Periodic Limb Movement Disorder (PLMD) in Adults
What is periodic limb movement disorder (PLMD)?
Periodic limb movement disorder (PLMD) is a condition that was formerly called sleep myoclonus or nocturnal myoclonus. It is described as repetitive limb movements that occur during sleep and cause sleep disruption. The limb movements usually involve the lower extremities, consisting of extension of the big toe and flexion of the ankle, the knee, and the hip. In some patients, the limb movements can occur in the upper extremities as well.
The limb movements occur most frequently in light non-REM sleep. The repetitive movements are separated by fairly regular intervals of 5 to 90 seconds. There can be significant night-to-night variability to the frequency of limb movements.
Who gets periodic limb movement disorder (PLMD)?
Many individuals have periodic limb movements in sleep (PLMS). This is observed in about 80% of patients with restless legs syndrome (RLS). PLMS can occur in over 30% of people aged 65 and older and can be asymptomatic. PLMS are very common in patients with narcolepsy and REM behavior disorder, and may be seen in patients with obstructive sleep apnea and during PAP therapy initiation.
True PLMD – the diagnosis of which requires periodic limb movements in sleep that disrupt sleep and are not accounted for by another primary sleep disorder including RLS – is uncommon.
PLMD has been less extensively studied than RLS. The exact prevalence is unknown. It can occur at any age; however, the prevalence does increase with increasing age. Unlike RLS, PLMD does not appear to be related to gender.
Symptoms and Causes
What causes periodic limb movement disorder (PLMD)?
The exact cause of PLMD is unknown. However, several medications are known to make PLMD worse. These medications include some antidepressants, antihistamines, and some antipsychotics. PLMD may be related to a low iron level or problems with limb nerve conduction due to diabetes or kidney disease. Though not necessarily a cause, the following are all thought to "influence" or increase the risk of periodic limb movements in sleep:
- Restless legs syndrome
- Side effects of some medications including antidepressants (eg, tricyclic antidepressants and SSRIs [selective serotonin reuptake inhibitors]), dopamine-receptor antagonists (eg, some anti-nausea drugs), lithium and some anticonvulsants
- Other sleep disorders such as narcolepsy (a sleep disorder involving overpowering urge to sleep during waking hours) and sleep-related eating disorder
- Neurodevelopmental and genetic disorders, including attention deficit hyperactivity disorder (ADHD) and William's syndrome
- Spinal cord injury/spinal cord tumor
What are some of the symptoms of periodic limb movement disorder (PLMD)?
Most patients are actually not aware of the involuntary limb movements. The limb jerks are more often reported by bed partners. Patients experience frequent awakenings from sleep, non-restorative sleep, daytime fatigue, and/or daytime sleepiness.
Diagnosis and Tests
How do I know if I have periodic limb movement disorder (PLMD)?
The diagnosis is based on the clinical history as well as an overnight polysomnogram (PSG). This is a test that records sleep and the bioelectrical signals coming from the body during sleep. A thorough neurological examination should be performed. Respiratory monitoring during the PSG allows one to rule out the presence of sleep disordered breathing as a cause for the disrupted sleep and excessive muscle activity. Occasionally, additional sleep laboratory testing is useful. Blood work may be ordered to check on iron, folic acid, vitamin B12, thyroid function, and magnesium levels.
Management and Treatment
How is periodic limb movement disorder (PLMD) treated?
First, certain products and medications should be avoided. Caffeine often intensifies PLMD symptoms. Caffeine-containing products such as chocolate, coffee, tea, and soft drinks should be avoided. Also, many antidepressants can cause a worsening of PLMD in many patients and should be reviewed, discussed and replaced by your doctor.
Generally, there are several classes of drugs that are used to treat PLMD. These include dopamine agonist, anticonvulsant medications, benzodiazepines, and narcotics. Current treatment recommendations consider the dopamine agonist as a first line of defense. Medical treatment of PLMD often significantly reduces or eliminates the symptoms of these disorders. There is no cure for PLMD and medical treatment must be continued to provide relief.