Tuesday, 3 February 2015

(First edited)) Most Common Diseases of Ages of 50 Plus - Musculoskeletal disorders (MSDs) - Polymalagia Arthritis(Rheumatica, PMR)

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By Kyle J. Norton
Health article writer and researcher; Over 10.000 articles and research papers have been written and published on line, including world wide health, ezine articles, article base, healthblogs, selfgrowth, best before it's news, the karate GB daily, etc.,.
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Some articles have been used as references in medical research, such as international journal Pharma and Bio science, ISSN 0975-6299.

Polymalagia Arthritis(Rheumatica, PMR)

Polymalagia Arthritis is a condition a common inflammatory rheumatic disease causeing pain, stiffness and tenderness in large muscles, including muscles shoulders and pelvic girdle as a result of the presence of a synovitis in proximal joints and periarticular structures.

A. Signs and Symptoms
1. According to University of North Carolina School of Nursing in Greensbor, polymyalgia rheumatica (PMR) is a periarticular rheumatic condition,
found in approximately 10% to 30% of people who have PMR characterized by 
a. Pain and stiffness, primarily in the neck, shoulders, hips, and pelvic girdle. 
b.Temporal arteritis (TA) or giant cell arteritis, the most common primary vasculitis in older adults, (3).

2. Other symptoms include
a. Fever and lumbar pain

Polymalagia Arthritis may causes symptoms of persistence of fever and lumbar pain. Administration of prednisolone (PSL) at 10 mg/day was found effectively for treatment of muscular pain involving the bilateral shoulders and forearms suddenly developed(4).
PMR is a rheumatic disease which mainly affects the elderly, and is seldom diagnosed in patients <50 years of age with symptoms of
b1. Spiking fever, 
b.2. Malaise, 
b.3. Fatigue, 
b.4. Weight loss 
b.5. Other features suggesting inflammation(5). 
b.6. Pain and stiffness in the proximal muscles, 
b.7. Anorexia,
b.8. Depression,
 b.9. Temporal headaches(6).
c. Etc.

B. Causes and Rick factors
B1. Causes

The cause of PMR is not well understood, but researchers believe it is a result of the abnormal inflammatory activity of inflammatory cells and proteins of the immune system caused bt the presence of a synovitis in proximal joints and periarticular structures.
1. Genetic factors 

Althernation of gene HLA-DRB1 is found to be associated to the susceptibility of development of polymyalgia rheumatica (PMR) in the Spanish populationin patients with polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) in the Spanish population.(7).
2. Environmental contagious factors 

 Environmental contagious factors could have trigger synchronous disease onset in up to one-fourth of the cases of polymyal-gia rheumatica (PMR(8).

3. Giant cell arteritis 

Giant cell arteritis (GCA) is an inflammatory vasculopathy involved large- and medium-sized arteries causing vision loss, stroke and aneurysms. GCA occurs in people aged >50 years and shares the same pattern of age and sex distribution as PMR(9)
4. Etc. 

B.2. Risk factors
1. Aging
If you are over 50 years of age, you are at increased risk of Polymalagia Arthritis (PMR). Polymyalgia rheumatica is a rheumatic disease which mainly affects the elderly, with approximately 16.8 to 53.7 per 100,000 of the population >50 years of age(10).

2. Diet
According to University of Manchester, high level of red meat consumption is a novel risk factor for inflammatory arthritis. It is also may be considered as a marker for a group of persons with an increased risk from other lifestyle causes(11).

3. Smoking 

According to a study of 3 years among patients newly presenting with inflammatory polyarthritis (IP), smokers being more likely to develop nodules and to be RF positive, current smokers did not have higher levels of radiologic damage, and had fewer swollen joints(12).

4. Gender
If you are women, you are at increased risk to develop Polymalagia Arthritis(9).

5. Geography 

 The prevalence of Polymalagia Arthritis increased presently, but it remains lower than that in developed countries(13).
6. Etc.

C. Complications
1. Visual
Polymyalgia rheumatica (polymyalgia arteritic) may induce the developed evidence of cranial arteritis,  following withdrawal of steroid therapy after apparent cure(14). 

2. Stroke 

Elder patients with PMR are susceptible to vascular events such as stroke, according to study of  researchers at the Taipei Medical University(15).

