Polymyalgia Rheumatica

Original Editors - Nicki Spencer from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Nicki Spencer, Naaike Verhaeghe, Claire Knott, Admin, Elaine Lonnemann, Kim Jackson, Rachael Lowe, Ines Musabyemariya, 127.0.0.1, Wendy Walker, Evan Thomas, Ina De Maeyer and WikiSysop

Definition/Description 

Polymyalgia rheumatica (PMR) is a rheumatic inflammatory disorder that has an unknown cause. It causes inflammation of the large muscles of the body and can be accompanied by systematic symptoms including malaise, fatigue, fever, and weight loss. In patients with PMR, the synovial membranes and bursae that line and lubricate the joints become inflamed, causing pain and discomfort. Unlike in some other inflammatory diseases, there is no associated permanent damage to the joints or the muscles. Polymyalgia rheumatic is also known as muscular rheumatism. PMR is a heterogeneous disease with a major impact on QOL.

Clinically Relevant Anatomy

PMR is a condition that causes many (poly) painful muscles (myalgia). PMR characteristically presents with pain and stiffness in the shoulder and hip girdles and an elevated acute phase response.

Epidemiology/etiology

Although polymyalgia rheumatic occurs worldwide, the highest incidence is seen in Scandinavian countries and in people of the northern European descent. [16] In the United States the lifetime risk of developing PMR is estimated at 2.43% for women and 1.66% for men. The lowest incidence rates occur at the more southern European countries like Italy, and Spain.

PMR is most commonly diagnosed in persons over the age of 50, PMR has a prevalence of approximately 7 in 100 for people over 50 years of age and 4 in 10,000 in adults over 60 years of age. The prevalence is gender dependent with the ratio of men to women affected 1:2. The disease is more common in Caucasian.

Some of the characteristics of PMR suggest that infectious disease expose could be an environmental factor. The disease has a very sudden onset and new cases occur in cycles, which could indicate an infection as the source. Attention has been focused on Chlamydia, Mycoplasma, parainfluenza virus or parvovirus B19 as possible infections responsible for developing PMR. Inheritance of the disorder has been suggested due to findings in some genetic studies and the pattern seen in family histories. The gene(s) that could be responsible for PMR have not been definitively identified. The HLA-DRB104 and HLA-DRB01 alleles have both been found to have a possible link to PMR and GCA although this remains controversial.

There may be an imbalance between immunosuppressive T-regulatory (Treg) lymphocytes and proinflammatory T-helper 17 (Th17) cells in PMR and giant cell arteritis (GCA). The frequency of Treg cells circulating appears to be reduced in patients with PMR compared with aged-matched volunteers. While on the other hand TH17 cells appear to be increased.

    

Characteristics/Clinical Presentation

   

The onset of PMR is very sudden. Individuals can usually remember the exact time and day that symptoms began. Individuals often wake up one morning with extreme stiffness and soreness for no apparent reason. Synovitis and bursitis of the shoulder and hip are the cause of the patient's pain and symptoms are typically bilateral

Other symptoms that are found in 40-50% of patients and include:
• stiffness after rising in the morning lasting 30 min or longer or after resting
• weakness
• fatigue
• malaise
• low-grade fever
• sweats
• headache
• weight loss
• depression
• vision changes

The symptom pattern is characteristic to PMR, although, several other autoimmune, infectious, endocrine and malignant disorders can present with similar symptoms. Ruling out the other illnesses is very important.

Differential Diagnosis

There are many conditions that can mimic PMR, like rheumatoid arthritis (RA) and spondyloarthropathies (SpA). Pain and swelling of the distal joints, like feet, hands and wrists should raise concern for an inflammatory arthritis. Some patients may present swelling and pitting edema of the hands and the feet, because of a tenosynovitits. The so called remitting seronegative symmetrical synovitis with pitting edema syndrome.

