Rhythmic movement disorder

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Rhythmic movement disorder
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Rhythmic movement disorder (RMD) is a neurological disorder characterized by repetitive movements of large muscle groups immediately before and during sleep often involving the head and neck. It was independently described first in 1905 by Zappert as jactatio capitis nocturna and by Cruchet as rhythmie du sommeil. [1] The majority of RMD episodes occur during NREM sleep, although REM movements have been reported. RMD is often associated with other psychiatric conditions or mental disabilities. The disorder often leads to bodily injury from unwanted movements. Because of these incessant muscle contractions, patients' sleep patterns are often disrupted. It differs from restless legs syndrome in that RMD involves involuntary muscle contractions before and during sleep while restless legs syndrome is the urge to move before sleep. RMD occurs in both males and females, often during early childhood with symptoms diminishing with age. Many affected individuals also have other sleep related disorders, like sleep apnea. The disorder can be differentially diagnosed into small subcategories, including sleep related bruxism, thumb sucking, hypnagogic foot tremor, and rhythmic sucking, to name a few. [2] In order to be considered pathological, the ICSD-II requires that in the sleep-related rhythmic movements should “markedly interfere with normal sleep, cause significant impairment in daytime function, or result in self-inflicted bodily injury that requires medical treatment (or would result in injury if preventive measures were not used)”. [3]

Contents

Signs and symptoms

Most RMD symptoms are relatively passive and do not cause any pain. Many patients are often unaware that an episode is occurring or has occurred. The rhythmic movements may produce some bodily injury via falls or muscle strains, but this is not reported in all patients [4] . In unique cases of RMD, they hum or moan while asleep during an episode. Some patients describe the repetitive movements as relaxing and are only occasionally awakened by an RMD episode. Often, it is the their partner or parent who first notes the symptoms. Additionally, it is often the partner or parent who led patients to seek medical attention.[ citation needed ]

Motor symptoms

Symptoms of rhythmic movement disorder vary, but most share common large muscle movement patterns. Many show consistent symptoms including:[ citation needed ]

Other less common muscle movements include:

The majority of affected individuals have symptoms that involve the head, and the most common symptom is head banging. Usually, the head strikes a pillow or mattress near the frontal-parietal region. There is little cause for alarm at the movements as injury or brain damage as a result of the movements is rare. Some infants with diagnosed Costello Syndrome have been observed to have unique RMD episodes affecting the tongue and other facial muscles, which is an uncommonly affected area. [5] Episodes usually last less than fifteen minutes and produce movements that vary from 0.5 to 2 Hz. Muscle movements during REM sleep are often twitches and occur simultaneously with normal sleep. The position of the body during sleep may determine which motor symptom is displayed. For example, Anderson et al. reported that one individual showed entire body rolling movements while sleeping on his side while displaying head rolling movements when sleeping supine. [4]

Sleep

Because of the abnormal writhing movements, often patients’ sleep patterns are disrupted. This may be due to RMD's comorbidity with sleep apnea, which has been observed in some patients [6] . Many find that their sleep is not refreshing and are tired or stressed the following day, despite getting a full nights rest. However, other patients report that their sleep patterns are infrequently interrupted due to RMD episodes and do not report being excessively sleepy during the next day as scored on the Epworth Sleepiness Scale. [4] Thus, as can be seen, the effects and severity of RMD vary from person to person.[ citation needed ]

Brain activity

Rhythmic movement disorder is observed using the standard procedure for polysomnography, which includes video recording, EEG during sleep, EMG, and ECG. These aforementioned brain monitoring devices eliminate the possibility of epilepsy as a cause. Other sleep related disorders like sleep apnea are ruled out by examining the patients' respiratory effort, air flow, and oxygen saturation. RMD patients often show no abnormal activity that is directly the result of the disorder in an MRI scan. [7] RMD episodes are strongly associated with stage 2 NREM sleep and, specifically, K Complexes [8] . Additionally, there is a close association with Alpha waves that contain a mixture of K complexes and arousals, regardless of the NREM stage in which the RMD occurred. The occurrence of these two sequences of brain waves suggests that the disorder is linked to an “unstable vigilance level” throughout NREM sleep [9] . It has been noted that there is a complete absence of any EEG signs during or immediately after an intense rhythmic movement [10] . After the episode, normal EEG patterns return. Functional MRI scans have shown that the mesencephalon and pons may be involved in the loss of motor control seen during an RMD episode, which is similar to other movement disorders [11]

