PARSONAGE-TURNER SYNDROME (BRACHIAL NEURITIS): SYMPTOMS, CAUSES, AND TREATMENT

Parsonage-Turner Syndrome (PTS) is a neuromuscular condition that impacts the nerves in the shoulder and upper arm. It is characterized by sudden, severe pain in the affected area, followed by weakness and numbness. While rare, PTS can be debilitating and can greatly impact a person's daily life.^[1]

The condition is named after two doctors, Maurice Parsonage and John Turner, who first described it in the 1940s. It is estimated to affect 1-3 people per 100,000 individuals per year. It is also known as brachial neuritis, brachial plexus neuropathy, or neuralgic amyotrophy.

In this article, we will discuss the symptoms, causes, and treatment options for Parsonage-Turner Syndrome.

Symptoms of Parsonage-Turner Syndrome

Parsonage-Turner syndrome symptoms occur in two main phases: the acute phase and the chronic phase.

Acute phase: The first noticeable symptom of Parsonage-Turner Syndrome is sudden, severe pain in the shoulder and upper arm. This pain can be described as burning, stabbing, or shooting and can last from a few days to a few weeks. The pain may also radiate down the arm and into the hand.

Chronic phase: After the initial pain, weakness and numbness may develop in the affected area. This can make it difficult to move the arm and perform daily tasks. In some cases, the muscles in the affected area may also start to shrink due to muscle atrophy (breakdown). The chronic phase can last anywhere from 6-18 months or more.

Other symptoms may include^[2]:

• Tingling or pins and needles sensation in the affected area.
• Loss of sensation in the affected area.
• Impaired fine motor skills, such as difficulty buttoning a shirt or holding a pen.
• Limited range of motion in the shoulder and arm.
• Twitching or muscle spasms in the affected area.

Up to 80% of cases occur in one shoulder and arm, yet roughly 20% occur in both shoulders.

If you experience any of these symptoms, it is important to seek medical attention to determine the cause and receive proper treatment.

Parsonage-Turner Syndrome in children. The condition usually affects those over 30 and has a male bias. While not as common as in adults, cases have been documented in children as young as 3 years old. The symptoms and treatment of Parsonage-Turner Syndrome in children are similar to those in adults.

Parsonage-Turner Syndrome and neck pain. While the condition does not typically cause neck pain, it is possible for the pain to radiate from the shoulder and upper arm to the neck. This is known as referred pain.

How Parsonage-Turner Syndrome Affects Nerves in the Shoulder and Arm

In PTS, the long thoracic nerve, suprascapular nerve, and peripheral nerves in the shoulder and upper arm are affected.

The long thoracic nerve feeds the serratus anterior muscle, which helps stabilize the scapula (shoulder blade) during arm movements. When affected, it can lead to weakness and paralysis of this muscle, causing winging of the scapula (abnormal protrusion or sticking out of the shoulder blade). This is why those with the condition may struggle to raise the affected arm overhead and perform certain movements.

In a similar way, the other affected nerves innervate a number of muscles in the shoulder and arm. Weakness and atrophy of these muscles result in shoulder pain, a limited range of motion, and sensory changes in the shoulder, upper arm, and sometimes even extending down to the forearm and hand.

Does Parsonage-Turner Syndrome Go Away?

In most cases, the symptoms of PTS will improve over time, and many people recover fully. To give a rough idea, it usually takes several months to 2 years for a full recovery. Some individuals may experience residual weakness or pain, but these symptoms are usually mild and do not significantly impact daily activities. This can be avoided by focusing on slowly building the muscle in the shoulder.

Causes of Parsonage-Turner Syndrome

The exact cause of the condition is unknown.

