Beyond Meds: Bone-Friendly Exercises and Wellness Tips for Polymyalgia Rheumatica

You’re probably well-acquainted with the symptoms of polymyalgia rheumatica (PMR), like stiffness and pain in the upper arms, neck, lower back, and thighs. But here’s something you might not know: People with PMR are also susceptible to bone weakness.

“We know that PMR classically affects an elderly population that already might have certain conditions, including cardiovascular disease, kidney disease, osteoporosis, and diabetes,” says rheumatologist Anisha Dua, MD, MPH, Associate Professor of Rheumatology at Northwestern University.

“Of course, when we add steroids on top of that, we’re increasing the risk of many of those things. You want to do everything you can to protect your bones and decrease side effects from taking that medication.”

That said, bone health can be managed in PMR patients through bone-friendly exercises, nutrition, and overall wellness. Here’s what to know about protecting your bones, especially if you have PMR and are taking steroids.

Understanding PMR and Bone Health

PMR tends to occur more in women than in men — and virtually never occurs in those under 50 years of age (although the reasons why are unclear, it likely has to do with the aging of the immune system).

This is the population that’s most affected by osteoporosis, and on top of that, PMR is usually treated with glucocorticoids like prednisone over a prolonged period of time, per a research article in the journal Women’s Health.

Glucocorticoids are a powerful course of treatment for those with conditions like PMR, but they can have several negative effects on bone health, per the American College of Rheumatology. They can cause glucocorticoid-induced osteoporosis, with patients experiencing a quick loss of bone and a much higher rate of bone fractures.

Some research shows that exercise can help you maintain your bone density, even if you take glucocorticoids. Patients taking the medication who exercised had better spine bone density compared to those who didn’t exercise in a 2023 review published in Rheumatology Advances in Practice. (That said, the same results were not seen in hip bone density.)

“Although more well-designed exercise studies are needed to address the issue of exercise effects on GC-induced osteoporosis in more detail, upcoming guidelines should pay more attention to the aspect of exercise for bone strengthening,” note the authors in the review.

The American College of Rheumatology guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis include recommendations for regular weight-bearing or resistance training exercise.

“Regular activity is very important for bone health,” says rheumatologist Carol Langford, MD, Director of the Center for Vasculitis Care and Research at Cleveland Clinic. “When someone needs to be on prednisone for some period of time, we’re making sure we know what their current bone density is and thinking proactively about bone protection, including what they’re doing for exercise.”

Bone-Friendly Exercises for PMR

In general, several studies show that weight-bearing exercise — even weight-bearing aerobic exercise like walking or running — can support your bone health, according to Harvard Medical School.

Activities that put some stress on bones trigger extra deposits of calcium and put bone-forming cells into action, helping to slow bone loss or even build bone.

“The exercise you choose depends on your baseline activity, but something simple like walking at a brisk pace or stretching like yoga can be helpful,” says Dr. Dua. “It’s also helpful to do bone-strengthening activities like low-weight, high-repetition weightlifting. Even if it’s a seated exercise, that can be helpful.”

A bone-strengthening exercise program should include four main components, per Harvard Medical School:

• Weight-bearing exercises like walking, climbing stairs, playing tennis, and dancing to encourage your body to work against gravity (which helps to strengthen bones).
• Muscle-strengthening exercises like free weights, weight machines, resistance bands, or exercises using your own body weight.
• Balance exercises like tai chi and yoga to prevent falls.
• Flexibility exercises like yoga and stretching to keep muscles limber and joints mobile.

If it’s accessible to you, swimming or water aerobics can be helpful due to the low impact on your joints. “It can also help with the flexibility of your joints,” says Dr. Dua.

Wellness Tips for PMR Patients

As part of your PMR management, your doctor may also look at your diet and any potential supplementation you may need to protect your bones.

“Work with your doctor to look at where you are with calcium and vitamin D intake,” says Dr. Langford. “It’s important to get a sense of each patient’s regular diet and what’s accessible to them. But generally, I do recommend diets that are high in calcium and vitamin D like the Mediterranean diet.”

The Mediterranean diet has been associated with lower risk of hip fracture, per a 2023 review in the journal Nutrients.

“A popular alternative dietary pattern, the Mediterranean diet (MD) has been recently shown to have a positive impact on musculoskeletal health and reduced incidence of hip fractures,” note the authors in the review. “Higher adherence to the MD has also been associated with an increase in calcium intake in peri- and postmenopausal women.”

