Friday, 18 March 2016

Most Common Disease of elder: The Clinical trials and Studies of Musculo-Skeletal disorders(MSDs) - Polymyalagia Arthritis (Rheumatica): The Diagnosis

Kyle J. Norton (Scholar)

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Musculoskeletal disorders (MSDs) are  medical condition mostly caused by work related occupations and working environment, affecting patients’ muscles, joints, tendons, ligaments and nerves and developing over time. A community sample of 73 females and 32 males aged 85 and over underwent a standardised examination at home. Musculoskeletal pain was reported by 57% of those interviewed(1).

      Types of Musculo-Skeletal disorders in elder(2)

1. Osteoarthritis
2. Gout
3. Rheumatoid Arthritis
4. Polymalagia Arthritis
5. Cervical myleopathy and spinal canal stenosis
6. Osteoporosis
7. Low back pain
8. Fibromyalgia


                  Polymyalagia Arthritis (Rheumatica)

Polymalagia Arthritis is defined as a condition a common inflammatory rheumatic disease which causes pain, stiffness and tenderness in large muscles, including muscles shoulders and pelvic girdle as a result of the presence of a synovitis in proximal joints and periarticular structures.
                                           The Diagnosis 

There is no specific test to diagnose polymyalgia rheumatica. If you are over age of 60 with some of the symptoms mentioned above without joint swelling, Joint tenderness, decreased range of motion in joints, Visible joint damage, etc., you may be already on the early onset of Polymyalgia Rheumatica(PMR)
Dr. Loeslie V said, ..." diagnosis of rheumatologic disorders in the elderly is often complicated " (due to) "clinician’s inability to differentiate among similar manifestations of rheumatologic disorders, the presence of comorbid conditions, and symptoms attributed simply to aging"(76).

1. Blood test
a. Erythrocyte sedimentation rate (ESR) is the blood test to exam the red blood cells in a test tube. he higher the ESR value is an indication of inflammation. Requisite indication of erythrocyte sedimentation rate (ESR)>40 mm/h is considered an important for the diagnosis of polymyalgia rheumatica (PMR)(78). Error reading may occur, normal erythrocyte sedimentation rate (ESR) reading has found to presence to approximately one-fifth of all PMR patients, more commonly in men(77).  A patient with PMR with an ESR lower than 40 mm/h is rare but has happened to men of that represent a clinically less severe than the classic form of PMR(78).

b. C-reactive protein (CRP)
Blood test measures the levels of C-reactive protein (CRP) produced by the liver in response to an injury or infection and people with polymyalgia rheumatic.Patient with PMR are associated to elevation of levels of both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)(79).

c. Blood test for thrombocytes
Patient with polymyalgia rheumatica have an unusually high number of thrombocytosis. On the other hand, People with anemic polymyalgia rheumatica have a lower number of red blood cells than normal. The associated of thrombocytosis acted as  an inflammation parameter to rheumatic diseases such as Rheumatic Polymyalgia is found to be correlated to disease activity(81)

d. Rheumatoid factor (RF)
RF is an antibody, a protein made by the immune system presented in the blood of people with rheumatoid arthritis, but not in the blood of people with polymyalgia rheumatica(82).

2. Biopsy
Polymyalgia rheumatica is often associated with giant cell arteritis with biopsy by taking a small sample from the scalp artery in the emporal artery and examined under a microscope in a laboratory(83). The biopsy would be helpful to rule the presence of giant cell arteritis through observation of abnormal cells in the artery walls

The Southend University Hospital diagnosed criteria of PMR include "patients ≥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness >45 minutes, elevated C-reactive protein and/or erythrocyte sedimentation rate, and new hip pain"(80).

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(76) Pain in the elderly: polymyalgia rheumatica by Loeslie V1.(PubMed)
(77) Polymyalgia rheumatica in patients with a normal erythrocyte sedimentation rate by Helfgott SM1, Kieval RI.(PubMed)
(78) Polymyalgia rheumatica without significantly increased erythrocyte sedimentation rate. A more benign syndrome by González-Gay MA1, Rodríguez-Valverde V, Blanco R, Fernández-Sueiro JL, Armona J, Figueroa M, Martínez-Taboada VM.(PubMed)
(79) Diagnosis, differential diagnosis and treatment of polymyalgia rheumatica by Nothnagl T1, Leeb BF.(PubMed)
(80) 2012 Provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative by Dasgupta B1, Cimmino MA, Kremers HM, Schmidt WA, Schirmer M, Salvarani C, Bachta A, Dejaco C, Duftner C, Jensen HS, Duhaut P, Poór G, Kaposi NP,Mandl P, Balint PV, Schmidt Z, Iagnocco A, Nannini C, Cantini F, Macchioni P, Pipitone N, Del Amo M, Espígol-Frigolé G, Cid MC, Martínez-Taboada VM,Nordborg E, Direskeneli H, Aydin SZ, Ahmed K, Hazleman B, Silverman B, Pease C, Wakefield RJ, Luqmani R, Abril A, Michet CJ, Marcus R, Gonter NJ, Maz M,Carter RE, Crowson CS, Matteson EL.(PubMed)

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