eMedicine Specialties > Neurology > Sleep-Related Diseases

Periodic Limb Movement Disorder

Author: Wayne E Anderson, DO, Assistant Professor of Internal Medicine/Neurology, Western University of Health Sciences; Assistant Professor of Family Medicine, Touro University College of Osteopathic Medicine; Consulting Staff in Pain Management, Department of Neurology, California Pacific Medical Center
Contributor Information and Disclosures

Updated: Mar 30, 2007

Introduction

Background

Periodic limb movement (PLM) disorder is unique in that the movements occur during sleep. Most other movement disorders manifest during wakefulness. The condition is remarkably periodic, and the movements may cause poor sleep and subsequent daytime somnolence. PLM disorder may occur with other sleep disorders and is related to, but not synonymous with, restless leg syndrome (RLS), a less specific condition with sensory features that manifest during wakefulness. The majority of patients with RLS have PLM disorder, but the reverse is not true. Treatment involves either dopaminergic medication in an attempt to modify activity of the subcortical motor system or, more commonly, sedative medications to allow uninterrupted sleep. Many new agents are proving efficacious for treatment as well.

Symonds first described PLM disorder in 1953. The original name, "nocturnal myoclonus," does not describe the condition accurately, since the movements are slower than are those of myoclonus. The original name seldom is used today.

Pathophysiology

The etiology of the primary form of PLM disorder is uncertain. Suprasegmental disinhibition of the descending inhibitory pathways may be a factor. Vetrugno and colleagues report that evidence supports neuronal hyperexcitability with involvement of the central pattern generator for gait as the pathophysiology of PLM. This results in decreased dopamine transmission, potentially supporting the use of dopaminergic therapy to treat the condition.

Because the etiology is not clear, treatment is primarily to treat symptoms and does not modify the disease. Studies differ regarding the frequency of polyneuropathy in cases of PLM disorder. Martinez-Mena and Pastor found that only 1 of 9 patients had signs of neuropathy (Martinez-Mena, 1998).

The secondary forms of PLM disorder may be due to diabetes mellitus, spinal cord tumor, sleep apnea syndrome, narcolepsy, uremia, or anemia. Many authors report an association between attention deficit hyperactivity disorder (ADHD) and PLM disorder. Antidopaminergic, dopaminergic, or tricyclic drug therapy or cessation of treatment with barbiturates or benzodiazepines may initiate the syndrome as well. Voderholzer and colleagues noted an increased incidence of periodic limb movements during sleep in patients with Gilles de la Tourette syndrome. However, the authors emphasized that the different responses to pharmacological treatments are evidence against a pathophysiological relationship between PLM disorder and Gilles de la Tourette syndrome.

Frequency

United States

The exact frequency is not known.

International

The exact frequency is not known.

Mortality/Morbidity

Comorbid conditions may include other sleep disturbances or coexisting disorders (see Causes). The morbidity of PLM disorder itself is related to sleep disturbance.

Age

Prevalence increases with increasing age. The idiopathic form is rare before age 40 years.

Clinical

History

  • The presenting symptom may be stereotyped periodic limb movements that cause awakening during the night, but often the presenting complaint is poor sleep and daytime somnolence. Haba-Rubio et al report that sleep changes induced by periodic limb movements during sleep (PLMS) are associated with decreased physical and psychological fitness on awakening.
    • Occasionally, a bed partner may provide the history of limb movements.
    • Nozawa and colleagues studied arousal index and movement index in PLM disorder and noted that the sleep-wake disorders associated with PLM relate to threshold of awakening.
  • Leg movements are stereotyped and involve one or both limbs.
    • The movement simulates triple flexion with leg flexion, ankle dorsiflexion, and great toe extension; it lasts approximately 2 seconds and thus is not consistent with the rapid jerk that defines true myoclonus.
    • The periodicity ranges from 20-40 seconds with a variable duration. The movements are said to occur mainly in non–rapid eye movement (REM) sleep.

Physical

Physical and neurological examinations are normal. In some cases, excessive somnolence may be noted.

Causes

  • Potential risk factors or etiologic factors for secondary PLM disorder include the following:
    • Sleep apnea
    • Narcolepsy
    • Cataplexy
    • Drug dependency
    • Benzodiazepine withdrawal
    • Barbiturate withdrawal
    • Neuroleptic medication
    • Dopaminergic medication
    • Uremia
    • Anemia
    • Iron deficiency
    • Spinal cord injury
    • Diabetes mellitus

More on Periodic Limb Movement Disorder

Overview: Periodic Limb Movement Disorder
Differential Diagnoses & Workup: Periodic Limb Movement Disorder
Treatment & Medication: Periodic Limb Movement Disorder
Follow-up: Periodic Limb Movement Disorder
References
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References

  1. Haba-Rubio J, Staner L, Krieger J, Macher JP. What is the clinical significance of periodic limb movements during sleep?. Neurophysiol Clin. Dec 2004;34(6):293-300. [Medline].

