Parsonage-Turner Syndrome

What is Parsonage-Turner Syndrome?

Parsonage-Turner syndrome is a condition in which the nerves of the shoulder and arm become inflamed or damaged, causing sudden severe pain followed by weakness. It is also called neuralgic amyotrophy or brachial neuritis. It is often underdiagnosed, and it has no single known cause.^{[1, 2]}

Common symptoms

The first symptom is usually sudden, severe pain in the shoulder girdle, on one side or sometimes both. The pain often spreads to the neck, arm and forearm, and in many people it lasts from a few days to about 4 weeks.^[1]

• Weakness in the shoulder or arm that appears after the pain begins^[2]
• Muscle wasting in the affected area, which can develop early^[3]
• Numbness or other sensory changes in some people^[1]

Causes and risk factors

The cause is not fully understood. Reviews describe a combination of genetic predisposition, an immune trigger and mechanical stress on the affected nerve segments.^[2] Reported triggers include infections, immunizations, injury, surgery and childbirth.^[3] A rare inherited form, hereditary brachial plexus neuropathy, can look the same and tends to recur.^[3]

How it is diagnosed and treated conventionally

Diagnosis is mainly clinical, supported by nerve conduction studies, needle electromyography, lab tests and imaging. Care teams need to tell it apart from similar conditions, because a wrong diagnosis can lead to unnecessary surgery.^[1] MRI or high-resolution ultrasound can show hourglass-like constrictions of a nerve, which help confirm the diagnosis.^[4]

Treatment depends on the phase of the illness. It often includes supportive care, physical therapy, corticosteroids and sometimes intravenous immunoglobulin.^[1] Early high-dose steroids may help initial pain, but weakness and later pain respond more to time, physical therapy and non-narcotic pain medicines.^[3] There are no randomized trials of treatment.^[2]

Surgery may be considered when imaging shows a constricted nerve and recovery stalls.^{[4, 5]} Many people recover well, but newer work shows that long-term pain, weakness and fatigue are common for years.^[5]

Why Parsonage-Turner Syndrome calls for a whole-person approach

Parsonage-Turner syndrome is not only a problem of one nerve. The acute attack, the weeks of weakness and the long recovery all affect sleep, mood, activity and work. In one review, a quarter of untreated patients were unable to work three years later.^[2]

For that reason, recovery is usually shared among several kinds of care. The factors below are the ones reviews highlight.

Nerve pain and its persistence

The severe early pain can turn into a chronic pain syndrome that needs multidimensional treatment.^[2] Pain from nerve injury can also amplify through the spinal cord and brain, a process called central sensitization.^[6]

Movement and fatigue

Rehabilitation aims to restore shoulder blade mechanics, conserve energy, prevent joint stiffness and manage pain.^[3] Some experts advise focusing on motor coordination and pacing rather than heavy strength training, which may worsen symptoms.^[5]

Immune and mechanical factors

An immune component is suggested by nerve biopsies and by triggers such as infection and immunization. Mechanical stress on the nerve also appears to matter.^{[2, 3]}

Exercise and stress

A systematic review and expert consensus found that appropriate exercise can ease neuropathic pain in a range of conditions.^[7] Parsonage-Turner syndrome was not among them, so exercise should be planned with your therapist.

Acupuncture as supportive care in Parsonage-Turner Syndrome

What the research shows

No controlled trial of acupuncture for Parsonage-Turner syndrome was found. The only report is a single case of a 26-year-old man with idiopathic brachial neuritis, diagnosed two years earlier, who improved after weekly ultrasound-guided electroacupuncture combined with daily rehabilitation. One case cannot show that acupuncture caused the improvement.^[8]

For nerve pain in general, the evidence is weak. A Cochrane review of six small studies of chronic peripheral neuropathic pain found very low-quality evidence and could not support or refute acupuncture.^[9] A review of non-drug treatments for painful neuropathies rated the evidence for acupuncture as weak, specifically in painful chemotherapy-induced neuropathy.^[10]

Acupuncture has better support for some common chronic pain problems, including shoulder pain, in an analysis of 39 trials. These results do not tell us whether it helps nerve-related shoulder pain.^[11] A review of limb musculoskeletal problems found inconsistent results for shoulder pain.^[12]

How acupuncture may work

Laboratory and review work suggests acupuncture strengthens the body's descending pain-inhibiting pathways, acts through opioid and other signaling systems, and locally lowers inflammatory mediators.^[6] Animal studies also point to effects on brain circuits and neuroinflammation.^[13] These are proposed explanations from mostly animal research, not proof of benefit in this condition.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place about 20 to 40 minutes. Points are chosen for the neck, shoulder, arm and the person as a whole. We would begin only once your diagnosis is established and your physicians know about the care, then reassess after a short series of visits.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at the needle site, and serious events occurred in about 1 in 10,000 patients.^[14] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). Needling over a weak, wasted or numb arm should be done gently and with your care team's knowledge.

