Blog

Polymyalgia Rheumatica

Intro

I have had a bit a glut of requests about Polymyalgia Rheumatica (PMR) recently so this blog aims to give an overview of the condition and non-pharmacological management for Physios.

PLEASE REMEMBER – THIS BLOG IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE

Overview

PMR is an inflammatory condition, main symptoms are shoulder and/or pelvic girdle pain and stiffness. The mainstay of treatment is pharmacological usually involving steroids. There has been almost no research into the effectiveness of non-pharmacological interventions2.

Onset is very unlikely prior to the age of 50, peak onset is 65 with women being affected at 3x the likelihood of men. There shouldn’t be any muscle weakness at presentation and likely proximal muscle tenderness to palpation.

Clinical Presentation

Proximal bilateral muscle aching and/or morning stiffness lasting greater than 45 minutes (shoulders 90%) are the most prevalent symptoms. Associated symptoms include general malaise, depression and loss of appetite. A sibling with PMR significantly increases the risk of development of this condition.1

Blood tests should show a raised ESR of >40 and/or a raised CRP. Other bloods will help to exclude differential diagnoses due to the lack of specificity of symptom presentation (more bloods info here).1

There is no role for imaging in suspected PMR.

If PMR is suspected, refer to GP for appropriate management and/or onward referral to Rheumatology.

Physiotherapy Management

As mentioned in the intro there has been no research into the non-pharmacological management of PMR so I have no “evidence base” to present to you for management. The following is based on my clinical experience and adapted from evidence in other conditions.

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Physiotherapy management should focus on function restoration and general health. Obvious targets include, increased capacity for tasks involving the proximal muscles, cardiovascular health and general health education.

Function Restoration/Maintenance

It sounds obvious to say but this is really going to depend on the function required and the current deficits. Pacing advice is an option if there are no overt physical deficits such as loss of strength or range of motion.

Progressive loading programs will be useful to restore or maintain muscle strength, there is evidence confirming these are safe and effective in many other Inflammatory Conditions so there is nothing to lead me to believe PMR will be different. Be mindful of patients on titrating doses of steroids, I have seen individuals flare up as their dose reduces, ensure they have appropriate options with their exercise programs in case of this outcome.

General exercise programs are important in all inflammatory conditions. All the systemic inflammatory arthropathies (spondyloarthritis, Rheumatoid Arthritis and Psoriatic Arthritis) are associated with an increase in cardiovascular disease risk. The associated benefits of this type of program will help to mitigate some of this risk. Again, the evidence in other inflammatory conditions has shown even high intensity exercise programs to be safe. I advocate these programs to be patient preference led.

Education

Education is massive part of what we do as Physios and for PMR patients this is no different. Knowledge is power as they say and this is part of being able to self-manage any condition.

Condition Education is rather difficult in a condition with such a lack of information regarding pathophysiology but explaining how the inflammatory system is linked to immunity, repair and normal reactions to exercise can help patients to understand why they get the muscle soreness and stiffness associated with PMR. Hopefully this will lead to an understanding that exercise and activities, while not symptomless, are also not harmful to them in the long term. It can also aid in understanding when they have overdone it.

General Health Education includes smoking cessation, dietary advice and of course sleep. All three of these components are associated with outcomes in ALL long-term conditions as well as specifically inflammatory ones.

Closing

Hopefully this blog has given you some insight into recognising PMR if it presents in clinic (think Female, 50+, bilateral stiffness/pain, raised inflammatory markers) and some ideas on how to manage those already diagnosed.

References

  1. Book by Drs Al-Sukaini, Azam and Samanta https://www.amazon.co.uk/Rheumatology-clinical-handbook-medical-students/dp/1907904263/ref=sr_1_1?ie=UTF8&qid=1538037053&sr=8-1&keywords=rheumatology+a+clinical+handbook
  2. Dejaco C, Singh YP, Perel P, et al 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative Annals of the Rheumatic Diseases 2015;74:1799-1807.

Inflammatory Arthropathy Bloods

Blood tests are a vital component when it comes to clinical reasoning in Rheumatology. Not everyone has the authorisation to order bloods for their patients but a working knowledge remains important to help you in management of a suspected rheumatology patient. This blog will outline the basic bloods for the most common arthropathies (i.e. it leaves out connective tissue disorders and myopathies etc.) It is important to remember here that interpretation is nuanced, requires clinical correlation and that formal diagnosis remains the role of Rheumatologists with this group of patients. Conditions will always remain “suspected” until investigation by a Rheumatologist.

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PLEASE REMEMBER – THIS LIST IS NOT A REPLACEMENT FOR CLINICAL REASONING, IF YOU ARE UNSURE GET ADVICE

Routine blood tests will always be carried out for suspected Inflammatory Arthropathies such as Rheumatoid Arthritis and the Spondyloarthropathies. These will consist of a Full Blood Count, inflammatory markers, biochemical tests and immunological tests. This blog will concentrate on the inflammatory markers and biochemical tests. It is by no means exhaustive and is designed to help Physiotherapists to order appropriate blood tests. Again I reiterate, if you are unsure what to order, please seek advice.

