PMR Presentation

1. Wendy thought her muscle aches
and poor vision were signs of aging,
but in fact….

2. MSKL II
Stephanie Walker
March 31, 2014

3. Objectives
 Students will understand the pathophysiology of
PMR
 Students will recognize key clinical features
associated with PMR
 Students will be able to list differential diagnoses
for PMR
 Students will understand the role that
pharmacology plays throughout treatment of
PMR
 Students will determine the physical therapists’
role throughout treatment of PMR

4. Prevalence
 Older white persons of
Northern European
descent2,6
 Age: 50+ (peaking between
ages 70 and 80)
 Females > Males2

5. Etiology
 Chronic inflammatory condition of
unknown etiology
 Most believe the underlying cause of
inflammation to be antigen-mediated2
 Prevalence amongst northern Europeans
may indicate genetic predisposition2

6. Pathophysiology
 Autoimmune response to an environmental
trigger (i.e. virus) resulting in inflammation around
the joints2
 Inflammation within the synovium and bursae is
recognized by antigens & macrophages thereby
increasing the inflammatory response2,9
 Nonerosive synovitis and tenosynovitis may be
responsible for many symptoms associated with
PMR

7. What will the
patient tell you?
 Bilateral pain and stiffness in the
shoulders and hips
 Pain most prominent in the morning or
after long periods of inactivity
 Aching in the proximal muscles
surrounding the shoulders and hips
 Difficulties with:
 Rising from a chair
 Turning over in bed
 Raising arms overhead
 Gradual onset over weeks to months2
 Feelings of fatigue, fever, loss of
appetite2

8. Examination
 Cardiopulmonary System
 Vitals
 Auscultation6
 Musculoskeletal System
 Posture
 ROM
 MMT
 Joint Accessory Motion
 Muscle Length
 PMR Classification Algorithm3,6
Can you think of any other systems?

9. ….but what else could it
be?
 Differential Diagnoses: 2
 Giant Cell Arteritis (needs to be ruled out IMMEDIATELY)
 Rheumatoid Arthritis
 Osteoarthritis
 Fibromyalgia
 Spondyloarthritis10
 Parkinson’s Disease
 Adhesive Capsulitis
 Rotator Cuff Pathology
 Subdeltoid Bursitis
 Malignancy5

10. Giant Cell Arteritis (GCA)
 Symptoms/Clinical Presentation
 Abrupt onset of headache
 Jaw or tongue claudication
 Limb claudication
 Prominent, beading, or diminished pulse of
temporal artery
 Temporal tenderness
 Upper cranial nerve palsies
 Visual disturbances
What else might you include in your examination?

11. So, what would you do…?
 A patient comes into your clinic presenting
with symptoms associated with PMR.
After performing your examination you’ve
ruled out GCA and other potential
diagnoses. Is this patient appropriate for
PT?
a. Yes
b. Yes with referral
c. No

12. Pharmacology
 Corticosteroid medication must be
administered to alleviate symptoms2
 Quick response to medication (2-3 days)
 Medication is slowly tapered once symptoms are
under control
 Suspected GCA indicates urgent need for high-dose
corticosteroids

13. Physical Therapy
Treatment
 Will focus on the following impairments:
 Pain
 Limited ROM
 Decreased strength
 Decreased aerobic endurance

14. Physical Therapy
Treatment
 Consider the following interventions to address
common impairments:
 Joint mobilizations
 Stretching (pecs, upper trapezius, hip ABD/ADD, hip
flexors/extensors)
 Progressive resistance exercise
 Aerobic endurance training (cycling, walking)

15. Physical Therapy
Treatment
 Patient Education:
 Relapse2
 Adverse effects of long-term corticosteroid use
○ Weight gain, osteoporosis, HTN, high cholesterol,
etc.
 Lifestyle modifications
○ Adhering to prescribed dosage of medications
○ Frequent aerobic activity
○ Progressive resistance exercise

16. Objective Measures
 VAS8
 Oswestry Disability Index
 Hip Outcome Score
 DASH
 Polymyalgia Rheumatica Disease Activity
Score (PMR-AS)7

17. Prognosis
 Favorable prognosis for return to PLOF in
conjunction with corticosteroid medication
 Duration of rehab depends on:
 The time of diagnosis
 Number of joints involved
 Joint integrity
 Response to medication

18. Summary
Although the etiology of
PMR is unknown, it is best
associated with an ______
response resulting in
inflammation.

19. Summary
What is the typical clinical
presentation for a patient
with PMR?

20. Summary
What condition is
essential to rule out when
performing an exam on a
patient with suspected
PMR?

21. Summary
Patients with PMR require
what type of medication
in order to return to PLOF?

22. Summary
List some physical therapy
interventions that could
be used to treat common
impairments associated
with PMR.

23. References
1. Available at: http://books.google.com?id=pukgv_IhKxgC. Accessed March 18, 2014.
2. Caylor TL, Perkins A. Recognition and management of polymyalgia rheumatica and giant cell
arteritis. Am Fam Physician. 2013;88(10):676-84.
3. Dasgupta B, Cimmino MA, Kremers HM, et al. 2012 Provisional classification criteria for
polymyalgia rheumatica: a European League Against Rheumatism/American College of
Rheumatology collaborative initiative. Arthritis Rheum. 2012;64(4):943-54.
4. Gonzalez-gay MA, Vazquez-rodriguez TR, Lopez-diaz MJ, et al. Epidemiology of giant cell
arteritis and polymyalgia rheumatica. Arthritis Rheum. 2009;61(10):1454-61.
5. Hennell S, Busteed S, George E. Evidence-based management for polymyalgia rheumatica for
rheumatology practitioners, nurses and physiotherapists. Musculoskeletal Care. 2007;5(2):65-
71.
6. Kermani TA, Warrington KJ. Advances and challenges in the diagnosis and treatment of
polymyalgia rheumatica. Ther Adv Musculoskelet Dis. 2014;6(1):8-19.
7. Leeb BF, Rintelen B, Sautner J, Fassl C, Bird HA. The polymyalgia rheumatica activity score in
daily use: proposal for a definition of remission. Arthritis Rheum. 2007;57(5):810-5.
8. Mackie SL, Arat S, Silva JD, et al. Polymyalgia Rheumatica (PMR) Special Interest Group at
OMERACT 11: Outcomes of Importance for Patients with PMR. J Rheumatol. 2014;
9. Narváez J, Nolla-solé JM, Narváez JA, Clavaguera MT, Valverde-garcía J, Roig-escofet D.
Musculoskeletal manifestations in polymyalgia rheumatica and temporal arteritis. Ann Rheum
Dis. 2001;60(11):1060-3.
10. Olivieri I, Garcia-porrua C, Padula A, Cantini F, Salvarani C, Gonzalez-gay MA. Late onset
undifferentiated spondyloarthritis presenting with polymyalgia rheumatica features:
description of seven cases. Rheumatol Int. 2007;27(10):927-33.