How to manage uncontrolled upper extremity movements in a 20-year-old post-head injury?

Management of Post-Traumatic Uncontrolled Upper Extremity Movements

Begin with intensive task-specific training combined with functional electrical stimulation (FES) as the primary treatment approach for uncontrolled upper extremity movements following head injury, as this combination addresses both the involuntary movement pattern and promotes restoration of normal motor control. 1

Initial Assessment: Distinguish Movement Disorder Type

The first critical step is determining whether you're dealing with:

• Adventitious movements (tremor, dystonia, chorea, myoclonus) - occurring in approximately 20% of severe head injury cases, often appearing or evolving months after injury 2, 3
• Spasticity with impaired motor control - more common presentation requiring different management 4
• Ataxia - cerebellar-pattern incoordination present in 68-86% of brainstem injuries 1

Key clinical distinction: Pure adventitious movements are rare; combinations with paresis, spasticity, or ataxia are the typical presentation 2. Observe whether movements are present at rest (suggesting chorea/dystonia) versus during voluntary action (suggesting tremor/ataxia).

Primary Treatment Protocol: Task-Specific Training + FES

Core Rehabilitation Approach

Implement intensive, repetitive, functional task practice that is progressively challenging and graded to individual capabilities. 1 This means:

• Practice actual functional activities (reaching, grasping, manipulating objects) rather than isolated exercises 1
• Increase difficulty systematically as control improves 1
• Focus on normal movement patterns with proper alignment during tasks 5
• Provide sufficient intensity, frequency, and duration of practice 1

Essential Adjunctive: Functional Electrical Stimulation

Apply FES to affected upper extremity muscles during active task practice - never as standalone treatment. 1, 5 FES is specifically beneficial for patients with impaired muscle contraction and motor control deficits 5, 6. The electrical stimulation provides sensory input that facilitates more complete muscle contractions and enhances motor learning 5.

Structured Resistance Training (When Appropriate)

Add resistance training as an adjunct when therapy time permits, starting at very low intensity. 5

• Begin at 40% of 1-repetition maximum with 10-15 repetitions 5
• Progress to moderate intensity (41-60% 1-RM) with 8-10 repetitions as tolerated 5
• Perform 2-3 times weekly to allow recovery between sessions 5
• Increase resistance only when 15 repetitions become "somewhat difficult" (Borg RPE 12-14) 5

Critical caveat: Do not progress resistance too quickly during initial sessions to avoid muscle damage 6. This is particularly important in post-traumatic cases where neuromuscular control is compromised.

Postural Training for Ataxia Component

If ataxia is present (delayed movement initiation, timing errors, dysmetria):

• Provide trunk support and postural training to improve proximal control 1
• Implement task-oriented upper limb training focusing on accuracy and reduced variability 1
• Reduce trunk motion during reaching activities 1

Pharmacological Considerations for Adventitious Movements

If true chorea is present (not simply uncoordinated voluntary movement), consider tetrabenazine - the only FDA-approved medication for involuntary movements, though indicated specifically for Huntington's chorea 7. However, this requires:

• Absolute contraindication if patient has depression or suicidal ideation 7
• Screening for liver problems 7
• Gradual dose titration over several weeks 7
• Close monitoring for depression, sedation, parkinsonism, and akathisia 7

Important limitation: Tetrabenazine does not treat the underlying cause and does not improve other neurological deficits 7. Most post-traumatic movement disorders respond better to rehabilitation than pharmacotherapy 2.

What NOT to Do: Critical Contraindications

• Do NOT use splinting or prolonged immobilization - this prevents restoration of normal movement and promotes learned non-use 5, 6
• Do NOT rely on passive range of motion alone - active motor practice is essential for recovery 5
• Do NOT use overhead pulleys - these encourage uncontrolled movements 1
• Avoid prolonged positioning at end ranges - this exacerbates symptoms and impedes recovery 5, 6

Surgical Options for Refractory Cases

Consider functional stereotactic surgery (deep brain stimulation or thalamic lesioning) only for disabling movement disorders refractory to 9-12 months of intensive medical and rehabilitation treatment. 3

• Deep brain stimulation is increasingly preferred over radiofrequency lesioning due to lower risk of dysarthria and gait disturbance 3
• Particularly relevant for kinetic tremor or dystonia causing marked disability 3
• Target selection (pallidal versus thalamic) remains unclear for post-traumatic dystonia 3

Timeline and Prognosis

• Most motor recovery occurs within the first 6 months - this is the critical window for intensive rehabilitation 5, 6
• Continue structured rehabilitation for 9-12 months depending on functional goals 5, 6
• Tremors may improve over time, but dystonia and other syndromes tend to persist without intervention 2
• Movement disorders often appear or evolve in the months following injury, not immediately 2, 3

Common Pitfall to Avoid

Do not assume uncontrolled movements will spontaneously resolve. While some transient movement disorders after mild-moderate head injury improve without intervention, persistent uncontrolled movements in a 20-year-old post-severe head injury require active rehabilitation 2, 3. The specific deficit pattern will not improve without structured resistance training and task-specific practice 5, 6.