Parsonage-Turner Syndrome After SARS-CoV-2 BNT162b2 Vaccine: A Case Report.

CASE: Parsonage-Turner syndrome, also known as brachial neuritis or neuralgic amyotrophy, is characterized by sudden-onset pain and subsequent weakness of the shoulder. Known precipitating factors include viral and bacterial infections and certain immunizations. Isolated cases after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported. We report the case of a 66-year-old woman with right shoulder dysfunction and medial scapular winging after immunization with the SARS-CoV-2 BNT162b2 vaccine (Pfizer). CONCLUSION: After physical therapy, the patient resumed her normal activities of daily living. Findings from this case represent the first known documentation of Parsonage-Turner syndrome after SARS-CoV-2 BNT162b2 vaccination.

NA-CONTROL: a study protocol for a randomised controlled trial to compare specific outpatient rehabilitation that targets cerebral mechanisms through relearning motor control and uses self-management strategies to improve functional capability of the upper extremity, to usual care in patients with neuralgic amyotrophy.

BACKGROUND: Neuralgic amyotrophy (NA) is a distinct peripheral neurological disorder of the brachial plexus with a yearly incidence of 1/1000, which is characterised by acute severe upper extremity pain. Weakness of the stabilising shoulder muscles in the acute phase leads to compensatory strategies and abnormal motor control of the shoulder - scapular dyskinesia. Despite peripheral nerve recovery, scapular dyskinesia often persists, leading to debilitating residual complaints including pain and fatigue. Evidence suggests that persistent scapular dyskinesia in NA may result from maladaptive cerebral neuroplasticity, altering motor planning. Currently there is no proven effective causative treatment for the residual symptoms in NA. Moreover, the role of cerebral mechanisms in persistent scapular dyskinesia remains unclear. METHODS: NA-CONTROL is a single-centre, randomised controlled trial comparing specific rehabilitation to usual care in NA. The rehabilitation programme combines relearning of motor control, targeting cerebral mechanisms, with self-management strategies. Fifty patients will be included. Patients are recruited through the Radboud university medical center Nijmegen, the Netherlands. Patients with a (suspected) diagnosis of NA, with lateralized symptoms and scapular dyskinesia in the right upper extremity, who are 18 years or older and not in the acute phase can be included. The primary outcome is the Shoulder Rating Questionnaire score, which measures functional capability of the upper extremity. Secondary clinical outcomes include measures of pain, fatigue, participation, reachable workspace, muscle strength and quality of life. In addition, motor planning is assessed with first-person motor imagery and functional magnetic resonance imaging. In a sub-study the patients are compared to 25 healthy participants, to determine the involvement of cerebral mechanisms. This will enable interpretation of cerebral changes associated with the rehabilitation programme and functional impairments in NA. DISCUSSION: NA-CONTROL is the first randomised trial to investigate the effect of specific rehabilitation on residual complaints in NA. It also is the first study into the cerebral mechanisms that might underlie persistent scapular dyskinesia in NA. It thus may aid the further development of mechanism-based interventions for disturbed motor control in NA and in other peripheral neurological disorders. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03441347 . Registered on 20 February 2018.

Reflections of patients and therapists on a multidisciplinary rehabilitation programme for persons with brachial plexus injuries.

PURPOSE: There is lack of knowledge, evidence, and guidelines for rehabilitation interventions for persons with neuralgic amyotrophy (NA) or brachial plexus pathology. A first pilot study, evaluating the effect of an integrated rehabilitation programme, showed improvements in activity and participation levels. AIM: To gain insight, from the perspective of patients and therapists, into the critical ingredients of the programme, that contributed to improvements in activity and participation. MATERIALS AND METHODS: A qualitative study using semi-structured interviews with eight patients and five therapists (three occupational therapists and two physical therapists). Participants were asked to identify and describe factors regarding the rehabilitation that they perceived as positive and aspects of the programme that could be improved. Data were analysed using a constant comparative approach. RESULTS: Patients reported (1) Time to diagnose: "Finally I'm in the right place;" (2) Awareness: "They gave me a mirror;" (3) Partnership: "There was real contact with the therapists; we made decisions together;" (4) Close collaboration: "Overlapping scopes of practice; doing the same from a different perspective;" and finally (5) Self-management: "Now I can do it myself." Therapists reported (1) "Patients knowledge and understanding is critical to success;" (2) "Activate problem solving and decision making;" (3) "Personalize your therapy; it's more than just giving exercises and information;" (4) "Constant consultation within the team; consistency in messages and approach;" and (5)" Ultimately the patient is in charge." CONCLUSIONS: The critical ingredients, correspond well with each other and include a person-centred approach, education, support in problem solving and decision making and an integrated team approach. These ingredients provided the patients with confidence to take responsibility to manage their everyday lives, the ultimate goal of the programme. Implications for rehabilitation Both patients and therapists believe that the ability to self-manage and take control should be the outcome of high quality integrated rehabilitation programmes for patients with neuralgic amyotrophy and/or other brachial plexus injuries. A person-centred, collaborative, and integrated team approach, among all members of the team, are critical components of care delivery in personalised interventions. Critical programme ingredients are knowledge and education of both the patient and therapists; partnership between patient-therapist and within the team; patient activation and self-reflection; and personalised care. Patients recommend more options for personalisation of the intensity and duration of rehabilitation, the possibility to consult a psychologist and peer support within a group setting.