Episodes

Episodes of RMD are short, lasting between 3 and 130 seconds. Rare cases of constant RMD can last for hours. The majority of RMD episodes usually occur just before or during sleep. Some cases have been reported on rhythmic movements during wakeful activities like driving. When occurring in sleep, RMD episodes are more likely to onset during non-REM, stage 2 sleep. Roughly 46% of sleep-RMD episodes occur only in non-REM sleep; 30% in non-REM and REM; and only 24% strictly in REM sleep. [12] Most patients are unresponsive during an episode and are unlikely to remember the movements occurring upon awakening. In some patients who also experience sleep apnea, episodes of apnea can be followed immediately by RMD-like symptoms, suggesting that the apnea episodes may trigger an RMD episode. Similarly, current studies suggest that external stimuli are not the cause of RMD episodes. [13]

Associated conditions

The disorder is closely associated with developmental disabilities or autism. More recent studies have shown there is a strong link between prolonged RMD and ADHD. [14]

Causes

The direct cause and pathophysiological basis of RMD is still unknown and can occur in children and adults of perfect or non-perfect health. Rare cases of adult RMD have developed due to head trauma, stress, and herpes encephalitis. [1] Familial cases have been reported suggesting there may be some genetic aspect to the disorder; however, to date, this explanation has not been directly tested. As familial incidence rate is still relatively low, it is believed that behavioral aspects may play a larger role in RMD than family history and genetics. [13] Many with the condition report no family history of the disorder. Another theory suggests that RMD is a learned, self-stimulating behavior to alleviate tension and induce relaxation, similar to tic movements. [15] An alternative theory suggests that the rhythmic movements help develop the vestibular system in young children, which can partially explain the high prevalence of RMD in infants. It has been seen that children who have underdeveloped vestibular systems benefit from performing RMD-like movements which stimulate the vestibular system [16] .

Diagnosis

Diagnosis of rhythmic movement disorder is done on an exclusionary basis in which other closely related movement disorders are systematically ruled out. Because of this, a thorough clinical evaluation is necessary. Often, impairments are not severe enough to warrant this process and so RMD is not often diagnosed unless there are extremely interfering or disabling symptoms. Many patients do not seek treatment for RMD directly and most seek professional help to alleviate sleep-affecting symptoms. To compound the issue, many are often misdiagnosed as having Restless Legs Syndrome or sleep apnea or some combination of the two. [6] Rhythmic movement disorder differs from Restless Legs Syndrome in that RMD involves involuntary contractions of muscles with no urge or uncomfortable sensation to provoke such movement. Additionally, 80-90% of individuals with Restless Legs Syndrome show periodic limb movements as observed on a polysomnogram, which are not common in RMD patients. Rhythmic movement disorder can also have symptoms that overlap with epilepsy. However, use of a polysomnogram can help distinguish one disorder from the other as RMD involves movements in both REM and NREM sleep, which is unusual for seizures. [17] Additionally, patients can usually stop the movements upon request, unlike the movements observed in epilepsy. Other movement disorders like Parkinson's Disease, Huntington's Disease, ataxia, and dystonia differ from RMD in that they occur primarily during wakefulness and reduced sleep, whereas RMD episodes occur in or around sleep. [18]

Treatment

Medication

Medication is often not necessary in children as symptoms usually alleviate spontaneously as the child ages. However, because the disorder may affect wakeful behavior, many adults who continue to have RMD may seek treatment. Benzodiazepines or tricyclic antidepressants have been considered as therapeutic options in managing the disorder. Infantile and adolescent RMD respond well to low doses of clonazepam. [19] Prescription medications such as ropinirole or pramipexole given to restless legs syndrome patients do not show any clinical improvement in many patients with RMD. [6]

Non-medication

Treatment of sleep apnea via a continuous positive airway pressure (CPAP) device has shown dramatic improvement in apnea and nearly complete resolution of RMD symptoms. [7] Behavioral interventions may alleviate some RMD symptoms and movements. In such a therapy, affected individuals are asked to perform RMD-like motions during the day in a slow and methodic manner. In such, patients come short of full rhythmic movements that they experience in sleep. Such behavioral training has been shown to carry over into sleep, and the forcefulness of the RMD movements is reduced or eliminated. [2] Hypnosis and sleep restriction have been used in some cases to good effect. [18]

Epidemiology

Sleep-related movements are commonly seen in children, especially infants. However, the majority of these movements stop as the child ages. Some 66% of infants of 9-months show RMD-like symptoms compared to only 8% of 4 year olds. [2]

Related Research Articles

<span class="mw-page-title-main">Sleep disorder</span> Medical disorder of a persons sleep patterns

A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Sleep disorders are frequent and can have serious consequences on patients’ health and quality of life. Polysomnography and actigraphy are tests commonly ordered for diagnosing sleep disorders.

