What physiotherapy program should be initiated for a patient over 60 years old with polymyalgia rheumatica who is already on low‑dose glucocorticoids?

Physiotherapy Management of Polymyalgia Rheumatica

Initiate a structured physiotherapy program focused on individualized graded exercises targeting the upper limbs and shoulder girdle, combined with self-management education including pacing strategies and activity modification, as an adjunct to ongoing glucocorticoid therapy. 1

Evidence Base for Physiotherapy in PMR

The 2015 EULAR/ACR systematic review specifically examined non-pharmacological interventions added to glucocorticoids in PMR (PICO question 12), though the evidence base remains limited. 2 Despite this limited research, recent UK practice data demonstrates that 80% of physiotherapists advocate a role for physiotherapy in PMR management, with 90% promoting self-management approaches. 1

A critical caveat: Only 5.8% of UK physiotherapists had treated ≥10 PMR patients in the previous year, and only 38% received any pre-registration education about PMR, indicating significant underutilization and knowledge gaps in current practice. 1

Assessment Priorities

Before initiating treatment, establish the following in order of priority:

• Patient's knowledge and understanding of PMR - this is the top assessment priority according to practicing physiotherapists 1
• Current pain levels and their impact on function 1
• Ability to perform activities of daily living (ADLs), particularly those requiring upper limb function 1
• Range of motion limitations, especially in the shoulder and hip girdles 1

Core Treatment Components

Exercise Prescription

Prescribe individualized graded exercises with the following specifications:

• Primary focus on upper limbs and shoulder girdle - 89% of experienced physiotherapists prioritize this region 1
• Goals: Improve movement quality, increase muscle strength, and restore ADL function 1
• Progression: Graded approach that respects current pain levels and glucocorticoid-related side effects 1

The rationale for upper limb emphasis relates to the characteristic proximal muscle involvement in PMR, which affects the shoulder girdle more prominently in functional terms. 3, 4

Self-Management Education

Implement comprehensive self-management strategies including:

• Pacing techniques to manage energy expenditure throughout the day 1
• Activity modification to maintain function while respecting disease limitations 1
• Education about PMR natural history and the role of glucocorticoids 1

This approach aligns with the understanding that PMR symptoms often do not correlate directly with physical findings, making patient education crucial for appropriate activity management. 3

Integration with Medical Management

Physiotherapy should complement, not replace, glucocorticoid therapy. Glucocorticoids remain the cornerstone of PMR treatment, with most patients requiring low-dose corticosteroids for symptom control. 3, 4, 5 The physiotherapy program serves as an adjunct to optimize functional outcomes and potentially mitigate glucocorticoid-related adverse effects such as muscle weakness and deconditioning. 1, 5

Timing Considerations

Initiate physiotherapy once glucocorticoid therapy has achieved initial symptom control. While the exact onset of prednisone action varies by condition, clinical symptom control for inflammatory conditions typically requires 1-4 weeks. 6 Starting physiotherapy during this window allows exercise prescription when pain is manageable but before significant deconditioning occurs.

Monitoring and Adjustment

Regular reassessment should focus on:

• ADL function improvement, particularly upper limb activities 1
• Pain levels during and after exercise 1
• Exercise tolerance and progression capability 1
• Glucocorticoid-related side effects that may impact exercise capacity, including osteoporosis risk, muscle weakness, and cardiovascular effects 5

Important Clinical Pitfalls

Avoid these common errors:

• Delaying physiotherapy referral - despite evidence supporting its role, referrals remain infrequent in practice 1
• Prescribing generic exercise programs - PMR requires individualized graded approaches respecting the inflammatory nature of the condition 1
• Ignoring glucocorticoid side effects - exercise prescription must account for steroid-induced osteoporosis, muscle weakness, and other adverse effects 5
• Focusing solely on lower limbs - while hip girdle involvement occurs, upper limb and shoulder function are primary physiotherapy targets 1