3. Low back pain and MRI-abnormalities
Abnormalities in shoulder and hip joints are most common, but signs of cervical and lumbar interspinous bursitis might be found in patients with PMR(16). 

4. Cervical interspinous bursitis
Cervical interspinous bursitis is a likely basis for discomfort in the neck found in all patients with PMR. (17). 

5. Renal failure
Renal involvement in PMR is extremely rare. According to Dr. Javaid MM,  patient with history PMR may develope nephrotic range proteinuria and rapidly deteriorating renal function secondary to AA amyloidosis within 18 months of the onset of symptoms of PMR(18).

6.  Perforated colonic diverticular disease
Patients with polymyalgia may have perforated colonic diverticular disease which mimics their rheumatic pathology. Steroid therapy, which is the mainstay of polymyalgia therapy, can be harmful(19).

7. Cancer
Patients hospitalized for PMR and GCA had a marginally increased risk of cancer, with the highest risk noted for the first year after hospitalization, including skin cancer and leukaemia(21)
8. Etc.

D. Diagnosis 

There is no specific test to diagnose Polymalagia Arthritis (PMR). If you are suspected to develop Polymalagia Arthritis, after a general physical exam, including the examination of shoulder motion, or swelling of the joints in the wrists, hands, etc., certain tests may be necessary.
1. Blood test(24)
a. Erythrocyte sedimentation rate (ESR) is the blood test to exam the red blood cells in a test tube. he higher the ESR value is an indication of inflammation.
b.  C-reactive protein (CRP) 
Blood test measures the levels of C-reactive protein (CRP) produced by the liver in response to an injury or infection and people with polymyalgia rheumatic.
c. Blod test for thrombocytes 
Patient with polymyalgia rheumatica have an unusually high number of thrombocytosis. On the other hand, People with anemic polymyalgia rheumatica have a lower number of red blood cells than normal.
 d. Rheumatoid factor (RF)
RF is an antibody, a protein made by the immune system  presented in the blood of people with rheumatoid arthritis, but not in the blood of people with polymyalgia rheumatica.

2. Biopsy
Polymyalgia rheumatica is often associated with giant cell arteritis in biopsy. A small sample from the scalp artery in the emporal artery to examine under a microscope in a laboratory. These patients may initially present with symptoms referable to the head and neck(25).

3. Etc.

E. Preventions
E.1. The do’s and  do not’s list
1. Reduce intake of saturated and trans fat and increase intake of omega 3 fatty acids

 Although Limited studies have shown that certain dietary fatty acids (ie, oleic acid and alpha-linolenic acid) reduce biomarkers of inflammation. Null effects, or conflicting results have been reported with saturated and trans fatty acids(26). But according to the results of over 13 double-blind, placebo-controlled studies involving a total of more than 500 people suggest that omega-3 fatty acids may improve symptoms of rheumatoid arthritis. One of the ways it appears to work is by decreasing the production of inflammatory chemicals(27). 

2. Increase intake of increasing the ratio of (n-3) : (n-6) PUFA 

Intake mega 3 fatty acids may lead to reductions of the incidence of  chronic inflammatory diseases as it increases the ratio of (n-3) : (n-6) PUFA(28). 

2. Increase intake of fruit and vegetable  

According to Tufts University, showed that FV variety, but not quantity, appears to be important in reducing inflammation(29).

3. Avoid high glycemic index diets
Other studies suggested that the consumption of high glycemic index diets, which have low fiber content and are rich in trans fat cause the activation of the immune system, leading to excessive production of pro-inflammatory mediators and the reduction of the anti-inflammatory ones(30).

4. Reduced intake of pro inflammatory foods, such as sugar, dairy products, red meat and processed, meat, alcohol, artificial ingredients, refined products, etc.

5. Increase in take of anti inflammatory foods, such as fresh vegetables and fruits, seeds and sprouts whole grain, fish, turkey, chicken, legumes, etc.

6. Stop smoking
Smoking is associated with increased of Polymalagia Arthritis.

7. Moderate exercise
Moderate exercise enhances immune function in fighting against inflammation and increase the blood circulation to provide nutrients to the body’s organs need.
8. Etc.

E.2. The diet
1. Organic Soy

 Isoflavones, such as genistein, in organic soy is found to ne a useful tool to dissect regulatory pathways and may have potential use as novel antiinflammatory therapeutic agents(31). 