PMR must be differentiated from :

Rheumatological diseases such as:

• Rheumatoid Arthritis
• Spondyloarthropathy
• Crystalline arthritis (calcium pyrophosphate disease and calcium hydroxyapatite disorders)
• Remitting seronegative symmetric synovitis with pitting oedema syndrome
• Connective tissue diseases
• Vasculitis (giant cell arteritis, antineutrophil cytoplasmic antibody-associated vasculitis).
• Inflammatory myopathies (dermatomyositis, polymyositis )

Non-inflammatory musculoskeletal disorders such as

• Rotator-cuff diseases (rotator cuff tears, rotator cuff tendinopathy)
• Adhesive capsulitis
• Degenerative joint disease (degeneratieve disc disease)
• Fibromyalgia
• Endocrinopathies
• Thyroid diseases
• Disorders of the parathyroid gland
• Infections - viral or bacterial i.e. sepsis, ends carditis, septic arthritis
• Mycobacterial – eg tuberculosis
• Malignant diseases
• Parkinsonism
• Depression
• Hypovitaminosis D
• Drug-induced myopathy-eg, from statins

Diagnostic Procedures & Treatment

Polymyalgia rheumatica is a clinical diagnosis . A careful history and physical examination are crucial in distinguishing this syndrome from other disorders that may present similarly, especially seronegative RA and paraneoplastic syndrome. Laboratory findings are non specific and show characteristic features of systemic inflammation. These include; anaemia, leukocytosis and raised markers of inflammation (ESR and CRP) and sometimes liver tests such as transaminases or alkaline phosphatase are raised. Some clinicians use an erythrocyte sedimentation rate (ESR) of higher than 30 or 40 mm/hr as a diagnostic criterium; however, 6-20% of patients with the disease have a normal sedimentation. Auto-antibodies including rheumatoid factor and antibody to cyclic citrullinated peptide, are usually negative, and if positive, RA must be considered.

Shoulder, hip, neck and upper arm pain associated with PMR is usually bilateral and symmetrical. Tenderness to palpation is expected however muscle weakness is not a feature of PMR. Usually, there will be minimal muscle atrophy unless the disease progression is advanced, when disuse atrophy can occur. Active range of motion is generally reduced due to pain. The 24-hour picture pattern of PMR typically presents with severe morning stiffness that improves somewhat by the evening and following periods of rest. Pain may radiate and mild synovitis may be seen in the wrist and knees. Associated systemic symptoms may include fatigue, fever and weight loss.

Radiographs of the affected joints in PMR are only useful for excluding alternative conditions. In the classification study of the EULAR/ACR, they found a high specificity for ultrasonography for discriminating PMR from other shoulder conditions (89%), but not for discriminating PMR from RA (70%)

Ultrasound (US) may be of value in the diagnosis of PMR. Shoulder abnormalities found using US, such as bursitis and tenosynovitis of the long head of the biceps tendon, is more likely to be seen in patients with PMR. However, in the absence of suggestive clinical features, the presence of isolated US abnormalities should not lead to a diagnosis of PMR.

Diagnostic Criteria

There are two sets of diagnostic criteria that have been created for PMR.

The Bird/Wood criteria, which includes:

• Bilateral shoulder stiffness
• Duration onset < 2 weeks
• Initial ESR > 40 mm/hour
• Stiffness > 60 minutes
• Age > 65 years
• Depression and/or weight loss
• Bilateral upper arm tenderness

If any 3 or more of the above criteria, or greater than 1 criteria and a clinical abnormality of the temporal artery, are present in a patient then PMR is probable. Definite PMR is characterised by probable PMR that has a positive response to corticosteroid therapy.

The Hunder criteria, which includes:

• Patient age > 50 years
• Bilateral aching and tenderness for > 1 month of neck or torso, shoulders or upper arms, and hips or thighs
• ESR > 40 mm/hour
• Exclusion of other diagnoses
All the above Hunder criteria must be present to have a diagnosis of definite PMR.
Both of the above criteria have been found to have a sensitivity of >90%.

