Polymyalgia Rheumatica

Wikis > Rheumatology > Polymyalgia Rheumatica

Relatively common clinical syndrome associated with ‘aching’ in the elderly – PMR is self limiting. Affects 1/200-1000 over the age of 50 (extremely rare <50yrs). F>M. Closely associated with temporal/giant cell arteritis where they are both possibly on the same continuum.

Characterised by severe pain/aching and stiffness in proximal muscle groups (shoulders and hips). Scintigraphy and thermography show involvement of hip and shoulder joint  suggests low-grade synovitis.

Unknown. Strong genetic predisposition (HLA-DR4), but no immune abnormalities have been detected yet.

Clinical features:
More common in elderly Caucasian woman. Onset may be acute or subacute/insidious – initial diagnosis may take several months. Prolonged morning stiffness is a cardinal feature.
Severe pain/disability and stiffness in neck, pectoral and pelvic girdles (symmetrical and bilateral) – usually insidious in onset; morning stiffness; stiffness after inactivity; poorly localised tenderness over joints (especially hips and shoulders); pain at night - may awaken patient; muscle strength is unaffected; malaise; fever; mild depression; fatigue; weight loss; raised alkaline phosphatase and ESR.
Up to 50% may have another diagnosed rheumatological condition  PMR may go unrecognised or undiagnosed.
Diagnosis is based on history and clinical examination (laboratory tests will rule out other causes of symptoms).

Differential Diagnosis:
Early rheumatoid arthritis, shoulder disorder; osteoarthritis, inflammatory muscle disorder, hypothyroidism malignancy

Diagnostic criteria:
Bilateral shoulder or hip pain or stiffness; onset of illness < 2 weeks; elevated ESR; morning stiffness; 65+ years of age; depression and/or weight loss; exclusion of other causes.Treatment: Reassurance and education. Usually follows a benign course  most complete resolution within 2 years, but some develop giant cell arteritis (could be up to 30%). ESR can be used to monitor progress and response to treatment. NSAID’s in first 4 weeks – only effective in up to 20% Low dose prednisone is usual drug of choice – immediate and dramatic response to small dose is often considered to be diagnostic (often only effective treatment) Physiotherapy – especially range of motion exercises; strengthening weakened muscles; management of unsteady gait.

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