 2.  Green tea
Green tea contains more amount of antioxidants than any drinks or food with the same volume, and is the leaves of Camellia sinensis, undergone minimal oxidation during processing, originated from China. 

a.  Immune system
a. 1. Decaffeinated green tea in lower doses of administration is found to be optimum to enhance the immunity of rainbow trout(32).
a.2. EGCG, a phytochemical found abundantly in green tea,
provide scientific evidence of the anti-rheumatic activity in many studies(33).

3. Olive oil
Olive is belongs to the the family Oleaceae, native to the coastal areas of the eastern Mediterranean Basin and south end of the Caspian Sea.
a. Olive oil phenolics
Olive oil phenolics of the Mediterranean diet showed a positive effects on certain physiological parameters, including plasma lipoproteins, oxidative damage, inflammatory markers, platelet and cellular function, and antimicrobial activity(34).
b. Antioxidants and weight lossMediterranean dietary pattern on plasma total antioxidant capacity (TAC) found that Mediterranean diet, especially rich in virgin olive oil, is associated with higher levels of plasma antioxidant capacity in reduction of body weight(35).

4. Salmon 
a. Antioxidants
Vitamin E found in salmon showed  not only having pro-oxidative activity, but  actually increased the anti-oxidative capacity of the liver(36)
b. Selenium
Salmon containing  trace minerals selenium is essential for the healthy function of the thyroid and immune system as it increases the antioxidant defense system by fighting against the forming of free radicals and reduce the risk of irregular cells growth causes of tumor and cancer, according to the study(37)
c.  Omega 3 fatty acids
Omega 3 fatty acids is necessary to maintain the ratio of good and bad cholesterol, for reduction of  the risk of cholesterol inflammation  and plaque forming in the arterial wall, thus also decreasing the risk of stoke, according to the study(38).

5.  Circuit fruits
Circuit fruit containing high amount of Quercetin showed to reduce the risk of Rheumatoid Arthritis through anti inflammatory and antioxidant effects
a. Anti-Inflammatory
According to Université du Québec à Chicoutimi , Chicoutimi, Québec, Canada.),  flavonoids have been reported to possess beneficial effects in cardiovascular and chronic inflammatory diseases associated with overproduction of nitric oxide.
b. Free radical scavenger
According to the University Coimbra, Portugal), three-fisetin, luteolin and quercetin-are showed  effectively in inhibition of free radicals.

 6.  Turmeric
Turmeric, is principal curcuminoid of the popular Indian spice, a rhizomatous herbaceous perennial plant of the ginger family, Zingiberaceae, native to tropical South Asia.
a. Anti inflammatory effects
In six human trials,  curcumin showed to be safe and to be safe and demonstrated anti-inflammatory activity, through inhibition of a number of different molecules that play a role in inflammation(39).
b. Antioxidants
 Curcumin, a component of turmeric, has been shown to be non-toxic, to have antioxidant activity, and to inhibit such mediators of inflammation in experimental animal models of a number of diseases, including arteriosclerosis, cancer, diabetes, respiratory, hepatic, pancreatic, intestinal and gastric diseases, neurodegenerative and eye diseases(40).
7. Etc.

E.3. Phytochemicals
1. Green tea Polyphenols

(-)-epigallocatechin-3-gallate (EGCG), the predominant green tea polyphenol showed to inhibit enzyme activities and signal transduction pathways that play important roles in inflammation and joint destruction in arthritis(41).
2. Curcumin

BDMC33, a curcumin Derivative found in curcumin, showed to exhibit its inflammatory action through activation of macrophage(white blood cell)-like cellular systems, related to chronic inflammatory diseases(42).

3. Resveratrol
Resveratrol (RES), a well-known antioxidant and anti-inflammatory compound, found abundantly in red wine has shown to exert numerous pharmacological effects, including hepatoprotection and cadioprotection(43).

4. Boswellic acid
Gum-resin extracts of Boswellia serrata used traditionally used in folk medicine for centuries to treat various chronic inflammatory diseases. Its antioxidant components are found to be responsible for inhibition of pro-inflammatory enzymes(44).

5. Cucurbitacins
High performance liquid chromatography-characterized (HPLC) dichloromethane fraction isolated from Wilbrandia ebracteata (WEDC) showed to inhibit the pro inflammatory parameters in experimental models of inflammation in vivo and in vitro(45).
6. Etc.

