What does pmr stand for in medical terms

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Polymyalgia rheumatica - NHS.

 

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Polymyalgia rheumatica (PMR) | Causes, symptoms, treatments - What is rehabilitation?

 

Please show them the card — depending on what additional treatment you need, the steroid dose may need to be adjusted. Like all medicines, steroids can have side effects. One of the side effects of steroids is osteoporosis , which can cause bones to become thinner and then fracture. The nationally recommended treatment for this is medicine called bisphosphonates biss-foss-fo-nates. These are a group of drugs that can slow down or prevent bone loss. You can ask your doctor about treatment with bisphosphonates.

Examples include alendronate and risedronate. Painkillers , such as paracetamol, or short courses of non-steroidal anti-inflammatory drugs NSAIDs , such as ibuprofen or naproxen, can help ease pain and stiffness.

They can be taken at the same time as steroid tablets. There may be some situations where your doctor will want to prescribe a type of drug called a disease-modifying anti-rheumatic drug DMARD , alongside steroids. The specialist may decide to prescribe a DMARD alongside steroid tablets, which may help to reduce the inflammation and lower the steroid dose. An example is methotrexate. Steroid treatment is usually very effective at treating polymyalgia rheumatica. Ensuring you get enough calcium and vitamin D , and that you do some weight-bearing exercise will reduce the risk of getting osteoporosis.

Too much exercise is likely to make your symptoms worse, but activity usually helps to ease pain and stiffness in the muscles of the shoulders, hips and thighs. Physiotherapy , including range of movement exercises for the shoulders, can help to reduce pain and maintain mobility.

Weight-bearing exercise is good for maintaining bone strength and reducing the risk of osteoporosis. Weight-bearing exercise is anything like jogging, walking, tennis, dancing or lifting weights, where some force or the weight of the body is impacted on bones during the exercise.

This is in contrast to swimming, for example, where the water supports the weight of the body. Walking is usually the most suitable weight-bearing exercise for people with polymyalgia rheumatica. Sitting for any length of time may cause stiffness, making activities such as driving more difficult. Stop from time to time on a long journey to stretch your shoulders, arms and legs. Simple measures such as a hot bath or shower can help to ease pain and stiffness, either first thing in the morning or after exercise.

A pint of milk a day, together with a reasonable amount of other foods that contain calcium, should be enough. The best source of vitamin D is sunlight on bare skin. These can be bought from supermarkets and health food shops. You can also discuss this with a pharmacist.

There are some at risk groups who are advised to take vitamin D supplements all year round, including:. We explain which foods are most likely to help and how to lose weight if you need to. Find out more about exercising with arthritis and what types of exercises are beneficial for certain conditions.

I was 57 when I developed polymyalgia rheumatica and giant cell arteritis. I was head of news and current affairs at Channel Four television and a single parent of a child of It began with a very sore neck. Then my shoulders started to ache. On a few mornings, when I woke up, I found it difficult to move my arms, though my hands moved easily. The problem would wear off quickly, and I would forget about it. Although I was young to get the condition, I knew I had polymyalgia rheumatica, as my mother had it.

I was given a blood test to check inflammation levels and was put onto steroid tablets. My daughter was very upset and frightened. I would have to go to bed as soon as I got home. Sometimes during the day, I would get into my car in the car park and sleep.

When I was put on the correct dose of steroids I felt OK, but did cut back my social life a lot. Eventually, I developed a terrible headache and my jaw became very stiff. I knew at once this was giant cell arteritis. I had to immediately take a very large dose of steroids to prevent sight loss, which is a very real risk with GCA.

For two-and-a-half years I had to take steroids and then I was moved onto methotrexate for a year. I put on weight and my face took on a moon shape. I became tired much more easily. I found it really helpful to meet other people with the condition and swap experiences and ideas.

After three-and-a-half years, the condition went away. I came off the drugs. The new PMC design is here! Learn more about navigating our updated article layout. The PMC legacy view will also be available for a limited time. Federal government websites often end in. The site is secure. Polymyalgia rheumatica PMR is a unique disease of elderly people, traditionally diagnosed based on a clinical picture. A typical case is a combination of severe musculoskeletal symptoms and systemic inflammatory response with spectacular response to corticosteroids treatment.