Current theories indicate that it may be caused by genetics, mechanical stress, or an autoimmune reaction. This means that the body's immune system mistakenly attacks the nerves in the shoulder and upper arm, causing inflammation and damage.^[3]

Some potential triggers for this autoimmune response may include^[4]:

• Infection: A viral or bacterial infection may trigger the immune system to attack the nerves. Common ones include the Coxsackie B virus and mumps. Rarely, the condition can be due to a COVID-19 infection.
• Surgery: In some cases, PTS may develop after surgery, particularly in the shoulder or upper arm area. A lumbar puncture is another known risk factor.
• Injury: A traumatic injury to the shoulder or upper arm may also trigger the condition.
• Vaccines: There have been rare reports of the syndrome occurring after receiving a vaccine.
• During pregnancy and after childbirth.
• Radiation exposure: Some individuals who underwent radiotherapy or received contrast dye for imaging reported symptoms of PTS.
• Genetic predisposition: The genetic makeup of some individuals might increase their likelihood of developing Parsonage-Turner Syndrome.

Is Parsonage-Turner Syndrome an Autoimmune Disease?

There is ongoing debate about whether PTS is an autoimmune disease. While it is believed that an autoimmune response is responsible for the condition, some experts argue that it may be more accurately classified as an immune-mediated disorder.

Regardless of its classification, the treatment for Parsonage-Turner Syndrome often involves managing the immune response and reducing inflammation.

Can the Flu Vaccine Cause Parsonage-Turner Syndrome?

There have been reported cases of PTS occurring after receiving a flu vaccine. However, the risk is extremely low, estimated to be less than one case per million vaccinations. This extends to just about all other vaccines, from tetanus to typhoid. A COVID-19 vaccine may also be a risk factor in susceptible individuals.^[5]

It is important to note that the flu vaccine is still recommended for individuals with Parsonage-Turner Syndrome, as the benefits of protection against the flu far outweigh the potential risks. The same applies to other recommended vaccines, especially if traveling to a high-risk area.

Diagnosing Parsonage-Turner Syndrome

Diagnosis can be challenging owing to its rarity and symptoms that can mimic those of other conditions, such as a pinched nerve or rotator cuff injury.

To make a diagnosis, a doctor will perform a physical assessment and review the patient's medical history. They may also order imaging tests, such as an MRI or nerve conduction studies, to rule out other conditions and assess the extent of nerve damage.

However, there are some tests that can help confirm a diagnosis, including:

• MRI (magnetic resonance imaging) scanning can provide detailed images of the nerves and muscles in the affected area. This can help identify any inflammation or damage to the nerves, which is a hallmark of Parsonage-Turner Syndrome.
• EMG (electromyography) is a diagnostic procedure that measures the electrical activity in the muscles. In PTS, the affected muscles may show signs of damage or weakness.

Radiology. In the above tests, classic signs observed include nerve damage and denervation of the brachial plexus, inflamed tissue, and muscle atrophy (breakdown).

X-rays cannot be used to diagnose Parsonage-Turner Syndrome.

Treatment Options for Parsonage-Turner Syndrome

There is currently no known cure for Parsonage-Turner Syndrome, and treatments are non-specific. Some methods that can help manage the symptoms and promote healing are reviewed below.

Pain Management

The initial pain can be severe and may require pain medication to manage. Prescription non-steroidal anti-inflammatory drugs (NSAIDs) or stronger pain relievers are the mainstay treatment options to help alleviate discomfort.^[6]

TENS and Electro-acupuncture

In some cases, a doctor may also recommend transcutaneous electrical nerve stimulation (TENS). This non-invasive technique uses electrical impulses to block pain signals. Many patients with neuropathies (nerve-related pain disorders like brachial neuritis) benefit from TENS and other electro-stimulation techniques, such as electro-acupuncture.

Physical Therapy

Physical therapy can aid in improving the range of motion, strength, and function of the affected arm. A physical therapist can also provide gentle exercises to help prevent muscle atrophy and maintain muscle strength.

Steroid Injections

In certain cases, steroid injections may be recommended to reduce pain and inflammation in the area affected. These injections are typically given directly into the shoulder or upper arm. However, steroids may only help to lower pain in the first month and may not be as effective as other treatment options.