The anti-inflammatory Mediterranean diet emphasizes vegetables, fruits, beans, lentils, nuts, extra virgin olive oil, and fish rich in omega-3 fatty acids, according to the Cleveland Clinic. It also includes a moderate amount of natural cheese and yogurt.

Olive oil is high in polyphenols, known to reduce inflammation, which can also prevent bone loss, add the authors of the Nutrients study. In general, research has found an association between inflammatory foods (like red and processed meat or high-sugar foods) and lower bone mineral density and content in overweight and obese individuals, per the Journal of Orthopaedic Surgery and Research.

Although you can get bone-boosting nutrients through food, your doctor may recommend calcium and vitamin D supplementation if you are not getting enough in your diet. In fact, it may be a conversation you had with your doctor prior to a PMR diagnosis.

“Your bone mass usually starts to decline earlier in life compared to patients who are getting affected by PMR, so a lot of them should already be on some calcium or vitamin D supplementation,” says Dr. Dua.

Ask your doctor if you’re a candidate for supplementation — and the impact that your steroids may be having on your bone health, based on your baseline bone mineral density and ongoing scans.

“As a rheumatology community, we always remember to put people on calcium and vitamin D prophylaxis [preventively], especially when they’re on high doses of prednisone for things like giant cell arteritis, which is related but not the same thing,” says Dr. Dua. “I think it might be overlooked a little bit in patients on these chronic low-dose steroids [like low-dose prednisone for PMR].”

Stress Management Techniques

Chronic stress can affect your entire body, including your skeleton.

Although more research is needed to determine the exact ways it does so (hypotheses range from low-grade inflammation to the effect of stress on the genetic regulation of skeletal development), stress is considered a risk factor for osteoporosis. Because of that, stress-coping methods should be part of an osteoporosis prevention strategy, per a 2021 review in the International Journal of Medical Sciences.

“We all have regular stressors in our life and it’s also stressful getting diagnosed with a new condition,” says Dr. Dua. “Stress is definitely something that I talk about with patients, especially because steroids can make you feel more hungry, jittery, and anxious — so you’re even more prone to baseline issues like increased stress because of the treatments.”

Dr. Dua recommends apps like Headspace or Calm for guided meditation, breathing exercises, and lightweight yoga that focuses on stress reduction.

“I also have some patients who are very interested in other modalities like massage therapy or acupuncture,” says Dr. Dua. “We don’t have a good, vast knowledge around some of those other integrative modalities, but for patients who are interested, I work with integrative practitioners on what tips might be helpful for them specifically.”

Sleep Hygiene Practices

If you’re in pain or on medication for PMR, getting good sleep can become a difficult task to manage.

“Prednisone and other glucocorticoids can disrupt sleep, which can cause problems as far as a reduced sense of wellbeing,” says Dr. Langford. “Your sleep cycle is very important for pain management, so we want to encourage good sleep habits.”

Even if you feel fatigued during the day, Dr. Langford recommends trying to maintain activity during the daytime hours, so you can sleep better at night.

Steroids may particularly affect your sleep when they’re taken in the evening, so your doctor may suggest you take your entire daily dose in the morning (speak to your physician before making this change yourself, though). This can help you sleep better at night, per the Hospital for Special Surgery.

Dr. Dua suggests additional lifestyle changes that can help you get better quality of sleep, like limiting caffeine in the latter half of the day and avoiding stimulating activities right before bed like checking your phone.

“If you’re not sleeping well, your body’s not healing throughout the night when it’s supposed to be,” says Dr. Dua. “You go into this vicious cycle where you’re waking up in more pain and you’re exhausted, then you’re more exhausted at the end of the day, so sleep hygiene is super important.”

If you do wake up in the middle of the night due to pain, try “relaxing distraction” — such as breathing meditation or guided imagery, in which you imagine you’re in a calm location, per Harvard Medical School. If that doesn’t work, you can also try getting up to read in a quiet room with low light, but avoid anything with bright lights like TV, smartphones, and computers.

Also aim to maintain a regular schedule, going to bed and waking up at the same time each day. This will help support your natural sleep drive by setting your internal clock. Speak to your doctor if pain continues to keep you up at night.

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This article was made possible with support from Sanofi.