Challenging Diagnosis and Inpatient Rehabilitation of Acute Bilateral Neuralgic Amyotrophy Possibly Attributed to Lyme Disease: A Case Report.

Neuralgic amyotrophy (NA) is a neurologic syndrome of unknown etiology primarily affecting the brachial plexus. We are reporting an unusual case of acute bilateral NA that was possibly secondary to Lyme disease. The patient demonstrated significant functional gains and was discharged home after 2 weeks of inpatient rehabilitation, supporting the role of inpatient rehabilitation in acute NA. In this report, we discuss the diagnosis, electrodiagnostic progression, pain management, goals for inpatient rehabilitation, and overall prognosis of NA. LEVEL OF EVIDENCE: V.

[Parsonage-Turner Syndrome - Case Report]. / Das Parsonage-Turner-Syndrom.

Neuralgic amyotrophy of the shoulder (Parsonage-Turner syndrome) is a rare condition of unknown aetiology which manifests as acute neuropathy of the brachial plexus. Diagnosis is based on typical symptoms and physical examination. In addition, magnetic resonance imaging of the affected shoulder and the cervical spine is advisable, in order to distinguish this syndrome from other conditions with similar symptoms. There is no specific treatment for neuralgic amyotrophy, but in about 50 - 67% of cases complete recovery occurs within two to three years, depending on the severity of the symptoms when they first appear. In patients whose strength and function are not fully restored, neurological deficits may remain, especially if the same shoulder is affected by recurrent attacks.

Cervical Lateral Glide Neural Mobilization Is Effective in Treating Cervicobrachial Pain: A Randomized Waiting List Controlled Clinical Trial.

BACKGROUND: Cervicobrachial pain (CP) is a high-incidence and prevalent condition. Cervical lateral glide (CLG) is a firstline treatment of CP. There is a current lack of enough high-quality randomized controlled double-blind clinical trials that measure the effectiveness of neural tissue mobilization techniques such as the CLG and its specific effect over CP. OBJECTIVES: The aim of the present study was to assess the effect of CLG neural mobilization in treating subjects who suffer from CP, compared with the complete absence of treatment. STUDY DESIGN: This investigation was a single-center, blinded, parallel randomized controlled clinical trial (RCT). SETTING: One hundred forty-seven individuals were screened in a medical center from July to November 2015. Fifty-eight participants were diagnosed with CP. METHODS: Participants were recruited and randomly assigned into two groups of 29 subjects. The intervention group received CLG treatment, and the control group (CG) was assigned to a six-week waiting list to receive treatment. Randomization was carried out by concealed computer software randomized printed cards. The primary outcome was pain intensity, reported through the Numeric Rating Scale for Pain (NRSP). Secondary outcomes were physical function involving the affected upper limb using the Quick DASH scale and ipsilateral cervical rotation (ICR) using a CROM device. Assessments were made at baseline and one hour after treatment. RESULTS: The CLG group NRSP mean value was significantly (P < 0.0001) superior to those obtained by the CG. Subjects treated with CLG reported an average NRSP decrease of 2.16 points (35%). CROM device and Quick DASH outcome values also reported significant (P < 0.0001) improvements only in the CLG group. Cohen's d showed a very large effect of the CLG intervention at subject discharge. LIMITATIONS: Due to the lack of dipper subgroup analysis and additional reproductions of the applied protocol, the authors considered the generalization of the study results to be impossible. CONCLUSIONS: CLG is superior to the absence of treatment in reducing pain and increasing the affected upper limb function of subjects who suffer from CP. CLG may be considered an effective treatment in specific cases of CP.