The severity of symptoms may be surprising in older patients where immunosenescence is normally expected. However, PMR may be diagnosed in haste if there is a temptation to use this diagnosis as a shortcut to achieve rapid therapeutic success. Overdiagnosis of PMR may cause more problems compared to underdiagnosis. However, questions arise if this is possible in PMR. This has been discussed in this review. Polymyalgia rheumatica PMR is an auto-inflammatory rheumatic disease of people over 50 years, presenting with pain and stiffness in the neck, shoulder and hip girdles 1.

The term PMR was first used to underline that it seemed substantially milder from rheumatoid arthritis RA as no joint damage had been observed 2. However, this name may be misleading as PMR is a disease but not a non-specific myalgic or paraneoplastic syndrome. Secondary PMR does not exist. What makes PMR so special is a sudden onset of severe musculoskeletal symptoms that strongly reduce daily performance and quality of life, together with systemic inflammatory reaction in elderly but usually generally healthy patient, frequently accompanied by depressive reaction, lack of pathognomonic laboratory or radiologic findings, and splendid reaction to low-dose corticosteroids CSs.

Strong auto-inflammatory response is normally unexpected in an elderly patient, but immunosenescence 3 seems not to apply in PMR. Good prognosis is also surprising as there is no good explanation to the fact that PMR patients apparently live longer than matched controls 4 , 5.

Further, generally favourable outcome of PMR may be easily wasted in case of excessive CSs treatment, resulting in side effect that eventually worsens patient's quality of life 7. The aim of this review article is to discuss about correct diagnosis of PMR.

It is uncommon in India 8 , 9. The highest prevalence is found in Caucasians, in Northern European countries, especially in Scandinavia. Vikings' ancestry is associated with increased risk of PMR marked by migration from Scandinavia 10 , in Western European lands invaded by Normands 11 or Eastern European settled by Varangians The incidence grows with age, starting from 50 yr, with peak above 70 yr 5.

These have similar genetic background and epidemiology, and frequently overlap However, PMR represents a non-specific immune-mediated inflammatory reaction triggered by innate immunity activation. GCA is manifested by vascular inflammation caused by faulty adaptive immune reaction that is mainly T cell dependent The clinical outcome is so different that it is continuously debated why some patients express only one pathway. Evidence of vascular inflammation in needed to diagnose GCA. It is usually recorded in about 10 per cent of PMR patients 17 , but detailed vascular examination may substantially increase that percentage The historical term polymyalgia arteritica 19 might still be accurate because it underlines suspected vascular pathogenesis of PMR.

Silent vasculitis has been demonstrated in some of PMR patients Small CSs doses used for PMR do not suppress concomitant GCA although this is more generally accepted than proved opinion 21 that may progress to cause blindness. Differences in treatment strategy underlining the need for identifying concomitant giant cell arteritis GCA in patients with polymyalgia rheumatic PMR. Proximal, musculoskeletal pain and stiffness are the leading manifestations and these raise little doubts about the diagnosis in a typical PMR case.

However, PMR pivotal manifestations may be less specific: fewer or raised C-reactive protein CRP of unknown origin, general weakness, weight loss, depressive reaction, decompensation of chronic diseases e. There is no universal answer to this question. Although clinical presentation is typical, in some cases, the disease may be surprising. The best strategy is a combination of different approaches based on clinical picture, classification criteria, exclusions and ex juvantibus diagnosing , together with extensive diagnostics and follow up observation of atypical cases Ninety per cent of rheumatologists in the United Kingdom UK declare the use of the classification criteria for PMR diagnosis although they admit not to adhere to the guidelines to exclude other diseases This approach may be accepted only in countries with high incidence of PMR resulting in relatively low number of PMR mimics Clinical assessment is most important for PMR diagnosis.

Clinical manifestations come from a combination of musculoskeletal pain and stiffness and acute inflammatory response, which is quite different in elderly compared to young patients. It is difficult to find PMR case without bilateral pain and stiffness of muscles and joints of neck, shoulder and hip girdles.

Generalized musculoskeletal pain is not a PMR manifestation. Small joints involvement is also not typical but may be rarely found Shoulder girdle involvement usually appears first and may gradually extend to the area of neck and hip girdle.

Symmetrical involvement is typical. The pain worsens during the night, typically waking the patient from sleep between and h in the morning. Morning stiffness of more than one hour is more specific for PMR than the pain, but the pain is more commonly reported.

Pain may overwhelm the symptoms of stiffness. It is illustrated by the way patients get up out of bed: large joints stiffness makes them to rock the whole body to slip out beyond the edge of bed. However, after overcoming morning stiffness, patients can usually perform their daily activities fairly well. The feeling of stiffness can also reoccur during the day, after a period of immobility. In extreme cases, musculoskeletal stiffness may cause even a daylong immobilization.