The European League Against Rheumatism and American College of Rheumatology have developed classification criteria rather then diagnostic criteria, which must still be validated, and can only be applied to patients in whom new-onset bilateral shoulder pain is not attributable to an alternative diagnosis:

The European League Against Rheumatism and American College of Rheumatology provisional criteria for classification of polymyalgia Rheumatica

Clinical criteria for scoring algorithm

2 points - Morning stiffness lasting more than 45 min                                                                                                                        
1 point - Hip pain or restricted range of motion                                                                                                                              
2 points - Absence of rheumatoid factor and antibody to cyclic citrullinated peptide                                                                    
1 point - Absence of other joint involvement                                                                                                                                      

Ultrasound criteria for scoring algorithm

1 point - At least 1 shoulder with subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis;

and at least one hip with synovitis or trochanteric bursitis                      

1 point - Both shoulders with subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis                                              

Requirements of application:

• age 50 years or older
• bilateral shoulder pain
• abnormal ESR, C-reactive protein, or both. With only clinical criteria, a score of greater than 4 had a sensitivity of 68 % and a specificity of 78 % for discriminating polymyalgia rheumatic form comparison patients.
  With combination of clinical criteria and ultrasound criteria, a score of greater than 5 had a sensitivity of 66 % and specific of 81 % for discriminating patients with the disorder from comparison

     

Medical Management

As stated above in the Medications section, PMR is generally treated with a long course of corticosteroids. Depending on the facility, the course of treatment will differ. There is no consensus on the initial dosage and subsequent tapering of corticosteroids. Some suggest an initial dose of 15-20 mg/day of prednisone and then a slow tapering over several weeks or months to find a maintenance dosage.[5]
If the patient also has GCA, then the initial dose of prednisone is much higher (usually 1 mg/kg of body weight).[5] GCA in the temporal artery is a serious medical condition and could result in blindness if not treated appropriately and quickly.
Although PMR responds very well to corticosteroids, there is still concern for the adverse effects that occur with long-term steroid use. This includes diabetes, osteoporosis, hypertension, worsening of cataracts, muscle weakness, and infection. Patients taking corticosteroids must have their blood sugar, blood pressure, and body weight routinely checked. Due to the increased risk for osteoporosis, vitamin D and calcium supplements should be initiated when the corticosteroids are initiated.[5]
Standard initial treatment
Oral prednisone: 15 mg per day for three weeks, then 12.5 mg per day for three weeks, then 10 mg per day for four to six weeks, then decrease by 1 mg every four to eight weeks.
Expected duration of treatment one to two years of treatment.
Alternate treatment
Intramuscular methylprednisolone (Depo-Medrol): depot formulation, 120 mg every three to four weeks; decrease by 20 mg every two to three months. [25]
Medications
Corticosteroids
If PMR is suspected to be the probable diagnosis for a patient, then a trial of low-dose corticosteroids (usually prednisone) is given. The response to corticosteroids is usually dramatic, and patients may report relief in symptoms after one dose. If symptoms are not better within 2-3 weeks of beginning the corticosteroid treatment, it is unlikely that the individual actually has PMR and more testing should be performed to find an appropriate diagnosis.[6]
If the patient has a favorable response to corticosteroids, they will continue to take a maintenance dosage for approximately 6 months to 2 years.[4] This maintenance dosage can help control the pain and stiffness associated with PMR. Over that time period, the dosage is gradually decreased until it is no longer needed. Complete clinical remission may take up to 5 years to occur.[4]
• Prednisone
Prednisone is a corticosteroid. Our own body makes this hormone in the adrenals. In drug form it is called prednisone or prednisolone. This hormone has a strong anti-inflammatory effect. In general, the symptoms disappear very fast, when using this drug. The Prednisone dose is basically 15mg a day. [11]
The use of prednisone can give a lot of side-effects, such as:
• Increased blood pressure
• Osteoporosis
• Increasing weight
• Gastrointestinal complaints
• Insomnia
• Blurred vision
• Steroid myopathy is usually an insidious disease process that causes weakness mainly to the proximal muscles of the upper and lower limbs and to the neck flexors.[39]

Because there is a long term use of prednisone, it is important that there is a check-up whether the patient suffers from one or more side-effects. If you suffer from osteoporosis, the doctor will prescribe you medications to counter osteoporosis, such as: [11]
• Calcium
• Vitamin D
• Biphosphonate (usually).

