Management of Full-Body Tremors and Associated Symptoms Following Whiplash Injury
This presentation is most consistent with post-concussive syndrome with cervical strain, and you should prioritize treating the cervical component with manual therapy while simultaneously addressing the anxiety and sleep disturbance that are perpetuating the symptoms. 1
Clinical Recognition and Diagnosis
This patient's constellation of symptoms—full-body tremors, anxiety, insomnia, fatigue, neck tightness, and progressive symptoms following whiplash with C5-C6 disc bulging—represents a cervical strain concussion-associated condition. 1 The key diagnostic features include:
- Neck pain with radiation patterns (front neck tightness encroaching on throat/upper chest) 1
- Persistent headache (implied by lightheadedness) with cervical origin 1
- Somatosensory dysfunction manifesting as full-body tremors and paresthesias 1
- Psychological symptoms (anxiety, insomnia) that predict persistent post-concussive symptoms 1
The cervical injury disrupts afferent pathways traveling to the brain, causing aberrant signaling that produces the tremor-like sensations and autonomic dysregulation you're observing. 1 Female gender, pre-existing or new-onset anxiety, and psychological factors are the strongest predictors of persistent symptoms beyond 3 months. 1
Immediate Management Priorities
1. Cervical Spine Treatment (Primary Intervention)
Manual therapy targeting the cervical spine and upper thoracic region should be your first-line treatment. 1, 2 This includes:
- Mobilization and/or manipulation of cervical and thoracic spine segments 2
- Suboccipital muscle release (these muscles show tenderness on examination in cervical strain) 1
- Paraspinal soft tissue work addressing C5-C6 level specifically 1
- Treatment frequency: at least once weekly for minimum 4 weeks 2
The rationale: Cervical strain shares common injury mechanisms with concussion, and treating the cervical component directly addresses the aberrant somatosensory signaling causing many of your patient's symptoms. 1
2. Vestibular Rehabilitation
Given the lightheadedness and full-body tremor sensations that worsen with position changes, vestibular rehabilitation is recommended. 2 This should include:
- Habituation exercises for dizziness 2
- Adaptation exercises for gaze stability 2
- Balance training 2
- Frequency: at least once weekly for 4 weeks minimum 2
3. Graded Physical Exercise Protocol
Implement a structured graded exercise program starting immediately (not strict rest beyond 48 hours post-injury, which you're well past). 2 The protocol should:
- Begin with light aerobic exercise (walking, stationary cycling at low intensity) 2
- Gradually increase intensity and complexity over time 2
- Perform at least once weekly for minimum 4 weeks 2
- Progress only if symptoms don't worsen significantly 2
Critical pitfall to avoid: Prolonged rest beyond the acute phase (first 48 hours) is detrimental to recovery. 2 Your patient has been symptomatic for months—they need activation, not rest.
Pharmacological Management
Current Medication Assessment
Continue gabapentin as it's providing partial benefit for the nighttime jerks and has evidence for neuropathic pain symptoms. 3 However, recognize that gabapentin alone won't address the core cervical and anxiety-driven components.
Anxiety and Sleep Management
The anxiety and insomnia are both symptoms AND perpetuating factors that must be addressed aggressively. 1 Consider:
- Tricyclic antidepressants (e.g., nortriptyline 10-25mg at bedtime, titrating up) for combined anxiety, sleep, and neuropathic pain benefits 3
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) as alternative if tricyclics not tolerated 3
- Short-term benzodiazepines (e.g., clonazepam 0.5mg at bedtime) may help both tremor and anxiety/sleep, but use cautiously given chronicity 4, 5
Avoid propranolol or other beta-blockers despite their use in essential tremor—this is NOT essential tremor, and beta-blockers won't address the underlying cervical/post-concussive pathophysiology. 4, 5
Addressing the Plasma Donation Factor
Immediately discontinue plasma donation. The twice-weekly donations for one year likely contributed to:
- Chronic volume depletion potentially worsening orthostatic symptoms
- Protein depletion contributing to fatigue
- Autonomic stress exacerbating tremor and anxiety symptoms
This is a reversible contributing factor that must be eliminated.
Monitoring and Red Flags
Watch for warning signs requiring urgent re-evaluation: 2
- Worsening headache or new focal neurological deficits 2
- Repeated vomiting 2
- Increased confusion or memory problems 2
- Seizures 2
- Progressive weakness beyond current symptoms 1
Expected Timeline and Follow-up
Most patients with post-concussive symptoms improve by 3-6 months, but 5-20% have symptoms at 12 months. 1 Your patient is in the persistent symptom category. 1
- Re-evaluate at 3 weeks: If no improvement with cervical treatment and anxiety management, refer to traumatic brain injury specialist 2
- Monitor for: Chronic headaches, persistent dizziness, vision problems, depression, memory/concentration difficulties, and ongoing sleep disturbance 2
- Academic/work accommodations: May need reduced workload, extended deadlines, shortened days 2
Treatment Algorithm Summary
- Week 1-4: Initiate manual cervical therapy (weekly), vestibular rehabilitation (weekly), graded exercise program, optimize anxiety/sleep pharmacotherapy, stop plasma donation
- Week 4-8: Continue therapies if showing improvement; if plateaued, intensify frequency or add psychological treatment for anxiety/PTSD symptoms 1, 6
- Week 8-12: If minimal improvement, refer to multidisciplinary TBI clinic for coordinated care 1
The tremors are likely a manifestation of cervical somatosensory dysfunction amplified by anxiety, not a primary movement disorder. 1 Treating the neck injury and psychological components together will address the root cause rather than just suppressing symptoms.