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By Kyle J. Norton
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papers have been written and published on line, including world wide
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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).
b. 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 complications
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
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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