Scapular kinematics and muscle performance in a single case of Parsonage-Turner.

This study characterized the impairments of range of motion, three-dimensional scapulo-thoracic kinematics, isokinetic muscle performance and disability in a patient with Parsonage-Turner Syndrome. The patient had a history of 2.5-years of shoulder pain, and electroneurodiagnostic testing indicative of suprascapular neuropathy. The patient-rated Disabilities of the Arm, Shoulder and Hand (DASH) score was 33.3% (0 = no symptoms/disability), and reduced shoulder internal rotation, external rotation, and flexion as compared bilaterally. There were deficits in isokinetic muscle performance at slow and fast speeds during abduction, lateral and medial rotations as compared to the uninvolved side. Alterations in scapular kinematics were decreased posterior tilt, increased internal rotation, and increased upward rotation during arm elevation and lowering. This information can be used to assist clinicians in developing treatment programs to address the alterations caused by this neuralgic amyotrophy.

Efficacy of a combined physical and occupational therapy intervention in patients with subacute neuralgic amyotrophy: a pilot study.

BACKGROUND: Neuralgic Amyotrophy (NA) is characterized by neuropathic pain, subsequent patchy paresis and possible sensory loss in the upper extremity. Many patients experience difficulties in performing activities of daily life and are unable to resume work. We developed a combined physical- and occupational therapy program for patients recovering from NA. OBJECTIVE: Evaluation of the effectiveness of a multidisciplinary intervention program for patients with subacute NA. METHODS: We performed a within subject proof-of-principle pilot study in eight patients with subacute NA. Patients followed 8 hours of physical and 8 hours of occupational therapy spread over a 16-week period. PRIMARY OUTCOME MEASURES: The Canadian Occupational Performance Measure (COPM) and Shoulder Rating Questionnaire (SRQ). SECONDARY OUTCOME MEASURE: Disability of Arm Shoulder and Hand (DASH). RESULTS: Improvements (mean (95% CI)) were found in the performance and satisfaction scores of the COPM +2.3 (0.9-3.7) and +1.4 (0.4-2.4) points, respectively and the SRQ +14.8 (7.4-22.0) points. The majority of patients (6 out of 8) also demonstrated improvements in the DASH. CONCLUSION: The proposed physical and occupational therapy program, may be effective for patients with subacute NA, as demonstrated by improvements in activity, performance and participation.

Neuralgia amiotrófica posterior a la vacunación contra la leptospirosis humana / Neuralgic amyotrophy following vaccination against human leptospirosis

Introducción: la neuralgia amiotrófica o síndrome de Parsonage-Turner se asocia a vacunaciones en 15 por ciento de los casos. No existen reportes que vinculen esta condición con la vacuna contra la leptospirosis humana. Objetivo: describir las características clínicas de un paciente que presentó una plexopatía braquial aguda posterior a la inmunización contra la leptospirosis humana. Presentación del caso: un varón de 31 años de edad, obrero agrícola en 2008 recibió una dosis de la vacuna cubana contra la leptospirosis humana (vax-Spiral); 3 semanas después presentó dolor intenso localizado en ambos hombros, a la semana siguiente aparece debilidad muscular y posteriormente atrofia del músculo deltoides derecho. La evaluación neurológica era compatible con afección aguda asimétrica de la porción superior del plexo braquial, con mayor intensidad en el lado derecho, en el cual también estaba involucrado el diafragma. Se comprobó el compromiso de la porción superior del plexo braquial con estudios de neuroconducción y electromiografía. El paciente es tratado con analgésicos y fisioterapia, evolucionando de modo favorable. Conclusiones: el evento ocurrido en este caso sugiere que la vacuna cubana contra leptospirosis humana pudiera producir inmunorreactividad cruzada contra antígenos del sistema nervioso periférico

Introduction: neuralgic amyotrophy or Parsonage-Turner syndrome is associated with vaccination in 15 percent of cases. There are no reports linking this condition to the vaccine against human leptospirosis. Objective: describe the clinical characteristics of a patient who developed acute brachial plexopathy after vaccination against human leptospirosis. Case presentation: a male 31 year-old agricultural worker received a dose of the Cuban vaccine against human leptospirosis (vax-SPIRAL) in 2008. Three weeks later he presented intense pain in both shoulders. The following week he had muscular weakness, and then atrophy of the right deltoid muscle. Neurological evaluation showed acute asymmetric damage to the upper brachial plexus, with greater intensity on the right side, and involvement of the diaphragm. Nerve conduction examination and electromyography revealed involvement of the upper brachial plexus. The patient was treated with analgesics and physical therapy, and was found to evolve favorably. Conclusions: the events described suggest that the Cuban vaccine against human leptospirosis might produce immunological cross-reactivity against antigens of the peripheral nervous system

Residual complaints after neuralgic amyotrophy.

