcumin can be improved by combining it with black pepper and/or ginger.

Devil's claw has been studied for its analgesic and anti-inflammatory properties and has been shown to be effective in rheumatic conditions such as rheumatoid arthritis.

Methyl-sulphonyl-methane (MSM) is a natural sulfur compound that your body makes to fight pain and inflammation. When taken as a supplement, MSM can help ease joint pain and inflammation.

Boswellia serrata has traditionally been used in Ayurvedic medicine for its antirheumatic (antiarthritis) activity and has been shown to inhibit the synthesis of pro-inflammatory cytokines that promote free-radical damage and inflammation.

Rosehip has been shown to reduce pain and inflammation in arthritis and back pain due to its antioxidant and anti-inflammatory activity.

For those taking corticosteroids, daily supplementation with calcium and vitamin D is usually added to treatment to help prevent bone loss. 1,000 - 1,200 mg of calcium and 600 to 800 IUs of vitamin D are recommended for anyone taking corticosteroids for three or more months.

Acupuncture for Polymyalgia Rheumatica

In Chinese medicine, dampness and a decrease in spleen energy with age and/or pathogens settling into muscles are thought to contribute to the muscle weakness and pain involved in PMR. Acupuncture can help bring balance back to the body and relieve symptoms of pain and excess inflammation. It has been shown to help related rheumatic conditions like rheumatoid arthritis by decreasing inflammation and regulating immune function.

Massage Therapy for Polymyalgia Rheumatica

Massage therapy can help to relieve symptoms of stiffness, pain, and inflammation in the muscles while also improving the range of motion to make daily activities easier.

Physical Activity for Polymyalgia Rheumatica

An individually customized exercise program can help with the overall treatment approach to PMR. Gentle exercises, such as yoga, tai chi, walking, cycling, and swimming, can help maintain muscle mass and loosen stiff muscles and joints to promote flexibility and pain relief while also promoting better bone health, body weight, blood circulation, stress management, and sleep.

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Summary

Polymyalgia rheumatica is an inflammatory disease causing pain and stiffness in the muscles, especially in the shoulders, neck, back, buttocks, hips, and thighs. The exact cause is still being studied, but risk factors include genetic factors, being female, being over the age of 50, and being of northern European or Scandinavian descent. Factors which increase inflammation, such as an imbalance in the microbiome and infections, may also play a role.

Laboratory testing can uncover contributing factors such as dysbiosis, rule out other causes of muscle pain and stiffness like rheumatoid arthritis, and monitor levels of inflammation over time to assess the effectiveness of treatment.

Conventional treatment typically includes a long-term low dose of steroids to reduce inflammation and pain. An integrative medicine approach to polymyalgia rheumatica management includes an anti-inflammatory diet, supplements like Boswellia, rosehip, and curcumin to balance inflammation and reduce pain, acupuncture and massage, and exercise or physical therapy to help maintain muscle mass and flexibility and reduce pain.