Introduction

What is polymyalgia rheumatica (PMR)

Polymyalgia Rheumatica is a muscle and joint-related disorder characterized by pain in the regions around the hips, shoulders and neck.

Polymyalgia rheumatica - an overview

Polymyalgia Rheumatica is a kind of disorder related to a large group of muscles and joints. In this disorder, the patient feels the symptoms of pain, inflammation and rigidity in the upper parts of the upper and lower limbs, besides, the back gets affected as well. Amongst all, the shoulders, neck and hips are the most impacted sites.^1,3

Erythrocyte sedimentation rate (ESR), an inflammatory indicator, gets elevated with PMR.1 It is mainly found in the population aged over half a century, and people aged near about 75 years suffer the most. It is important to notice that women experience PMR more often than men.^1,3,4 

PMR is treated with drugs, which cancels the inflammatory effects. However, long treatment with the drugs mentioned earlier shows side effects like a rise in blood pressure, bones become fragile, and the patient gains weight, which might lead the patient to diabetes as well.^1,2,5

Exercise plays a key role in the management of PMR in the long term, if it is performed in a balanced manner. It helps in many ways, viz. by making the joints less rigid, allowing the patient to get rid of the negative impacts of medicines uplifting the mood of the patient, etc.

Various kinds of exercise and their benefits in the management of PMR

A PMR Study illustrates that after half a decade of the diagnosis of PMR 85% of the total participants reported to be the beneficiary of the exercise; and a noticeable decrease in the pain and rigidity of the muscles were reported.¹¹ It is not all, as there are numerous benefits of opting for an exercise routine in the management of PMR.

Basic stretching

In PMR, sitting still for a long time worsens the condition as it makes the muscles more rigid and decreases their mobility further. To begin with, it is good for the patient to initiate the physical activity with mild stretching, once the patient gets up. Then, a short walk even from one side of the room to the other.

There are a few stretching techniques which can be performed easily while sitting on a chairthe patient can rotate his/her neck to make the neck muscles less rigid. Knee raises relax the hip muscles and increase their flexibility.

Shrugging the shoulders increases the mobility of shoulder muscles. When the patient raises the arms upward and tries to keep the arms perpendicular to the floor; and puts the hands behind the head and elbows are stretched further backward. This certainly allows the shoulders and back muscles to feel relaxed.¹³

Balance exercise

It is crucial for a PMR patient to feel steady, otherwise, the patient can fall; and this can cause serious issues, as due to anti-inflammatory drug therapy, bones are way more prone to get fractured than any other person without PMR. However, stiff muscles might not allow the PMR patient to be balanced, so steadily.

To maintain the body balance, a PMR patient might need to work on certain muscles. This type of exercise can be performed in a standing position. It can be regarded as the next step to basic stretching.

In this technique, the patient needs to stand straight and try to lift one knee upward, and the endpoint is when the thigh is perpendicular to the body and parallel to the floor. This is then repeated with the other knee. This helps the patient get the hip muscles’ flexibility and power increase, and eventually, the body balance gets better.¹⁴

Endurance training/Conditioning of the muscles

In this type, exercise gets further intensified, and the prime purpose of this type of exercise is to increase the strength of the muscles. In Conditioning training, muscle is put under a slightly increased workload, so that the muscle generates more power to tackle the workload.

This gradual increase in the intensity of the task to be performed, allows the muscle to increase its endurance. It is mostly performed utilizing weight and resistance techniques, by which a certain area’s muscles are targeted.

Arm curl

In the curling of arm technique, any handy weight or even a bottle can be used. The patient stands or sits with a straight back and holds a weight with the hand. The region from shoulder to elbow is kept still and the forearm is moved in a way that the hand, which is holding the weight, moves towards the shoulder. This is then done with the other hand and repeated. 

This technique helps to strengthen the bicep (if the palm is pointed upward while training) and triceps (if the palm is facing downward while training), and these muscles are vital in making a person comfortable to perform many other exercises

Arm raises

In this technique, the PMR patient is told to stand straight with his/her palms touching the respective thighs laterally. Then, the fully stretched arm is raised in a way that it becomes parallel to the floor. The intensity of this exercise can be increased by using the resistance band. This technique increases the strength of the shoulders and the back muscles.

Hip extensions

In hip extension, the patient stands straight (can have the support of a chair), and stretches the leg in the backward direction. This is repeated for a few seconds and then, the second leg is trained. This technique can be intensified using a resistance band or weight. This technique is used to strengthen the hip muscles.^11,13

Aerobic exercise

This is an advanced training technique to make the heart rate faster, which is vital for various body activities. This is performed once the patient has gained strength in the muscles which were weak, stiff and full of pain. 

Many techniques come under this type of exercise, viz.

• Running
• Cycling
• Swimming
• Rowing

It allows the lungs and heart to feel an intense load, thereby their endurance increases indeed. This gives the PMR patient increased stamina to take care of the muscles regularly.

In addition, PMR patients have reported to have mood improvement with exercise as well.¹¹

What stops a PMR patient from exercise

There are many different factors which do not allow a PMR patient to start exercise. Many of these factors are the complications that arise from the prolongation of the PMR; and prolonged treatment quite a few times.¹⁰

• High Blood pressure
• Bones become fragile
• Diabetes
• Muscle weakness
• Extreme tiredness

Points to be considered with exercise in PMR

If a PMR patient wants to get the most out of the exercise, the most important factor he/she needs to keep in mind is to start slowly and raise the intensity of the exercise gradually.¹³ Since, the muscle is in a rigid state, so the sudden burden of the exercise might lead to the serious destruction of muscle.^{7, 8}

At times, exercise can be generalized, however, a customized exercise program for a specific patient may be required to be finalized by the medical practitioner after the complete evaluation of a PMR patient. Exercise program depends on various factors, like what kind of restriction and/or disorientation a muscle is experiencing.^12,13

This evaluation starts with the questions providing the medical practitioner with information about the daily routine of the patient, whereby the doctor comes to know activities, the patient feels difficulty while performing.

Evaluation of the posture is done as well, so that the doctor can know, if the patient is leaning towards any specific side (viz. Forward, backward and/or sidewise). This helps to know the potential problems associated with back muscles and joints.

Observation of the patient’s walking speed can tell a lot about the issue(s) related to the hips region, which certainly helps the doctor to customize the exercise. Additionally, Lower limbs can be evaluated in a detailed manner, once the sit-down and stand-up ability of the PMR patient is observed with the activities mentioned earlier.

Thus, it is always good to start by changing your daily routine a bit, which makes sure that you are working physically; and moving your muscles and joints, but still not worsening the pain.

• This kind of activity is to use a walking aid as a support to take care of your full of pain and stiff hips.
• If small handy tools/objects are replaced with long handles, then, a stiff back can be helped.
• Load on shoulders and back can be reduced by just replacing a dirty handy laundry container with a cart.⁹

One of the most important aspects is to be vigilant of the returning symptoms. A PMR patient might be doing advanced training, but the symptoms might have just been covered by the medicine he/she is taking. So, whenever any of the signs and/or symptoms, which a patient was diagnosed with, is/are observed, try to take care of that first.⁸

Summary

Polymyalgia Rheumatica (PMR) is a medical condition in which large muscles, especially of the hips, neck and shoulders get rigid and painful. PMR is managed with exercise, as exercise allows the patient to reduce the pain and rigidity of the impacted muscles. Exercise always starts with the lowest intensity and then, intensity is increased slowly. A specially designed exercise program, designed for a particular patient, helps the most. However, it is always important to balance the rest and exercise phases, so that the muscles can get enough time to restore the energy it uses while performing any activity.