Methotrexate (Trexall)

This immune- suppressing medication may help lower the dose of corticosteroid that’s needed, which can help preserve the bone mass. It’s often given long term, for a year or more. [12]
Anti-TNF Drugs
TNF (= tumor necrosis factor) is a substance that causes inflammation. These drugs block that substance and reduce inflammation. Research results have been mixed on using these medications in PMR, but they might be helpful for people who can’t take corticosteroids, such as people with diabetes or osteoporosis. [12]
NSAID’s
NSAID’s (= Non steroid anti-inflammatory drug) are anti-inflammatory painkillers without hormones. These drugs reduce the pain, stiffness and the inflammation. An NSAID has less side effects than prednisone and it is easier to reduce the use. [11]
The use of prednisone gives better results. [11]
 

Medical Management (current best evidence)

     As stated above in the Medications section, PMR is generally treated with a long course of corticosteroids.  Depending on the facility, the course of treatment will differ.  There is no consensus on the initial dosage and subsequent tapering of corticosteroids. Some suggest an initial dose of 15-20 mg/day of prednisone and then a slow tapering over several weeks or months to find a maintenance dosage.

     If the patient also has GCA, then the initial dose of prednisone is much higher (usually 1 mg/kg of body weight). GCA in the temporal artery is a serious medical condition and could result in blindness if not treated appropriately and quickly.

     Although PMR responds very well to corticosteroids, there is still concern for the adverse effects that occur with long-term steroid use.  This includes diabetes, osteoporosis, hypertension, worsening of cataracts, muscle weakness, and infection.  Patients taking corticosteroids must have their blood sugar, blood pressure, and body weight routinely checked. Due to the increased risk for osteoporosis, vitamin D and calcium supplements should be initiated when the corticosteroids are initiated.

Physical Therapy Management (current best evidence)

   There is currently no evidence for the use of physical therapy in the treatment for PMR. However, as physical therapist, it is still important to be aware that patients may be referred to you with a primary diagnosis of PMR, or as a co-morbidity. It is extremely important to be aware of the risk for developing GCA because, as stated above, this is a medical emergency (red flag). See the Co-Morbidities section above for the associated signs/symptoms of GCA.
If a patient with PMR begins to have increased complains of muscle pain and stiffness, it is important to ask them if they are still taking their corticosteroids as prescribed. These medications must be tapered appropriately. Patients may not be fully aware of that and may end their medications prematurely.[4: LOE 5]
Long-term corticosteroid use also leads to many side effects, such as weight gain, cataracts, mood swings, rounding of the face, difficulty sleeping, glaucoma, diabetes, easy bruising, and hypertension. Osteoporosis and compression fractures can also be of great concern with these patients.[4: LOE 5]
Patients may also come into the clinic with a missed diagnosis of PMR. It is important to keep the signs/symptoms and diagnostic criteria of PMR in mind so that patients get the appropriate treatment they need.
Physical therapy should be a regular part of any therapeutic regimen in order to reduce the risk of early functional impairment and severe disability in older patients. [30: LOE 3B]
Objectives and expected outcomes:
- Pain reduction
- Reduction of joint swelling or inflammation
- Maintain or gain strength
- Enhance joint integrity and stability
- Better ROM
- Improve endurance for functional activities
- Independence for ADL's
- Gait (safe and efficient)
- Enhance functional mobility
- Boost quality of life
- Self management
Interventions:
- ROM/Flexibility: range of motion exercices and exercise programs can delay the loss of joint function, for reducing stifness, improve the pain and maintain muscles. (Stretching, yoga, pilates,.... 10-15minutes; 2 times a week). They should be done daily to derive the maximum benefit. [31: LOE 5]
- Applications: heat, ice, massage, ultrasound, hydrotherapy and electrotherapy may be used to reduce pain and improve joint movement. As complementary therapy spa therapy is very popular. The main goals are to relieve pain, to improve functional capacity, to increase the awareness and knowledge of patients about their disease, to help the patients in learning the strategies needed to cope with the problems related to their chronic disease, and to improve health-related quality of life in general. As a rehabilitation and treatment method, spa therapy possibly meets all these goals when it is performed in a comprehensive manner based on a combination of physical therapy and a routine spa treatment program. [32: LOE 2B] [33: LOE 2A] [34: LOE 2A]
- Joint protection: assistive devices, splints or orthotic gear to support and align joints may be very helpful.
- Energy conservation: frequent rest periods between activities, as well as 8-10 hours sleep per night, are recommended.
- Aerobic endurance: aerobic capacity/endurance conditioning. (Cycling, walking, swimming,.... 60-80% HR Max, 30-60 min/session, 3-5 days a week; Increase duration, then intensity over time.)
- Therapeutic exercise: gait training, balance, aquatic programs, range of motion techniques, stretching, strength, power and endurance training. (One leg stance, stability ball, strengthening core muscles (on regular basis). Free weights, weight machines, therabands. 60-80% 1RPM, 8-10 exercises (large muscle groups), 8-12 repetitions, 2-3 sets, increase intensity over time).
- Functional training: ADL's, task adaptation, injury prevention.
- Manual therapy: passive range of motion, soft tissue mobilization.
- Patient education
- Lifestyle changes: physical activity, dietary and emotional changes.
Expert opinion recommends physiotherapy for some patients who have difficulty regaining mobility . [19: LOE 2A] There are no studies found which focus primary on the effectiveness of ROM exercices. [27: LOE 5]

