Polymyalgia Rheumatica AND Physiotherapy

A new approach this week in a couple of different ways, I am adding two new features, “Legend of the Blog” and if you scroll all the way to the bottom you can listen to the music I was listening to when I wrote this.

My Polymyalgia Rheumatica Blog was very popular and I decided to follow it up after continued twitter conversations. I have done a rudimentary Literature Search and have outlined it below. I hope that it serves to help understanding where we are or even someone more intelligent than I to start a publication.

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Legend of the Blog

This weeks legend is The Endurance Physio himself Mike James, he has some cool new sessions targeted at runners on recovery and so on that we can sign post to. More than that he has helped me out a number of times so check him out on Facebook or Twitter or Instagram

Introduction

Polymyalgia Rheumatica is primarily managed with steroids, NSAIDs and DMARDs, I have seen a few of these patients attend Physio for restoration of function (range of motion and strength) or for bone protection due to the risks of the steroids.

It never particularly occurred to me that Physio evidence would be lacking, its pretty decent in RA and AxSpA, until I realised that from a pathophysiological point of view PMR is still a bit of a mystery. Then I realised there was nothing available for me to use as an evidence base. Doh.

Anyway, following the blog previous, there were a few tweets regarding guidleines for PMR and Physiotherapy. I thought there was very little but I didn’t KNOW so here we are. I looked.

I have put the search strings at the bottom of the blog as well so you can recreate what I did if you so wish…

Guidelines

2015 EULAR / ACR guidelines https://ard.bmj.com/content/74/10/1799 (open access)

“Recommendation 9: (PICO 12) The panel conditionally recommends considering an individualised exercise programme for PMR patients aimed at the maintenance of muscle mass and function, and reducing risk of falls.

There are no studies investigating the value of non-pharmacological therapies (eg, physiotherapy, relaxation techniques, diets, etc) in PMR and there is insufficient clinical experience on this issue to agree on a specific recommendation. Nevertheless, the panel agreed on recommending an individualised exercise programme (see overarching principles) in view of its benefit for maintaining muscle mass and function and reducing risk of falls, especially in older persons on long-term GCs as well as in frail patients.”

In the research agenda

“What is the value of non-pharmacological therapies in PMR? Particularly, it is assumed but not yet demonstrated that physiotherapy may support preservation of function and reduce the risk of adverse events related to GC use. Patients may benefit from exercise by maintaining muscle mass and function as well as by fall prevention especially in the frail. What is the role of diet in PMR and nutrition supplements (eg, fish oil) related to outcomes?”

The BSR and BHPR guidelines do not mention therapy other than Medical

https://academic.oup.com/rheumatology/article/49/1/186/1789113 (open access)

Very honest of the guidelines in my opinion taking a best punt (consensus) that Physiotherapy might be of some assistance offsetting the problems incurred by steroids, systemic inflammation and loss of function.

The Search

I went to PubMed (you can see what I did below). Initially I just searched the titles for Polymyalgia Rheumatica as a reference point. 1766 results. Excellent, one of those has to be about physio surely…

Nope. Polymyalgia Rheumatica and Physiotherapy (0 results) and Polymyalgia Rheumatica and Physical Therapy (0 results).

I expanded the searches to include the abstract and finally got 5 and 2 results respectively but none we relevant in any way except one from 1994 “Therapeutic modalities, such as physical therapy, medications, and surgery should be modified sometimes to accommodate age-related changes in body mechanics and function” but I cannot access the full article to read more specifically. Nesher G, Moore TL. Clinical presentation and treatment of arthritis in the aged. Clin Geriatr Med. 1994 Nov;10(4):659-75. PMID: 7850696. if someone can get at that I would be grateful!

Where Are We

Ok, so this seems problematic. We can make some assumptions I think, Physiotherapy for bone density and falls risk should be effective in PMR patients. I am not sure muscle mass has been shown to improve with strengthening programs in inflammatory conditions but function has so again I think we are on steady ground here.

Clearly we can’t say Physio helps PMR specifically, we also can’t currently say that it will be tolerated which I think is problem 1. Tolerance I think is a priority here to build further research off the back of it. “when, why and how” follows.

I look forward to seeing some of that research take place! Happy to discuss that further with anyone keen.

End

I hope this has been interesting, the search strings are at the bottom of the page. If anyone has got any specific questions about PMR and Physio, I am happy to try and answer them!

Get me any feedback you might have so that I can grow and improve.

See you next time!

Music Choice: Bring Me The Horizon – “Medicine”

“Some people are a lot like clouds, you know

‘Cause life’s so much brighter when they go…”