Ayurvedic medicine as supportive care in Parsonage-Turner Syndrome

The Ayurvedic view

Ayurveda has no classical name for Parsonage-Turner syndrome. Practitioners usually describe sudden severe pain with later weakness and wasting as a Vata disorder, Vata being the principle said to govern movement and nerve function. Classical arm and shoulder conditions such as Vishwachi and Avabahuka are sometimes used as reference points. These are traditional categories, not biomedical diagnoses.

Therapies that may be used

Care is individualized and may include:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep hours
• Gentle warm oil massage of the neck, shoulder and arm, once acute inflammation has settled
• Herbs prescribed individually by a qualified practitioner
• Stress-reduction practices such as breathing exercises

Panchakarma is a traditional course of cleansing procedures. It is not appropriate during the acute painful phase, during pregnancy, acute illness or frailty, or when the arm is very weak. We would consider it only with your physician's agreement.

What the research shows

No clinical studies of Ayurvedic treatment for Parsonage-Turner syndrome were found. A PubMed search for Ayurveda in nerve pain and neuritis also turned up no controlled trials in this area. Ayurvedic therapies therefore have no evidence behind them for this condition, and any benefit is unknown.

Turmeric, a common Ayurvedic herb, has been reviewed in peripheral neuropathies, including laboratory and animal work, but none of that concerns Parsonage-Turner syndrome.^[15] Product quality is also a concern, since about one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[16]

Herbal medicine as supportive care in Parsonage-Turner Syndrome

Herbs and formulas that have been studied

No herb or formula has been tested in Parsonage-Turner syndrome. Studies of herbs in related nerve pain are few. A review of curcumin, from turmeric, in peripheral neuropathies describes anti-inflammatory and nerve-protective effects in laboratory and animal studies, and notes that it is poorly absorbed.^[15] Nutmeg spray and St John's wort have been tested in small trials of chronic neuropathic pain.^[17]

What the research shows

A Cochrane review found only two small trials of herbal products for neuropathic pain lasting three months or more. The evidence was very low quality, and the authors could not say whether nutmeg or St John's wort helps.^[17] These findings concern long-standing neuropathic pain from other causes, not this condition.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Reviews describe interactions with warfarin, with bleeding reported for herbs including dang gui, dan shen, ginseng and ginger, and St John's wort can lower the blood levels of many drugs, including ciclosporin and tacrolimus.^{[18, 19]} This matters if you take blood thinners, immunosuppressants or antidepressants.

About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[16] Herbs should come from tested sources. Tell us if you are pregnant or breastfeeding or have liver or kidney disease.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine describes sudden arm pain with later weakness as obstruction of qi and blood in the channels, with weakness suggesting a deficiency. Researchers studying acupuncture for nerve pain measure things that loosely parallel this: descending pain inhibition, inflammatory mediators and central sensitization.^[6]

Ayurveda's aggravated Vata describes pain, movement loss and wasting. No study has shown that a dosha corresponds to a particular biological process.

How this care fits with your medical care

This care is supportive and complementary. Keep your neurologist, physiatrist, physical or occupational therapist and primary physician, and do not stop or change prescribed medicines, including steroids, without your prescriber. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Please bring your diagnosis, nerve test and imaging reports, a full list of medicines and supplements, and details of any planned surgery or immunoglobulin treatment. We do not diagnose the cause of arm pain or weakness.

When to seek urgent medical care

Sudden shoulder or arm pain with weakness needs prompt medical assessment, because other conditions can look the same.^[1]

• New arm or hand weakness, or weakness that is getting worse
• Shortness of breath, especially when lying flat, which can signal involvement of the nerve to the diaphragm^[3]
• Weakness or numbness in both legs, trouble walking, or new bladder or bowel changes
• Chest pain, or arm pain with sweating or breathlessness
• Fever with severe neck or arm pain
• Hoarseness or trouble swallowing that is new

If any of these occur, call 911 or go to the nearest emergency department.