<span class="mw-page-title-main">Sleep paralysis</span> Sleeping disorder

Sleep paralysis is a state, during waking up or falling asleep, in which one is conscious but in a complete state of full-body paralysis. During an episode, one may hallucinate, which often results in fear. Episodes generally last no more than a few minutes. It can recur multiple times or occur as a single episode.

<span class="mw-page-title-main">Restless legs syndrome</span> Long-term disorder that causes a strong urge to move ones legs

Restless legs syndrome (RLS), also known as Willis–Ekbom disease (WED), is generally a long-term disorder that causes a strong urge to move one's legs. There is often an unpleasant feeling in the legs that improves somewhat by moving them. This is often described as aching, tingling, or crawling in nature. Occasionally, arms may also be affected. The feelings generally happen when at rest and therefore can make it hard to sleep. Due to the disturbance in sleep, people with RLS may be sleepy during the day, have low energy, and feel irritable or depressed. Additionally, many have limb twitching during sleep, a condition known as periodic limb movement disorder. RLS is not the same as habitual foot-tapping or leg-rocking.

<span class="mw-page-title-main">Rapid eye movement sleep behavior disorder</span> Medical condition

Rapid eye movement sleep behavior disorder or REM behavior disorder (RBD) is a sleep disorder in which people act out their dreams. It involves abnormal behavior during the sleep phase with rapid eye movement (REM) sleep. The major feature of RBD is loss of muscle atonia during otherwise intact REM sleep. The loss of motor inhibition leads to sleep behaviors ranging from simple limb twitches to more complex integrated movements that can be violent or result in injury to either the individual or their bedmates.

A hypnic jerk, hypnagogic jerk, sleep start, sleep twitch, myoclonic jerk, or night start is a brief and sudden involuntary contraction of the muscles of the body which occurs when a person is beginning to fall asleep, often causing the person to jump and awaken suddenly for a moment. Hypnic jerks are one form of involuntary muscle twitches called myoclonus.

<span class="mw-page-title-main">Night terror</span> Sleep disorder causing feelings of panic or dread

Night terror, also called sleep terror, is a sleep disorder causing feelings of panic or dread and typically occurring during the first hours of stage 3–4 non-rapid eye movement (NREM) sleep and lasting for 1 to 10 minutes. It can last longer, especially in children. Sleep terror is classified in the category of NREM-related parasomnias in the International Classification of Sleep Disorders. There are two other categories: REM-related parasomnias and other parasomnias. Parasomnias are qualified as undesirable physical events or experiences that occur during entry into sleep, during sleep, or during arousal from sleep.

<span class="mw-page-title-main">Myoclonus</span> Involuntary, irregular muscle twitch

Myoclonus is a brief, involuntary, irregular twitching of a muscle, a joint, or a group of muscles, different from clonus, which is rhythmic or regular. Myoclonus describes a medical sign and, generally, is not a diagnosis of a disease. These myoclonic twitches, jerks, or seizures are usually caused by sudden muscle contractions or brief lapses of contraction. The most common circumstance under which they occur is while falling asleep. Myoclonic jerks occur in healthy people and are experienced occasionally by everyone. However, when they appear with more persistence and become more widespread they can be a sign of various neurological disorders. Hiccups are a kind of myoclonic jerk specifically affecting the diaphragm. When a spasm is caused by another person it is known as a provoked spasm. Shuddering attacks in babies fall in this category.

Hypersomnia is a neurological disorder of excessive time spent sleeping or excessive sleepiness. It can have many possible causes and can cause distress and problems with functioning. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), hypersomnolence, of which there are several subtypes, appears under sleep-wake disorders.

Sexsomnia, also known as sleep sex, is a distinct form of parasomnia, or an abnormal activity that occurs while an individual is asleep. Sexsomnia is characterized by an individual engaging in sexual acts while in non-rapid eye movement (NREM) sleep. Sexual behaviors that result from sexsomnia are not to be mistaken with normal nocturnal sexual behaviors, which do not occur during NREM sleep. Sexual behaviors that are viewed as normal during sleep and are accompanied by extensive research and documentation include nocturnal emissions, nocturnal erections, and sleep orgasms.

<span class="mw-page-title-main">Hyperkinesia</span> Excessive movements due to basal ganglia dysfunction

Hyperkinesia refers to an increase in muscular activity that can result in excessive abnormal movements, excessive normal movements, or a combination of both. Hyperkinesia is a state of excessive restlessness which is featured in a large variety of disorders that affect the ability to control motor movement, such as Huntington's disease. It is the opposite of hypokinesia, which refers to decreased bodily movement, as commonly manifested in Parkinson's disease.