Case report
Polymyalgia rheumatic and exercise: a single case report on one woman: [9: LOE 4]
This article describes the outcomes that resulted from exercise participation in one woman with PMR. The exercise program involved aerobic, muscle strength/endurance, and range-of-motion training 3 days per week for approximately 15 months. Additionally, health education and resource support were provided. Data indicate that she improved on various fitness measures and in quality of life during the course of the study, and she felt that her activities of daily living were enhanced. Also, she wanted to continue the program. Outcomes from this study should motivate others with PMR to become physically active until more is known about the effects of exercise on PMR.
•patient education. [26: LOE 2A] [27: LOE 5] ,forms an important part of management for the patient. An ARC ( Arthritis Reasearch UK) patient information booklet is available; [26: LOE 2A]
• ultrasound : Based on the currently available evidence and best practice, the guideline development team neither recommends nor discourages the use of mechanical energy delivered by means of ultrasound (1 or 3 MHz) to improve functional status and reduce pain and disease activity in patients with RA [27: LOE 5]
• Combination treatment : the guideline development team recommends the use of a combination of exercise therapy and education to improve the functional status of patients with RA. [27: LOE 5]
•TENS: Based on the currently available evidence and best practice, the guideline development team neither recommends nor discourages the delivery of electric energy by means of TENS to reduce pain in patients with RA. [27: LOE 5]
•mind techniques : relaxation technique, learning to de-stress : Yoga [11: LOE 5]

Key evidence

•Polymyalgia rheumatic and exercise: a single case report on one woman[9] [view article in EBSCOhost]
•Isolated lower extremity vasculitis in a patient with polymyalgia rheumatica[10] [view article in EBSCOhost

Resources

• American College of Rheumatology-http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/polymyalgiarheumatica.asp
• National Library of Medicine - http://www.nlm.nih.gov/medlineplus/polymyalgiarheumatica.html
• National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse -http://www.niams.nih.gov/Health_Info/Polymyalgia/default.asp
• Arthritis Foundation - http://www.arthritis.org/conditions/diseasecenter/pmr.asp
• Anatomy and diseases http://vidvarious.com/polymyalgia-symptoms.html
• Arthritis Research UK. http://www.arthritisresearchuk.org/shop/products/publications.aspx

. Clinical Bottom Line

Polymyalgia rheumatica (PMR) is a rheumatic inflammatory disorder that has an unknown cause. PMR affects mostly people over the age of 50 years old.[1] Classic symptoms are pain and stiffness; often symmetric and bilateral of the neck, shoulder girdle, and pelvic girdle. There are no validated international guidelines available for the diagnosis and treatment of PMR; however, diagnostic and classification criteria are currently being developed. PMR is a diagnosis of exclusion.[3] There are no definitive diagnostic tests to identify PMR[4]. There are several other disorders that can mimic polymyalgia Rheumatica. PMR is generally treated with a long course of corticosteroids. There is no consensus on the initial dosage and subsequent tapering of corticosteroids. There is currently no evidence for the use of physical therapy in the treatment for PMR. However, a physical therapist is recommended for patients who have difficulty regaining mobility and it is also important to reduce the risk of early functional impairment. A combination of exercise therapy and education is recommended in the treatment of PMR.