Surgery

In rare cases, surgery may be required to repair damaged nerves or muscles in the affected area. This is usually only considered if other treatment options have not been effective or if the cause is an obvious indication for surgery, such as nerve compression.

Parsonage-Turner Syndrome Exercises

As explained above, physical therapy exercises can be beneficial for individuals with PTS. These exercises can help enhance the range of motion, strength, and function of the affected arm.

Exercises that may be recommended can include:

• Shoulder shrugs: Start in a standing position with your arms at your sides. Slowly raise your shoulders towards your ears. Hold for a few seconds, then relax.
• Shoulder rolls: Stand straight with your arms resting at your sides. Now, slowly roll your shoulders forward and then backward.
• Arm circles: Stand with your arms at your sides and slowly rotate your arms in small circles, progressively increasing the size of the circles.
• Bicep curls: Hold a light weight in your hand and slowly bring the weight towards your shoulder as you bend your elbow. Slowly lower the weight back down.
• Tricep extensions: Hold a light weight in your hand and slowly straighten your arm behind you. Slowly bend your elbow as you return to the starting position.

It is important not to overexert your arm or shoulder when attempting to exercise the area.

If severe, you may need to consult a physical therapist before starting any exercises to be sure that they are appropriate for your specific condition.

Coping with Parsonage-Turner Syndrome

Living with Parsonage-Turner Syndrome can be challenging, but there are some things you can do to cope with it and manage your symptoms.

• Rest: It is important to give your affected arm time to rest and heal. Avoid activities that may aggravate your symptoms.
• Use assistive devices: If you are experiencing weakness or limited range of motion, using assistive devices such as a sling or brace can help support your arm and make daily tasks easier.
• Seek support: Joining a support group or talking to others with the condition can help you cope with the emotional and physical challenges.

Preventing Parsonage-Turner Syndrome

While the exact cause of the syndrome is not yet completely understood, there are some steps that could help reduce your risk of developing the condition. Here are a few tips for prevention:

1. Maintain a healthy lifestyle: Regular exercise, a balanced diet, and stress management can help strengthen your immune system and promote overall health. This may help reduce the likelihood of developing PTS.
2. Use anti-inflammatories when required: During an infection, after receiving a vaccine, or if one accidentally injures their arm or shoulder, it is advisable to make use of anti-inflammatory medications or supplements. This may help to balance any potential immune reactions that can increase the risk of brachial neuritis from occurring.
3. Avoid excessive repetitive motions: Certain activities that involve repetitive motions or excessive strain on the shoulder and arm can increase the risk of developing the condition. Try to avoid or minimize these activities, and if they cannot be avoided, take frequent breaks and practice proper ergonomics.
4. Warm up and stretch: Prior to any physical activity or exercise, it is important to warm up your muscles and perform stretching exercises. This can help improve flexibility, reduce the risk of injury, and potentially prevent conditions like Parsonage-Turner Syndrome.
5. Practice good posture: Maintaining proper posture while sitting, standing, and performing daily activities can help alleviate strain on the shoulder and arm. Be mindful of your posture and make adjustments as necessary to lower your susceptibility.
6. Listen to your body: Pay attention to any discomfort or pain in your shoulder and arm. If you notice any persistent symptoms, such as weakness or numbness, seek medical attention promptly. Early diagnosis and treatment can help prevent further complications associated with PTS.

Remember, while these prevention tips may be helpful, Parsonage-Turner Syndrome is a complex condition, and its development cannot always be prevented. If you have concerns about your risk or experience any symptoms, it is always best to consult a healthcare practitioner for personalized advice and guidance.

Conclusion

Parsonage-Turner Syndrome is a rare condition that can cause sudden, severe pain and weakness in the shoulder and upper arm. While there is no specific treatment for the condition, there are options available to manage symptoms and promote healing. If you are experiencing symptoms of Parsonage-Turner Syndrome, it is important to seek medical attention to receive a proper diagnosis and treatment plan. With proper management, many people with the condition can regain function and live a fulfilling life.

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