OBJECTIVE: To develop recommendations regarding outcome measures and topics to be addressed in rehabilitation for persons with neuralgic amyotrophy (NA), this study explored which functions and activities are related to persisting pain in NA and which questionnaires best capture these factors. DESIGN: A questionnaire-based survey from 2 cross-sectional cohorts, one of patients visiting the neurology outpatient clinic and a cohort seen at a multidisciplinary plexus clinic. SETTING: Two tertiary referral clinics based in the Department of Neurology and Rehabilitation from a university medical center provided the data. PARTICIPANTS: A referred sample of patients (N=248) with either idiopathic or hereditary NA who fulfilled the criteria for this disorder, in whom the last episode of NA had been at least 6 months ago and included brachial plexus involvement. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Two custom clinical screening questionnaires were used as well as the Shoulder Rating Questionnaire-Dutch Language Version, the Shoulder Pain and Disability Index (SPADI), the Shoulder Disability Questionnaire (SDQ), and Overall Disability Sum Score. RESULTS: The survey confirms the high prevalence of persisting pain and impairments. More than half of the patients were restricted by pain, while in those without pain 60% experienced residual paresis. Correlations show an intimate relation between pain, scapular instability, problems with overhead activities, and increased fatigability. A standard physical therapy approach was ineffective or aggravated symptoms in more than 50%. CONCLUSIONS: Pain and fatigue are strongly correlated to persisting scapular instability and increased fatigability of the affected muscles in NA. Our results suggest that an integrated rehabilitation approach is needed in which all of these factors are addressed. We further recommend using the SPADI and SDQ in future studies to evaluate the natural course and treatment effects in NA.

A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain.

Cervicobrachial pain is a common cervical spine disorder. It is frequently managed through non-invasive therapy. The objective of this systematic review was to assess effectiveness of non-invasive therapy for the management of cervicobrachial pain, in terms of pain, function and disability. Computerised searches were performed to January 2010. Studies were selected using pre-specified criteria. Methodological quality of included studies was assessed using PEDro and level of inter-reviewer agreement reported using Kappa values. Meta-analyses were conducted on pain scores for similar interventions using DerSimonian-Laird random-effects model to allow for heterogeneity. Effect sizes and 95% confidence intervals were reported. Qualitative analyses, based on Centre for Evidence Based Medicine levels of evidence, were conducted for function and disability. Eleven studies were included in the review. Interventions included general physiotherapy, cervical traction, manual therapy, exercise therapy, and behavioural change approaches. There was inconclusive evidence for the effectiveness of non-invasive management of cervicobrachial pain. Potential benefits were indicated in the provision of manual therapy and exercise and behavioural change approaches to reduce pain. General physiotherapy and traction were no more effective than comparators in reducing pain (level A evidence). Effects of non-invasive management on function and disability were mixed. Future studies should identify which sub-groups of cervicobrachial pain respond to specific interventions.

[Neuralgic amyotrophy as the primary cause of shoulder pain in a patient with rotator cuff tear]. / Rotator manset yirtigi olan bir olguda omuz agrisinin ana nedeni: Nöraljik amiyotrofi.

A 66-year-old woman with no history of trauma presented with severe shoulder pain. Magnetic resonance imaging revealed rupture of the supraspinatus tendon, for which surgical treatment was considered. However, it was noted that shoulder pain was accompanied by weakness in the shoulder muscles, and the patient underwent electroneuromyographic examination, which revealed neuralgic amyotrophy. Following physical therapy and rehabilitation combined with appropriate medical therapy, her symptoms significantly improved. In cases with severe shoulder pain without a trauma history, characteristics of pain should be thoroughly analyzed and neuralgic amyotrophy considered in the differential diagnosis.

Sustained effects of comprehensive inpatient rehabilitative treatment and sleeping neck support in patients with chronic cervicobrachialgia: a prospective and randomized clinical trial.

