Polymyalgia Rheumatica
Polymyalgia rheumatica (PMR) is a chronic, inflammatory disorder of unknown cause, which typically presents with diffuse shoulder and hip pain and stiffness [1]. It is a condition, which is often difficult to diagnose, and a significant cause of pain and disability.
Prevalence and Presentation
PMR is most common among women (50-66% PMR) [3]. It occurs after the age of 50 and its incidence gradually increases with age [3], reaching its highest at 70-79 years [4].
PMR is a disorder with widespread diffuse muscle pain. Symptoms can present at the sternoclavicular joints, lower back and buttocks; however the primary locations are the neck, shoulder and pelvic girdles [2] [4]. Characteristically PMR pain presents bilaterally as a dull ache that may radiate distally to the knees and elbows [4].
The onset of PMR is commonly insidious, with the patient waking up one morning with pain and stiffness for no apparent reason. The symptoms progressively exacerbate over the following days and weeks [2] [5]. Aggravating activities for PMR symptoms are mostly related towards physical demands of everyday activities particularly those of higher joint loading. PMR patients commonly report pain is greatest late at night and early morning [6]. Marked morning stiffness lasting greater than 45 minutes is a major indicator of PMR [7] Stiffness is also common throughout the day, particularly following periods of rest [1].
The onset of PMR is commonly insidious, with the patient waking up one morning with pain and stiffness for no apparent reason. #performbetter @pogophysio Click To TweetAssessment and Further Testing
Patients with PMR can have general symptoms of systemic inflammation, such as fever, pallor, malaise and unexplained weight loss [8]. Giant cell arteritis (GCA) is present with PMR in 15-20% of cases [1]. The presence of GCA or its symptoms (new headache, pain over temporal or occipital regions and jaw claudication) adds stronger support for PMR diagnosis. PMR is commonly associated with increased inflammatory blood markers; erythrocyte sedimentation rate (ESR) and or C-reactive protein (CRP). ERS and CRP levels form part of the classification criteria for PM [7].
Further information to confirm diagnosis can be obtained from an objective examination. PMR will often have painful multidirectional restriction of AROM and PROM at the glenohumeral and hip joints, without detectable joint swelling [5]. Observation may reveal swelling in peripheral joints (fingers, wrist, ankles) for 20% of PMR, due to synovitis [6]. PMR patients will have a normal neurological examination and tenderness on palpation primarily confined to the neck, greater trochanter, shoulder and surrounding musculature [6].
Core Inclusion Criteria
Bilateral shoulder or pelvic girdle aching – or both
Morning stiffness longer than 45 minutes
Age older than 50 years
Duration >2 weeks
Evidence of an acute phase response (raised ESR/CRP)
Management
The standard treatment of PMR is low-dose glucocorticoids, which characteristically induce rapid resolution of symptoms. There is increased risk of osteoporosis in long term use of corticosteroids. Thus the decision about the use of a bone sparing agent (eg. oral biphosphonate) for bone protection when initiating steroids for PMR depends on the clinical risk of developing glucocorticoid induced osteoporosis [1] [4] [5]. PMR has a high reoccurrence rate, estimated at approximately 50% [6]. All patients should be provided with written information on PMR and corticosteroid treatments. They should also be given information on range-of-motion exercises for the shoulder or involved joints and provided with contacts to their local Polymyalgia Rheumatica and Giant Cell Arteritis supports. Physiotherapy and exercises can be used in regaining strength and mobility. Relapse of PMR is often grounds for specialist referral.
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References
- Kermani, T. A., & Warrington, K. J. (2013). Polymyalgia rheumatica. Lancet, 381(9860), 63-72. doi: 10.1016/S0140-6736(12)60680-1
- Goodman, C. C., & Fuller, K.S. (2009). Pathology: implications for the physical therapist (3rd Edition ed.). St Louis, Mo: Saunders/Elsevier.
- Salvarani, C., Cantini, F., & Hunder, G. G. (2008). Polymyalgia rheumatica and giant-cell arteritis. Lancet, 372(9634), 234-245. doi: 10.1016/S0140-6736(08)61077-6
- Kennedy, S. (2012). Polymyalgia rheumatica and giant cell arteritis: an in-depth look at diagnosis and treatment. J Am Acad Nurse Pract, 24(5), 277-285. doi: 10.1111/j.1745-7599.2012.00717.x
- van Hecke, O. (2011). Polymyalgia rheumatica — diagnosis and management. Aust Fam Physician, 40(5), 303-306.
- Nothnagl, T., & Leeb, B. F. (2006). Diagnosis, differential diagnosis and treatment of polymyalgia rheumatica. Drugs Aging, 23(5), 391-402.
- Dasgupta, B., Cimmino, M. A., Kremers, H. M., Schmidt, W. A., Schirmer, M., Salvarani, C., . . . Matteson, E. L. (2012). 2012 Provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheum, 64(4), 943-954. doi: 10.1002/art.34356
- Mackie, S. L., & Pease, C. T. (2013). Diagnosis and management of giant cell arteritis and polymyalgia rheumatica: challenges, controversies and practical tips. Postgrad Med J, 89(1051), 284-292. doi: 10.1136/postgradmedj-2012-131400