Recent Related Research (from Pubmed)

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1V1PUFNy3O6tKlb_wM_OLWVmHI1Z25TGe1smLjxLo2b9z88s0s: Error parsing XML for RSS

References

• [1]↑Goodman, Snyder. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis Missouri. 2007.
• [2]↑LeGrove L. Polymyalgia rheumatica: management guidelines. Practice Nurse [serial online]. May 8, 2009;37(9):33-37. Available from: CINAHL with Full Text, Ipswich, MA. Accessed April 4, 2011.
• [3]↑Siebert S, Lawson T, Wheeler M, Martin J, Williams B. Polymyalgia rheumatica: pitfalls in diagnosis. Journal Of The Royal Society Of Medicine [serial online]. May 2001;94(5):242-244. Available from: MEDLINE, Ipswich, MA. Accessed April 5, 2011.
• [4]↑Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis: Saunders Elsevier; 2009. (LOE 5)
• [5]↑Nothnagl T, Leeb B. Diagnosis, Differential Diagnosis and Treatment of Polymyalgia Rheumatica. Drugs & Aging [serial online]. May 2006;23(5):391. Available from: Academic Search Premier, Ipswich, MA. Accessed April 5, 2011.
• [6]↑merican College of Rheumatology: Polymyalgia rheumatica.http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/polymyalgiarheumatica.asp. Accessed March 31, 2011.
• [7]↑ Soubrier M., Dubost J., Ristori J. Polymyalgia rheumatica: diagnosis and treatment. Joint Bone Spine. October 2006;73:599-605. Available online:www.sciencedirect.com. Accessed March 31, 2011.
• [8] Mayo Clinic: Polymyalgia rheumatica.http://www.mayoclinic.com/health/polymyalgia-rheumatica/DS00441. Accessed March 31, 2011.
• ↑ [9] Karper W. Polymyalgia Rheumatica and Exercise: A Single Case Report on One Woman. Activities, Adaptation & Aging [serial online]. October 2009;33(4):256-262. Available from: Academic Search Premier, Ipswich, MA. Accessed April 6, 2011. (LOE 4)
• ↑ [10] Kermani T, Warrington K. Images in vascular medicine: Isolated lower extremity vasculitis in a patient with polymyalgia rheumatica. Vascular Medicine [serial online]. April 2010;15(2):135-136. Available from: Academic Search Premier, Ipswich, MA. Accessed April 6, 2011.
• [11] Reumafonds: polymyalgia rheumatica. http://www.reumalier.be/PDF-FILES/112.juli13_BS_Polymyalgia_Reumatica.pdf. Accessed July 2013. (LOE 5)
• [12] Mayo Clinic: Polymalgia rheumatica: http://www.mayoclinic.org/diseases-conditions/polymyalgia-rheumatica/basics/treatment/con-20023162. Mayo Clinic Family Health Book, 4th edition., 1998-2015.
• [13] Tanza A Kermani et al, Polymyalgia rheumatic, Lancet 2013 : 381 : 63-72.LOE : 2A
• [14] Kalke S et al, A study of the health assessment questionnaire to evaluate functional status in polymyalgia rheumatic. Rheumatology (Oxford) 2000 : 39 : 883-85. LOE : 2C
• [15] Migual A. et al, Giant cell Arteritis and polymyalgia Rheumatica : an Update, Curr Rheumatol Rep. (2015) 17 : 6. LOE : 2A
• [16] Gonzalez-Gay MA et al . Epidemiology of Giant cell Arteritis and polymyalgia Rheumatica , Arthritis Rheum 2009 : 61 : 1454-612. LOE : 2A
• [17] Gonzalez-Gay MA. Giant cell Arteritis and polymyalgia Rheumatica : two different but often overlapping conditions. Semin Arthritis Rheum 2004; 33: 289-93. LOE : 2A