  2. Hening WA, Allen RP, Earley CJ, et al. An update on the dopaminergic treatment of restless legs syndrome and periodic limb movement disorder. Sleep. May 1 2004;27(3):560-83. [Medline].

  3. Horiguchi J, Inami Y, Sasaki A, et al. Periodic leg movements in sleep with restless legs syndrome: effect of clonazepam treatment. Jpn J Psychiatry Neurol. Sep 1992;46(3):727-32. [Medline].

  4. Inami Y, Horiguchi J, Nishimatsu O, et al. A polysomnographic study on periodic limb movements in patients with restless legs syndrome and neuroleptic-induced akathisia. Hiroshima J Med Sci. Dec 1997;46(4):133-41. [Medline].

  5. Iriarte J, Urrestarazu E, Alegre M, et al. Oscillatory cortical changes during periodic limb movements. Sleep. Dec 15 2004;27(8):1493-8. [Medline].

  6. Littner MR, Kushida C, Anderson WM, et al. Practice parameters for the dopaminergic treatment of restless legs syndrome and periodic limb movement disorder. Sleep. May 1 2004;27(3):557-9. [Medline].

  7. Martinez-Mena JM, Pastor J. [Polyneuropathy in patients with periodic leg movements during sleep]. Rev Neurol. Nov 1998;27(159):745-9. [Medline].

  8. Mello MT, Silva AC, Rueda AD, et al. Correlation between K complex, periodic leg movements (PLM), and myoclonus during sleep in paraplegic adults before and after an acute physical activity. Spinal Cord. Apr 1997;35(4):248-52. [Medline].

  9. Nozawa T, Ichikawa H, Takeuchi T. Periodic limb movements and sleep-wake disorder. Psychiatry Clin Neurosci. Apr 1998;52(2):192-4. [Medline].

  10. Picchietti DL, England SJ, Walters AS, et al. Periodic limb movement disorder and restless legs syndrome in children with attention-deficit hyperactivity disorder. J Child Neurol. Dec 1998;13(12):588-94. [Medline].

  11. Pieta J, Millar T, Zacharias J, et al. Effect of pergolide on restless legs and leg movements in sleep in uremic patients. Sleep. Sep 15 1998;21(6):617-22. [Medline].

  12. Ulfberg J, Jonsson R, Lindberg E, et al. [Restless legs. A much neglected syndrome]. Lakartidningen. Mar 10 1999;96(10):1183-4, 1187-8. [Medline].

  13. Vetrugno R, D'Angelo R, Montagna P. Periodic limb movements in sleep and periodic limb movement disorder. Neurol Sci. Jan 2007;28 Suppl 1:S9-S14. [Medline].

  14. Vignatelli L, Billiard M, Clarenbach P. EFNS guidelines on management of restless legs syndrome and periodic limb movement disorder in sleep. Eur J Neurol. Oct 2006;13(10):1049-65. [Medline].

  15. Voderholzer U, Muller N, Haag C, et al. Periodic limb movements during sleep are a frequent finding in patients with Gilles de la Tourette''s syndrome. J Neurol. Aug 1997;244(8):521-6. [Medline].

  16. Wetter TC, Pollmacher T. Restless legs and periodic leg movements in sleep syndromes. J Neurol. Apr 1997;244(4 Suppl 1):S37-45. [Medline].

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Further Reading

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Keywords

PLM, restless leg syndrome, RLS, nocturnal myoclonus, sleep disorders, PLMS, periodic limb movements during sleep, ADHD, attention deficit hyperactivity disorder, PLM disorder, diabetes mellitus, spinal cord tumor, sleep apnea syndrome, narcolepsy, uremia, anemia, sleep disturbances, sleep apnea

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Contributor Information and Disclosures

Author

Wayne E Anderson, DO, Assistant Professor of Internal Medicine/Neurology, Western University of Health Sciences; Assistant Professor of Family Medicine, Touro University College of Osteopathic Medicine; Consulting Staff in Pain Management, Department of Neurology, California Pacific Medical Center
Wayne E Anderson, DO is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Medical Association, American Society of Law Medicine and Ethics, California Medical Association, and San Francisco Medical Society
Disclosure: Cephalon Honoraria Speaking and teaching; Janssen Honoraria Speaking and teaching; Ligand Honoraria Consulting; Alpharma Honoraria Speaking and teaching

Medical Editor

Sydney Louis, MD, Emeritus Professor, Department of Neurology, Brown University School of Medicine
Sydney Louis, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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