F. Treatments
F.1. In conventional medicine perspective

1. Non Medication
The aim of non medical treatment is to control painful myalgia, improve muscle stiffness, and  relieve the symptoms of constitutional features of the disease.
a. Fasting as part of a naturopathic treatment
Fasting may be formed part of polymyalgia rheumatica (PMR) treatment. According to the report of a 67-year-old woman with proven diagnosis of giant cell arteritis (GCA) and polymyalgia rheumatica (PMR)(56).
b. Diet therapy
Leucine-rich milk and whey proteins may be a potential treatment of age related loss of muscle mass and strength, according to Helsinki University Central Hospital(57).  Exercise and amino acid supplementation (AAS) together may be effective in enhancing not only muscle strength, but also combined variables of muscle mass and walking speed and of muscle mass and strength in sarcopenic women(58).
c. Etc.

2. Medical treatment
2.1. Tocilizumab (TCZ)
Tocilizumab (TCZ) is the first humanized interleukin-6 receptor-inhibiting monoclonal antibody developed to treat rheumatoid arthritis.
a.  TCZ  is highly effective and generally well tolerated(60)for improvement of  refractory/relapsing GCA, TAK, or PMR(59).
b. Side Effects are not limit to
b.1. Dizziness
b.2. Headache
b.3. Allergic effects, such as rash; hives; itching; difficulty breathing, etc.
b.4. Skin changes
b.5. Tiredness or weakness
b.6. Etc.

2.2. Corticosteroids [CS] and nonsteroidal antiinflammatory drugs [NSAIDs])
2.2.1.. Corticosteroids, a drug, a common presentation in primary care, and non-selective non-steroidal anti-inflammatory drugs (sometimes also referred to as traditional NSAIDs or tNSAIDs) and selective cyclo-oxygenase 2 inhibitors (COX-2 inhibitors)(PMR) also be the first choice of treating of Polymalagia Arthritis(61).

2.2.2. Side effects
a. Corticosteroids [CS]
a.1. Corticosteroid withdrawal syndrome
b.2. Hyperglycemia
b.3. Insulin resistance
b.4. Diabetes mellitus
b.5. Osteoporosis
b.6. Depression
b.7. Colitis
b.8. Etc.

b. Nonsteroidal antiinflammatory drugs [NSAIDs]
NSAIDs may cause large intestinal ulcers, bleeding, and perforation, relapse of classic inflammatory bowel disease and contribute to serious complications of diverticular disease (fistula and perforation). NSAIDs may occasionally cause small intestinal perforation, ulcers, and strictures requiring surgery. NSAIDs, however, frequently cause small intestinal inflammation, and the associated complications of blood loss and protein loss may lead to difficult management problems, according to King’s College School of Medicine and Dentistry(61).
2.3. Etc. 

F.2. In Herbal medicine perspective
1. Comfrey
Comfrey used in herbal and traditional medicine to ease excessive bleeding or on open wounds, relief pain and swollen, treat circulation issues, reduce cholesterol, etc., is a perennial Plant in the genus of Symphytum, belonging to the family Boraginaceae, native to Europe.
  Comfrey root extract ointment is well suited for the treatment of osteoarthritis of the knee, through  Pain reduction, improvement of mobility of the knee improved and increased  quality of life increased(46).

2. Devil’s claw
Devil’s claw, used as herb in traditional and herbal medicine to treat fever, rheumatoid arthritis, skin, gallbladder, pancreas, stomach and kidneys conditions, etc., also known as wood spider, is a plant of genus Harpagophytum in the family of Pedaliaceae, native to South Africa.
2.1. Antiinflammatory effects
Standardized ethanol Hp extract from Harpagophytum procumbens inhibits induction of pro-inflammatory gene expression, possibly by blocking pro inflammatory pathway(47).
2.2. Osteoarthritis
Devil’s Claw showed effectively in the reduction of the main clinical symptom of pain(48)(49).
2.3. Degenerative diseases of the musculoskeletal system
Extracts of the secondary tubers of Devil’s Claw (Harpagophytum procumbens) inhibits degenerative painful rheumatism effects through its analgesic, antiphlogistic and antiinflammatory actions(50)
2.4. Arthrosis of hip or knee
In observation of Preparations made from the secondary tubers of Devil’s claw (Harpagophytum procumbens) inhibits rheumatic diseases (arthrosis and low back pain) with a continuous improvement in typical clinical findings such as 45.5% for pain on palpation, 35% for limitation of mobility and 25.4% for joint crepitus, after administration(51)
2.5. Low back pain
 Harpagophytum extract at a daily dose equivalent of 50 mg harpagoside may be used for treatment of acute exacerbations of chronic NSLBP(52).