• [18] Sakellariou G et al, Ultrasound imaging for the rheumatologist XLIII. Ultrasonographic evaluation of shoulders and hips in patients with polymyalgia rheumatica: a systematic literature review. Clin. Exp. Rheumatol. 2013;31:1-7. LOE : 3A
• [19] Clement J michet etal . Polymyalgia rheumatic . BMJ 2008;336. (LOE: 2A)
• [20] Dasgupta B et al ,2012 provisional classifi cation criteria for polymyalgia rheumatica: a European League Against Rheumatism/ American College of Rheumatology collaborative initiative, Ann Rheum Dis 2012; 71: 484-92 LOE : 5
• [21] Dasgupta B et al ,2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative., Arthritis Rheum, 2012;64:943-54 LOE : 5
• [22] Hutchings A et al, Clinical outcomes, quality of life, and diagnostic uncertainty in the first year of polymyalgia rheumatica., Arthritis Rheum. 2007 Jun 15;57(5):803-9 LOE: 2a
• [23] Sara Muller et al., The epidemiology of polymyalgia rheumatica in primary care: a research protocol, BMC Musculoskelet Disord. 2012; 13: 102. LOE: 2a
• [24] Ameer F. et al., polymyalgia rheumatic: clinical update, Aust Fam Physician. 2014 Jun;43(6):373-6. LOE: 4
• [25] Tonya L., Recognition and Management of Polymyalgia Rheumatica and Giant Cell Arteritis, Am Fam Physician. 2013 Nov 15;88(10):676-684. LOE: 2a
• [26] Bhaskar Dasgupta ET AL ? BSR and BHPR guidelines for the management of polymyalgia rheumatica ? Rheumatology Advance Access published November 12, 2009 (LOE: 2A)
• [27] ] KNGF-guideline for physical therapy in partients with rheumatoid arthritis. 2008 , volume118 https://www.fysionet-evidencebased.nl/images/pdfs/guidelines_in_english/rheumatoid_arthritis_practice_guidelines_2008.pdf (LOE : 5)
• [28] Advances and challenges in the diagnosis and treatment of polymyalgia rheumatica; Tanaz A. Kermani et al.; February 6 2014. LOE:2a
• [29] Giant-Cell Arteritis and Polymyalgia Rheumatica; Corneliam. Weyand, et al.; Juli 3 2014 LOE:2A
• [30] Wollenhaupt et al, Geriatric rheumatology: Special aspects of clinical diagnostics and therapy of rheumatic diseases in the elderly, 2000. (LOE 3B)
• [31] Rheuminfo: polymyalgia theumatica. http://rheuminfo.com/diseases/polymyalgia-rheumatica-pmr/treatment-polymyalgia-rheumatica-pmr. Accessed July 2013. (LOE 5)
• [32] Cimbiz et al, The effect of combined therapy (spa and physical therapy) on pain in various chronic diseases, 2005 (LOE: 2B)
• [33] Karagülle et al, Balneotherapy and spa therapy of rheumatic diseases in Turkey: a systematic review, 2004 (LOE: 2A)
• [34] A.P. Verhagen, S.M. Bierma-Zeinstra, J.R. Cardoso, R.A. de Bie, M. Boers, H.C. de Vet, Balneotherapy for rheumatoid arthritis, Cochrane Database Syst Rev, 4 (2003), p. CD000518. (LOE: 2A)
• [36]Arthritis New Zealand: http//www.arthritis.org.nz/wp-content/uploads/2012/06/4618_Polymyalgia_Flyer_4-1.pdf
• [37]Http://healthletter.mayoclinic.com/content/preview.cfm/n/276/t/Polymyalgia%20rheumatica/
• [38]Anatomy and diseases http://vidvarious.com/polymyalgia-symptoms.html