The objective of this study was to investigate the long-term efficacy of inpatient rehabilitation using sleeping neck support in patients suffering from chronic cervicobrachialgia. A prospective, randomized clinical trial with a 12-month follow-up was done. A total of 149 patients suffering from chronic cervicobrachialgia received a 4-week inpatient rehabilitation programme. The patients were randomly divided into two groups. The patients in one group were given a special neck pillow to use during and after the rehabilitative treatment (n=76); the patients in the other group were not given the pillow (n=73). Two weeks before, during, and after (3, 6, 9, and 12 months) the 4-week treatment period, the patients completed a questionnaire dealing with the intensity of their cervicobrachial complaints (pain intensity, muscular tension, paraesthesia, and sleep disorders caused by pain or paraesthesia). During the inpatient treatment period, no significant differences were detected between the groups; however, 1-12 months after discharge, the group with sleeping neck support showed a significantly (P<0.05) smaller increase in the intensity of cervical spine pain. Sleep disturbances caused by pain were also reduced significantly (P<0.001 after 3 months, respectively, P<0.05 after 12 months). Inpatient rehabilitative treatment has sustained effects in patients suffering from chronic cervicobrachialgia, particularly when a sleeping neck support is added.

[Prospective study of the long-term effectiveness of inpatient rehabilitation of patients with chronic cervicobrachial syndromes and the effect of prescribing special functional pillows]. / Prospektive Studie über die Langzeitwirksamkeit stationärer Heilverfahren bei Patienten mit chronischen Zervikobrachialsyndromen und zum Effekt einer zusätzlichen Verordnung spezieller Funktionskopfkissen.

In order to investigate the long-term effect of clinical rehabilitation measures as well as the additional effect of prescription of a special pillow in patients suffering from chronic cervicobrachialgia a total of 149 patients was investigated. All patients suffered from chronic cervicobrachialgia and were admitted for rehabilitative treatment in the orthopaedic Elfenmaar-Klinik of Bad Bertrich. For a four-week period the patients were treated with physical therapy including gymnastics, electrotherapy, thermotherapy, and massage. Additionally they underwent a health-promoting programme specially designed for patients with spondylopathia. The patients were randomly divided into two groups, one receiving a special pillow (Curavario, Pala-Medic-Company) for the use during and after the rehabilitative treatment (n = 76 or n = 73, respectively). For two weeks before the treatment, during the four-week treatment period and for two weeks after the treatment the patients had to fill in a questionnaire, comprising among others six questions on the intensity of their cervicobrachialgic symptoms (pain-intensity [local pain, radiation of pain], muscular tenseness, paraesthesia and sleep disorders [caused by pain or paraesthesia]). Three, six, and nine month after the treatment period the patients received a similar questionnaire. Immediately after the treatment period a significant reduction of mean pain intensity and muscle tenseness (p < 0.001; Rep.-Mes.-ANOVA) was found. At the same time significantly lower frequencies of pain radiation and sleep disorders caused by pain or paraesthesia (p < 0.001; chi-square-test) were found. During the following nine months the intensity of the symptoms slightly re-increased, however, all parameters were still reduced nine months after treatment compared to the values before treatment (p < 0.01). Before and during the treatment no difference between the two groups could be detected, however, the follow-up showed significantly lower scores of pain intensity (p < 0.05; Student-t-test) and sleep disorders (p < 0.01; chi-square test) in the patients who had received the special pillow. It is concluded that the rehabilitative treatment is effective in patients suffering from chronic cervicobrachialgia and that the complaints in the post-treatment period can be reduced by prescription of special pillows.

Nerve trunk pain: physical diagnosis and treatment.

The management of peripheral neuropathic pain or nerve trunk pain relies upon accurate differential diagnosis. In part neurogenic pain has been attributed to increased activity in, as well as to abnormal processing of non-nociceptive input from, the nervi nervorum. For neurogenic pain to be identified as the dominant feature of a painful condition there should be evidence of increased nerve trunk mechanosensitivity from all aspects of the physical examination procedure. Consistent dysfunction should be identified on key active and passive movements, neural tissue provocation tests as well as nerve trunk palpation. A local cause for the neurogenic pain disorder should also be identified if the condition is to be treated by manual therapy. A treatment approach is presented which has been shown to have efficacy in the relief of pain and restoration of function in cervicobrachial pain disorders where there is evidence according to the outlined examination protocol of nerve trunk pain.