However, the course may also be self-limiting. Patients report limb weakness by which they understand the limitation of motion due to stiffness and pain.

In contrast with polymyositis, PMR does not cause actual muscle weakness 24 , Bilateral tenderness of proximal muscles is a valuable sign both for the diagnosis and treatment monitoring. It is surprising in PMR patient as to how intense inflammatory reaction in elderly may manifest. However, it is also possible to cause anergy-like state with depressive reaction and cachexia. In both situations, PMR may be confused with symptoms of premature ageing both by patients and their physicians Acute or sub-acute onset of the disease up to 2 wk is characteristic, which means a sudden deterioration of daily performance and reduced quality of life.

Depressive reaction may be the first or the leading manifestation. Inflammatory reaction in elderly can manifest atypically, by reduction of psychomotor activity and decreased appetite. They can be difficult to differentiate from the endogenous depression. Pro-depressive characteristics of interleukin-6 IL-6 , which plays substantial role in PMR pathogenesis 31 , should be taken into account for a better explanation of this phenomenon Another reason for behavioural change in PMR patients may be an adaptive response associated with rapid deterioration of physical performance, causing anxiety of getting old and loosing self-reliance Weight loss is a common manifestation and may progress severely.

Low-grade fever and night sweats may persist for months. These are possible but frequently remain controversial. These include atypical musculoskeletal manifestations distal or asymmetrical joints involvement, sternoclavicular joints involvement, lack of shoulder girdle involvement, lack of morning stiffness , younger age at the disease onset, normal erythrocyte sedimentation rate ESR and CRP serum levels, lack of good response to CSs treatment 23 , Classification criteria are not developed for diagnosing but are generally used for this purpose.

Systems of classification of the diseases are demanded by clinical trials, public health and insurance systems. These criteria define most typical manifestation of the disease and provide an organized summary of its main manifestations. Yet, PMR is not a disease diagnosed by simple ticking signs and symptoms on a checklist. If it were so, a coincidence of depression and shoulder joints osteoarthritis OA in an elderly patient would be misclassified as PMR according to Bird's criteria.

The interpretation of the importance of complaints and findings in an individual patient by an expert remains fundamental for PMR diagnosis.

Shoulder girdle pain must have inflammatory character and depression cannot be endogenous to be accounted in Bird's criteria. Jones and Hazleman's criteria have a potential superiority in countries with low PMR prevalence as they have a higher specificity and include a list of most important exclusions.

These may only be applied in patients meeting preliminary criteria: age over 50 yr, bilateral shoulder aching, elevated CRP or ESR. These are a good example of classification philosophy to reduce heterogeneity of positively classified cases by selecting the subset of the most typical manifestations. Therefore, these criteria are not to be met in atypical cases of PMR.

On the other hand, these have a potential to reduce the rate of false positive diagnosis Source : Ref Musculoskeletal ultrasound gains importance in rheumatology. PMR criteria integrated ultrasonographic evaluation into classification process for the first time in rheumatology Ultrasound criterion requires examining both shoulders for glenohumeral synovitis, bursitis or biceps tenosynovitis and hips for joint synovitis or trochanteric bursitis.

The intention for this is assessment of the symmetry of changes between inflammatory changes in both shoulders and between upper and lower limbs involvement. Each of these will score an additional point to the scoring algorithm. Final sum of five out of eight 6 from algorithm without ultrasound plus 2 from ultrasound examination points enables to classify a patient as PMR with 66 per cent sensitivity and 81 per cent specificity Ultrasound evaluation is relatively simple to perform as the findings of merely the presence of joint effusion, tenosynovitis or bursitis are sufficient.

However, these abnormalities are hardly specific for PMR. A short ultrasound examination of proximal joints usually fails to demonstrate differences between inflammatory joint diseases. A more detailed ultrasound assessment can demonstrate joints' erosions and extensive synovial proliferation of both small and large joints that are more typical for RA.

Ultrasound can demonstrate degenerative or post-traumatic joint lesions as well as detect GCA overlap 40 Fig. Ultrasound examination of glenohumeral joint from axillary approach revealing no significant effusion inside a joint capsule bottom of the picture.

