What is the role of physical medicine and rehabilitation (PM&R) in the management of Polymyalgia Rheumatica (PMR)?

The Role of Physical Medicine and Rehabilitation in Polymyalgia Rheumatica Management

Physical medicine and rehabilitation (PM&R) interventions are recommended as supportive therapy in polymyalgia rheumatica (PMR) to maintain muscle mass and function, prevent falls, and reduce the risk of adverse events related to glucocorticoid use. 1

Rationale for PM&R in PMR Management

PMR is characterized by bilateral pain and stiffness in the shoulders, neck, and pelvic girdle, primarily affecting adults over 50 years of age. While glucocorticoids remain the cornerstone of treatment, they are associated with significant side effects, particularly with prolonged use. PM&R interventions can play a valuable complementary role in:

1. Mitigating glucocorticoid-related adverse effects
2. Maintaining functional capacity
3. Improving quality of life
4. Supporting long-term disease management

Specific PM&R Interventions

Exercise Therapy

• Muscle strengthening exercises: Focus on proximal muscle groups (shoulders, hips) to counteract muscle atrophy from both the disease and glucocorticoid treatment
• Range of motion exercises: To maintain joint mobility and prevent contractures
• Balance training: Critical for fall prevention, especially in elderly patients on long-term glucocorticoids who are at increased risk of osteoporosis 1

Functional Training

• Activities of daily living (ADL) training: To maintain independence despite pain and stiffness
• Energy conservation techniques: To manage fatigue associated with PMR
• Assistive device training: When appropriate for mobility and safety

Pain Management Modalities

• Heat therapy: To reduce morning stiffness and pain
• Gentle massage: For muscle relaxation
• Transcutaneous electrical nerve stimulation (TENS): For localized pain management

Implementation Timing

PM&R interventions should be considered:

1. Early in disease course: To prevent deconditioning and maintain function
2. During glucocorticoid tapering: To support patients through potential symptom flares
3. Long-term: For patients with chronic disease requiring prolonged glucocorticoid therapy 1

Clinical Considerations and Caveats

• Exercise intensity: Must be carefully calibrated to avoid exacerbating symptoms while still providing therapeutic benefit
• Monitoring: Regular assessment of functional status to adjust interventions as needed
• Integration with medical therapy: PM&R should complement, not replace, appropriate pharmacological management with glucocorticoids and potentially methotrexate or other DMARDs 2, 3
• Individualization: Exercise programs must account for comorbidities common in the elderly PMR population

Research Gaps

The 2015 EULAR/ACR guidelines specifically highlight the need for more research on non-pharmacological therapies in PMR, noting that while physiotherapy is assumed to be beneficial, robust evidence demonstrating its specific effects on outcomes is still lacking 1. The research agenda specifically calls for studies to evaluate:

1. The value of physiotherapy in preserving function
2. The role of exercise in maintaining muscle mass
3. The effectiveness of fall prevention strategies
4. The potential benefits of dietary interventions and nutritional supplements 1

Practical Implementation

While awaiting more definitive evidence, clinicians should consider:

• Referring PMR patients to physical therapy early in their treatment course
• Encouraging regular, gentle exercise appropriate to the patient's capabilities
• Educating patients about the importance of maintaining physical activity despite pain and stiffness
• Monitoring for and addressing functional limitations that may develop during the course of the disease

By incorporating PM&R approaches alongside appropriate pharmacological management, clinicians can help optimize outcomes for patients with PMR, potentially reducing disability and improving quality of life.