Polymyalgia Rheumatica

Pain and stiffness across both shoulders and often both hips, severe in the morning, making it hard to get out of bed, dress or raise the arms; the international classification criteria apply to people aged 50 or over and include morning stiffness lasting more than 45 minutes, and in the study behind them the median was two hours 2. Onset is often relatively sudden — people can date it to within a week or two.

It is accompanied by fatigue, sometimes low-grade fever and weight loss. Blood inflammatory markers are usually raised, which supports the diagnosis but does not make it alone.

Giant cell arteritis occurs in a proportion of patients with polymyalgia rheumatica. New headache, tenderness of the scalp or temples, jaw pain on chewing, or any visual disturbance require same-day assessment.

Untreated giant cell arteritis can cause sudden, irreversible loss of sight. This is the most important thing to know about polymyalgia rheumatica and it is why we lead with it.

Most people improve markedly on corticosteroid treatment, but not all: in the study behind the international classification criteria, 71% had a complete response at four weeks, so the response alone does not confirm the diagnosis 2. Treatment is then tapered slowly over many months.

Rehabilitation works on maintaining range and strength during treatment, and on the muscle loss and bone loss that prolonged corticosteroid use causes. Resistance training and falls prevention matter here more than in most rheumatological conditions.

Most people improve substantially and many can taper off steroids over one to two years 1. Relapse during tapering is common and is managed by adjusting the dose rather than by starting again.

Bone protection is considered from the start given the steroid course, and the risk of steroid-induced muscle weakness is one of the main reasons exercise is prescribed rather than suggested.

Giant cell arteritis occurs in a proportion of people with this condition and can cause permanent loss of sight, which is why European recommendations call for specialist assessment within 24 hours of suspicion, and for steroid treatment to start without waiting for test results when suspicion is strong 3.

New headache, scalp tenderness, jaw pain when chewing, or any visual change is an emergency requiring same-day treatment rather than an appointment. Every patient is told this explicitly.

Current European recommendations start treatment with 15 to 25 mg a day of prednisolone or an equivalent steroid 3. Guidance from Germany, Austria and Switzerland plans the reduction over 4 to 12 months, depending on whether a steroid-sparing drug is added 4. In practice, treatment often lasts longer than planned 5. For relapsing disease, or when the risk of steroid side effects is high, an interleukin-6 receptor blocker can be added, with methotrexate as an alternative 4.

Exercise does not treat the inflammation, but guidance recommends offering older and frail patients an individualised exercise programme 4. Its aim is to maintain muscle mass and function and to reduce the risk of falls during long-term steroid treatment 1.