 3. Valerian
Valerian, used as a sedative and relaxing agent and to treat the liver, the urinary tract, the digestive tract problem, nerve conditions, etc.  is a perennial flowering plant, in the genus Valeriana, belonging to the family Valerianaceae, native to Europe and parts of Asia.
  V. officinalis extracts showed to exert its antioxidant properties against iron in hippocampal neurons in vitro(53). The herb valerian may also be useful as a mild sleep aid in clinical populations, such as persons with rheumatoid arthritis, according to the research team at the University of Virginia, School of Nursing(54).

F.3. In traditional Chinese medicine perspective
Du huo Ji Sheng Tang (DHJST), the Chinese herbal medicine formula is to enhance the immune system and promote kidney’s Qi.
a. According to the Shanghai Municipal Hospital of Traditional Chinese Medicine, Du huo Ji Sheng Tang (DHJST) showed that at the end of the sixth week after surgery, significantly effects on osteoarthritis rabbits, through inhibition of  stimulation of vasculogenesis and angiogenesis (VEGF) and HIF-1α expression(a modulator of degradation)(62).
b. Ingredients
1. Du Huo (Radix Angelicae Pubescentis)       
2. Chuan Xiong (Rhizoma  Chuanxiong)      
3. Sang Ji Sheng (Herba Taxilli)           
4. Ren Shen (Radix  et Rhizoma Ginseng)      
5. Du Zhong (Cortex Eucommiae)         
6. Gan Cao (Rx et Rz Glycyrrhizae)       
7. Niu Xi (Radix Cyathulae)            
8. Dang Gui (Radix Angelicae Sinensis)      
9. Xi Xin (Radix et Rhizoma Asari)          
10. Bai Shao (Radix Paeoniae Alba)       
11. Qin Jiao (Radix Gentianae Macrophyllae)          
12. Sheng Di Huang (Radix Rehmanniae)       
13. Fu Ling (Poriae)                  
14. Gui Xin (Cortex Rasus Cinnamomi)            
15. Fang Feng (Radix Saposhnikoviae)(63)

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(23) http://www.ncbi.nlm.nih.gov/pubmed/11858317
(24) http://web.archive.org/web/20080623203621/http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441/DSECTION=tests-and-diagnosis
(25) http://www.ncbi.nlm.nih.gov/pubmed/3619280 

(28) http://www.ncbi.nlm.nih.gov/pubmed/22570770
(29) http://www.ncbi.nlm.nih.gov/pubmed/22696854
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(31) http://www.ncbi.nlm.nih.gov/pubmed/19281374
(32) http://www.ncbi.nlm.nih.gov/pubmed/21985858
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(41) http://www.ncbi.nlm.nih.gov/pubmed/20462508
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 (46) http://www.ncbi.nlm.nih.gov/pubmed/17169543
(47) http://www.ncbi.nlm.nih.gov/pubmed/22072539
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(51) http://www.ncbi.nlm.nih.gov/pubmed/14669250
(52) http://www.ncbi.nlm.nih.gov/pubmed/15369596
(53) http://www.ncbi.nlm.nih.gov/pubmed/19191025
(54) http://www.ncbi.nlm.nih.gov/pubmed/15222600

(56) http://btcm.ehrenwerks.com/index.php?main_page=product_info&cPath=28_29&products_id=1938
(57) http://www.ncbi.nlm.nih.gov/pubmed/17848800
(58) http://www.ncbi.nlm.nih.gov/pubmed/21623468
(59) http://www.ncbi.nlm.nih.gov/pubmed/22674883 
(60) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3194518/
(61) http://www.ncbi.nlm.nih.gov/pubmed/9336424

(62) http://btcm.ehrenwerks.com/index.php?main_page=product_info&cPath=28_29&products_id=1938
(63) http://www.ncbi.nlm.nih.gov/pubmed/17848800 

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