Disclosures: Daniel Krasna, MD: Nothing to disclose

Case Description: TBI patient who developed a tremor in his right upper extremity during rehabilitation after propranolol was tapered off.

Setting: 21 days after initial hospital admission patient was transferred to an inpatient rehabilitation center.

Patient: 22-year-old male presented to the ED following gunshot wound to the right temporal region. Initial GCS 11. CT head showed multiple traumatic subarachnoid hemorrhages, cerebral edema and minimal midline shift. The patient was taken for right craniectomy. He became febrile and experienced tachycardia. Blood cultures returned with no growth and patient was placed on 7 days of intravenous antibiotics. Fevers and tachycardia persisted so patient was started on propranolol 40 mg Q6H for sympathetic storming.

Assessment/Results: One week after rehabilitation admission patient made gains in FIM scores. He had no symptoms of central storming, so propranolol was weaned off. Over the next 3 days an intention tremor was noted for the first time. Physical therapy noted the tremor affected his balance. Occupational therapy noted that he displayed deficits in speed and dexterity. Propranolol was resumed at a dose of 10 mg Q12H and tremor subsided.

Discussion: Weaning propranolol is generally done during the rehabilitation phase of recovery, however no protocol exists for timing or dosing. Aggravation of the cerebellar pathways can go undetected on initial conventional MRI and may present as a delayed onset movement disorder after TBI. When tremor does arise, no protocol exists for treatment. For this particular case, the least effective dose was 10 mg Q12H PO.

Conclusion: This case highlights need for Physical Medicine and Rehabilitation physicians to be on alert for tremor and other sequelae of traumatic brain injury throughout recovery, especially as medications are adjusted. In addition, the patient’s tremor was resolved with lower than recommended doses of propranolol, illustrating the need for further research of least effective dose of medications used to treat tremor.

Level of Evidence: Level V

« Back to AAPM&R Annual Assembly 2019

PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/emerging-intention-tremor-after-tbi-case-report-and-literature-review/