<span class="mw-page-title-main">Polysomnography</span> Multi-parameter study of sleep and sleep disorders

Polysomnography (PSG), a type of sleep study, is a multi-parameter study of sleep and a diagnostic tool in sleep medicine. The test result is called a polysomnogram, also abbreviated PSG. The name is derived from Greek and Latin roots: the Greek πολύς, the Latin somnus ("sleep"), and the Greek γράφειν.

Periodic limb movement disorder (PLMD) is a sleep disorder where the patient moves limbs involuntarily and periodically during sleep, and has symptoms or problems related to the movement. PLMD should not be confused with restless legs syndrome (RLS), which is characterized by a voluntary response to an urge to move legs due to discomfort. PLMD on the other hand is involuntary, and the patient is often unaware of these movements altogether. Periodic limb movements (PLMs) occurring during daytime period can be found but are considered as a symptom of RLS; only PLMs during sleep can suggest a diagnosis of PLMD.

<span class="mw-page-title-main">K-complex</span>

A K-complex is a waveform that may be seen on an electroencephalogram (EEG). It occurs during stage 2 NREM sleep. It is the "largest event in healthy human EEG". They are more frequent in the first sleep cycles.

<span class="mw-page-title-main">Obstructive sleep apnea</span> Sleeping and breathing disorder

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, which – in combination with disturbances in blood oxygenation – is thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime.

Parasomnias are a category of sleep disorders that involve abnormal movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep. Parasomnias are dissociated sleep states which are partial arousals during the transitions between wakefulness, NREM sleep, and REM sleep, and their combinations.

The International Classification of Sleep Disorders (ICSD) is "a primary diagnostic, epidemiological and coding resource for clinicians and researchers in the field of sleep and sleep medicine". The ICSD was produced by the American Academy of Sleep Medicine (AASM) in association with the European Sleep Research Society, the Japanese Society of Sleep Research, and the Latin American Sleep Society. The classification was developed as a revision and update of the Diagnostic Classification of Sleep and Arousal Disorders (DCSAD) that was produced by both the Association of Sleep Disorders Centers (ASDC) and the Association for the Psychophysiological Study of Sleep and was published in the journal Sleep in 1979. A second edition, called ICSD-2, was published by the AASM in 2005. The third edition, ICSD-3, was released by the AASM in 2014. A text revision of the third edition (ICSD-3-TR) was published in 2023 by the AASM.

When we sleep, our breathing changes due to normal biological processes that affect both our respiratory and muscular systems.

<span class="mw-page-title-main">Sleep study</span> Sleep Medicine

A sleep study is a test that records the activity of the body during sleep. There are five main types of sleep studies that use different methods to test for different sleep characteristics and disorders. These include simple sleep studies, polysomnography, multiple sleep latency tests (MSLTs), maintenance of wakefulness tests (MWTs), and home sleep tests (HSTs). In medicine, sleep studies have been useful in identifying and ruling out various sleep disorders. Sleep studies have also been valuable to psychology, in which they have provided insight into brain activity and the other physiological factors of both sleep disorders and normal sleep. This has allowed further research to be done on the relationship between sleep and behavioral and psychological factors.

Classification of sleep disorders comprises systems for classifying medical disorders associated with sleep. Systems have changed, increasingly using technological discoveries to advance the understanding of sleep and recognition of sleep disorders.

Infantile apnea is a rare disease that is characterized by cessation of breathing in an infant for at least 20 seconds or a shorter respiratory pause that is associated with a slow heart rate, bluish discolouration of the skin, extreme paleness, gagging, choking and/or decreased muscle tone. Infantile apnea occurs in children under the age of one and it is more common in premature infants. Symptoms of infantile apnea occur most frequently during the rapid eye movement (REM) stage of sleep. The nature and severity of breathing problems in patients can be detected in a sleep study called a polysomnography which measures the brain waves, heartbeat, body movements and breathing of a patient overnight. Infantile apnea can be caused by developmental problems that result in an immature brainstem or it can be caused other medical conditions. As children grow and develop, infantile apnea usually does not persist. Infantile apnea may be related to some cases of sudden infant death syndrome (SIDS) however, the relationship between infantile apnea and SIDS is not known.

References

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  5. ↑ Della Marca G, Rubino M, Vollono C, Vasta I, Scarano E, Mariotti P, Cianfoni A, Mennuni GF, Tonali P, Zampino G (2006). "Rhythmic tongue movements during sleep: a peculiar parasomnia in Costello syndrome". Mov. Disord. 21 (4): 473–8. doi:10.1002/mds.20741. PMID   16250029. S2CID   22316426.
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