There are no pathognomonic antibodies or other PMR-specific markers discovered. Other acute phase markers fibrinogenemia, thrombocythemia and elevated IL-6, the latter correlates best with the disease activity 42 are also present. Anaemia of chronic disease type is common and is reversed shortly after CSs treatment initiation. Sometimes, slightly increased transaminases and alkaline phosphatase levels are present. Sparse studies indicated a significantly higher occurrence of anti-phospholipid antibodies, but these have not been proved to be associated with ischaemic or thromboembolic complications 42 , 43 , 44 , The benefits and drawbacks of classification criteria sets must be duly considered before applying them for diagnosis.

However, ESR, rheumatoid factor and ultrasound changes still have only limited specificity. The drawbacks of all of the PMR criteria sets are their unsatisfactory sensitivity and specificity.

They were also formulated in populations with a high PMR prevalence. If classification criteria are not met which usually takes place in atypical PMR , the disease should not be diagnosed hastly but only after excluding other causes of similar symptoms 23 , The need for considering PMR exclusions was underlined in the previous criteria 37 and is also found in the current guidelines The typical clinical picture of PMR requires only basic differential diagnostics.

The more atypical the clinical picture, the wider differential diagnostics is required. The differential diagnostics in countries with low PMR incidence requires considering the relatively higher number of PMR mimics.

It was illustrated in a study from Turkey that 30 per cent of patients with final PMR diagnosis were hospitalized, 30 per cent were treated with antibiotics, and in 29, 22 and 19 per cent abdominal, chest and brain computed tomography CT , respectively, were performed.

Why do PMR-like manifestations mask the symptoms of other diseases? PMR pathogenesis is mediated by innate immunity. It triggers non-specific inflammatory reaction which is not unique for PMR Acute inflammatory response can mask more characteristic symptoms of a disease that are not reported by patients. For example, elderly onset RA may go with systemic inflammatory manifestations and large joint involvement that cause patient immobilization.

Therefore, small joints inflammation is not reported by a patient whose main complaint is inability to get out of bed. Further, serious, GCA-associated ischaemic manifestations such as double vision or jaw claudication that are typical prodromal symptoms of vision loss can be unreported by patients seeking medical advice because of much more disturbing manifestations of overlapping PMR.

Paraneoplastic syndromes that can be manifested long before an appearance of symptoms associated with tumour growth may also be misclassified as PMR Differentiation between PMR and seronegative, elderly onset RA affecting proximal joints is actually a common reason for diagnostic uncertainty.

It may also be a case if bilateral painful shoulder syndrome coexists with depression and elevated ESR. Ultrasound examination of the shoulder joints may be helpful in determining the cause of the pain.

Diagnosing the sources of inflammatory reaction and mood disorders in the elderly may be demanding, requiring knowledge on geriatrics. Musculoskeletal symptoms resembling PMR may originate from myopathy due to hypo- or hyperthyroidism, CSs or statins use, amyloidosis; Addison's disease also adynamia suggesting depression and a good response to CSs 49 , Typical PMR age group is associated with a high risk of cancer.

Manifestations of PMR may also resemble paraneoplastic syndromes. However, PMR frequently starts suddenly and manifests more dynamically. Spontaneous remission, which can occur in PMR, is unusual for cancer. Attempts should be made to minimize this period by differential diagnostics and careful observation of atypical PMR cases Some of the PMR symptoms fever, night sweats and joint pain may suggest systemic lupus erythematosus or other autoimmune diseases and infectious diseases, including endocarditis or tuberculosis.

Focus on musculoskeletal pain can mask the endogenous or reactive depression being the real cause of deterioration of patient's state. Due to PMR and GCA overlap, physical examination of PMR patients should encompass temporal arteries for tenderness, loss of pulsation and large arteries analogically to Takayasu arteritis upper and lower limbs intermittent claudication, differences in blood pressure between both limbs, presence of vascular bruits.

Treatment-resistant PMR indicates a special need for imaging of large arteries for overlapping vasculitis. It may include ultrasound examination of temporal and large axillary, sub-clavian, common carotid arteries by a specialist experienced in differentiating vascular wall inflammation from arteriosclerosis, as well as assessment of the aorta and its branches with contrasted computed tomography CT , magnetic resonance imaging MRI or positron emission tomography PET with CT 52 , Lack of GCA manifestations at the time of PMR diagnosis should not stop the awareness of developing vasculitis during follow up.

PMR patients should be educated to immediately seek medical advice in case of vision disturbance double vision, transient ischaemic attacks , jaw claudication or scalp tenderness. Rapid and spectacular improvement shortly after CSs introduction enables concluding on a cause based on an observed response to the treatment. Therefore, PMR patients are much pleased shortly after treatment initiation and grateful to their doctors