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: Aug 26, 2009

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. Periodic limb movement disorder may occur with other sleep disorders and is related to, but not synonymous with, restless legs syndrome (RLS), a less specific condition with sensory features that manifest during wakefulness. The majority of patients with restless legs syndrome have periodic limb movement 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 periodic limb movement 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 term nocturnal myoclonus is seldom used today.

Pathophysiology

The etiology of the primary form of periodic limb movement 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 periodic limb movement.1 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 periodic limb movement disorder. Martinez-Mena and Pastor found that only 1 of 9 patients had signs of neuropathy.2

The secondary forms of periodic limb movement 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 periodic limb movement 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.3 However, the authors emphasized that the different responses to pharmacological treatments are evidence against a pathophysiological relationship between periodic limb movement 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 periodic limb movement disorder itself is related to sleep disturbance.

Age

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

Clinical

History

  • Unexplained insomnia is a possible presenting symptom of periodic limb movement disorder.4
  • 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 are associated with decreased physical and psychological fitness on awakening.5
    • Occasionally, a bed partner may provide the history of limb movements.
    • Nozawa and colleagues studied arousal index and movement index in periodic limb movement disorder and noted that the sleep-wake disorders associated with periodic limb movement relate to threshold of awakening.6
  • 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.
  • Growing evidence suggests a link between restless legs syndrome and periodic limb movement or sleep disorder. Picchietti et al provide evidence supporting the concept that periodic limb movement disorder may be a marker for an RLS genotype.7
  • The patient history may include ADHD. Walters et al provide an association between ADHD and sleep movement disorders including periodic limb movement disorder.8

Physical

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

Causes

Potential risk factors or etiologic factors for secondary periodic limb movement 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. 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].

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

  3. Voderholzer U, Müller N, Haag C, Riemann D, Straube A. 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].

  4. Ferri R, Gschliesser V, Frauscher B, Poewe W, Högl B. Periodic leg movements during sleep and periodic limb movement disorder in patients presenting with unexplained insomnia. Clin Neurophysiol. Feb 2009;120(2):257-63. [Medline].

  5. 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].

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

  7. Picchietti DL, Rajendran RR, Wilson MP, Picchietti MA. Pediatric restless legs syndrome and periodic limb movement disorder: Parent-child pairs. Sleep Med. Mar 20 2009;[Medline].

  8. Walters AS, Silvestri R, Zucconi M, Chandrashekariah R, Konofal E. Review of the possible relationship and hypothetical links between attention deficit hyperactivity disorder (ADHD) and the simple sleep related movement disorders, parasomnias, hypersomnias, and circadian rhythm disorders. J Clin Sleep Med. Dec 15 2008;4(6):591-600. [Medline].

  9. Picchietti MA, Picchietti DL, England SJ, Waiters AS, Couvadelli BV, Lewin DS, et al. Children show individual night-to-night variability of periodic limb movements in sleep. Sleep. Apr 1 2009;32(4):530-5. [Medline].

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

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

  17. 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].

  18. 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].

  19. [Guideline] 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].

  20. 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

periodic limb movement disorder, 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 Medical Association, American Society of Law Medicine and Ethics, California Medical Association, and San Francisco Medical Society
Disclosure: Cephalon Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; King Honoraria Consulting

Medical Editor

Sydney Louis, MB, BCh, MD, Emeritus Professor, Department of Neurology, Brown University School of Medicine
Sydney Louis, MB, BCh, 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: eMedicine Salary Employment

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.

Chief 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.

 
 
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