Clinical Management
What is the Clinical Management of Parsonage Turner Syndrome?
Parsonage Turner syndrome is best managed with; analgesics, steroid therapy and physiotherapy.
Analgesics
Acute pain responds best to: 1
- Regular Paracetamol
- Regular long-acting non-steroidal anti-inflammatory drugs
- Regular slow-release opioid analgesics
Increased mechanical sensitivity sometimes needs treatments with co-analgesics (pregabalin, amitriptyline)1
Musculoskeletal pain is usually unresponsive to medication and therapy here is best directed towards expert physiotherapy to maintain joint mobility and careful strengthening as rehabilitation allows.1
Steroid Therapy
As Parsonage-Turner syndrome is likely be induced by an auto-immune-mediated inflammatory process in response to the peripheral nervous system then it is reasonable to expect immunomodulation of this response through corticosteroids or IV Gammaglobulin therapy.2 The difficulty in finding evidence to support this is due to the often-delayed diagnosis of parsonage-turner syndrome consistent with a median time to diagnose neuralgic amyotrophy
of 11 weeks1.
An observational study based on 50 patients in the acute pain phase of Parsonage-Turner syndrome under a treatment regimen of oral prednisolone 60mg/day for 7 days tapered by 10mg a day for the next 5 days with 5mg on day 13 was compared to a historical control group of 203 patients with untreated parsonage-turner syndrome3.
Outcomes (Prednisolone group / Control Group / Statistical significance)
Median time until initial pain relief (days 12.5 / 20.5 / p=0.13
Recovery of strength within 1 month 18.0% / 6.3% / p=0.01
Full functional recovery within the first year 12.0% / 1.0% / p=<0.001
Good (but not full) self-reported recovery within
- 6 months 32% / 2.9% / p=<0.001
- 12 months 44% / 10.7% / p=<0.001
Main points:
In the Steroid [treatment] group
- Shorter time to initial pain relief (no statistical significance)
- Greater proportion of patients with recovery of strength at 1 month
- Greater proportion of patients with full functional recovery at 6 and 12 months.
- Greater proportion of patients with full recovery within first year
Further analysis:
· Prednisolone treatment is particularly effective in patients with a reported antecedent infection as more patients in this sub-group eventually recovered fully and earlier than in patients where antecedent trigger was from other causes.
· Patients experiencing a recurrent attack (compared to first) may have a worse outcome associated with an exacerbation of neuropathic pain following steroid cessation (22%) and progression of paresis during treatment.
o This may be due to residual damage incurred by previous attacks1, treatment schedule too short or damage occurring by different ‘steroid non-responsive’ pathological mechanisms.
Physiotherapy
Physiotherapy plays an important role in the long-term recovery from this condition. It must be started at an appropriate time, i.e. after the acute pain phase. The main considerations of physiotherapy are that the condition inflicts on the patient a multi-focal muscular weakness and atrophy around the shoulder and upper extremity, causing persistent scapular instability, increased fatigability, chronic pain and difficulty moving the upper extremity around its full range of motion.
Physiotherapy can support the patient through patient education, maintaining range of movement of the shoulder joint, strengthening exercises to maintain periscapular motion and modalities for adjunct pain relief.4
References
1. Nens van Alfen & Baziel G. M. van Engelen. The clinical spectrum of neuralgic amyotrophy in 246 cases, Brain, 2006, 129, 438–450. https://doi.org/10.1093/brain/awh722
2. van Alfen N (2011) Clinical and pathophysiological concepts of neuralgic amyotrophy. Nat Rev Neurol 7: 315–322. https://doi.org/10.1038/nrneurol.2011.62
3. van Eijk JJJ, van Alfen N, Berrevoets M, et al Evaluation of prednisolone treatment in the acute phase of neuralgic amyotrophy: an observational study Journal of Neurology, Neurosurgery & Psychiatry 2009;80:1120-1124. https://www.doi.org/10.1136/jnnp.2008.163386
4. https://www.physio-pedia.com/Parsonage-Turner_Syndrome accessed 02/08/2021