Inflammatory Markers

These will often be raised in Inflammatory Arthropathies but remember many, many other things can cause increased levels of inflammatory markers in the blood (e.g. obesity, acute injury, infection) and  a negative result does not rule out a suspected condition on its own.

ESR (Erythrocyte Sedimentation Rate) – non specific test of inflammation

Normal range – Men 0-14, Women 0-20. Note that there is some variance with age so proceed with caution when interpreting if the levels are near to the top of these ranges.

CRP (C-reactive protein) – non specific test of inflammation

Normal range – <5. Note that this is very reactive to any activation of the immune system.

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Immunological Tests

Immunological tests have much more utility in diagnosis and can have value with prognosis in inflammatory arthropathies. Just a reminder that these still have diagnostic limitations. I would recommend this book by Drs Al-Sukaini, Azam and Samanta (https://www.amazon.co.uk/Rheumatology-clinical-handbook-medical-students/dp/1907904263/ref=sr_1_1?ie=UTF8&qid=1538037053&sr=8-1&keywords=rheumatology+a+clinical+handbook) as it has a brilliant breakdown of the sensitivity and specificity of these tests for the various diagnoses.

Rheumatoid Factor (RF) – note 15-20% of RF+ve patients have no associated conditions

Rheumatoid Arthritis – Sensitivity 60-90%, specificity 70-80%, higher values prognostic of poorer outcome.

Psoriatic Arthritis – A negative RF result has diagnostic utility in PsA

Anti-cyclic citrullinated peptide (Anti-CCP)

Rheumatoid Arthritis – highly specific 95%+ for diagnosing RA

HLA-B27 – Note present in roughly 8% of the population

Spondyloarthropathy – 90% of diagnosed SpA patients will be positive for the HLA-B27 gene

Psoriatic Arthritis – 40%+ will be positive for the HLA-B27 gene

I hope that this gives you a good reference point to aid with clinical reasoning. Remember that due to a lack of sensitivity and specificity these blood tests are best used in conjunction with clinical correlation. It would be a rare case indeed to refer (or not refer) to Rheumatology purely based upon a positive/negative blood result. Use your clinical judgement and seek advice where needed.

Also remember this list does not cover many other types of Rheumatology conditions!

Other resources to help you include the mentioned clinical handbook and my “suspecting RA tool” which is free to download here

 

24 Hours Inflammatory Pattern

Intro

Day to day in our MSK clinics we discuss the daily pattern of symptoms with pretty much everyone that attends. The obvious reason being that it can tell you an absolute ton about the nature of the condition and therefore is a significant factor in our clinical reasoning. We learn early on in our training about night pain, I recall drumming it into my brain “unremitting night pain is a red flag”. Everyone who attends though seems to bring with them a nuanced pattern of symptoms almost as if they are all individuals… To try and help you out with your clinical reasoning I have outlined the patterns to look for to recognise when your attendee may have a systemic inflammatory condition that warrants further questioning and/or onward referral.

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In this context the symptoms referred to are pain and/or joint stiffness, don’t forget this can be in any combination i.e. for an Axial Spondyloarthropathy, spinal stiffness and hand pain OR spinal pain and spinal stiffness OR just spinal pain OR just spinal stiffness etc could be reported by the individual.

Night time

As mentioned above night pain is an important line of subjective questioning. When it comes to inflammatory conditions there are specific patterns of the symptoms (pain and/or joint stiffness) that when present warrant deeper questions to assess the index of suspicion and likelihood you need to refer this individual onwards.

Waking with symptoms in the second half of the night, especially requiring the need to get out of bed and move around is our first indicator, this is related to the inflammatory systems more active and passive periods of during the sleep cycle.

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Symptoms that are present on waking and linger are our next line of questioning. The guidelines used in research relating to inflammatory conditions stipulate this lasts greater than 60 minutes, I am an advocate of relaxing this time frame down to greater than 30 minutes. I believe this will still help to differentiate between other conditions which will have symptoms in the morning but usually ease quite quickly (Osteoarthritis and Tendinopathies spring to mind).

Activity/Exercise/Rest

The relationship of symptoms to rest and activity is our final call on the 24-hour pattern line of reasoning. Most conditions we see come into the clinic will be worse with activity and better with rest (low back pain, Osteoarthritis, ligament sprain and so on…). Inflammatory conditions are the opposite, worse in the car, sat at a desk, watching TV… Better on walking, in the gym, gardening… Look for phrases such as “If I just carry on and don’t stop I am better off”, “It is terrible at work but so much better during and after the gym”.

Outro

Remember that these factors on their own are not diagnostic, they need to be taken in the context of the individual’s symptoms, history, co-morbidities and other medical investigations. They are however an important part of your clinical reasoning process when retaining systemic inflammatory conditions in your differential diagnosis.