Movement Disorders in

Dylan Moquin BS, RST, RPSGT Sleep Program Coordinator UF Health Sleep Center Program Coordinator Santa Fe College Program Overview

• Define Movement Disorders in Sleep • Pathophysiology • Review the various types of movement disorders • Treatment Movement Disorders in Sleep – Characterized by simple movements that disturb sleep or during the period Types of Movement Disorders in Sleep

There are ten primary sleep-related movement disorders identified in the current International Classification of Sleep Disorders 3rd Edition. Sleep-Related Movement Disorders

• • Propriospinal at • Periodic Limb Movement Sleep Onset • Sleep Related Leg Cramps • Sleep Related Movement Disorder Due to a Medical • Sleep Related Disorder • Sleep Related Rhythmic • Sleep Related Movement Movement Disorder Disorder Due to Medication or • Benign Sleep Myoclonus of Substance Infancy • Unspecified Restless Legs Syndrome (Willis-Ekbom disease)

• Sensorimotor disorder – strong need to move limbs • Urge to move legs – uncomfortable sensation – “creepy – crawly , ants, shock- like” • Worse during inactivity • Relieved by movement (depending on severity Sleep Relate Movement Disorder - RLS

• Prevalence approximate 2-5% population (depending on region) • Children and Adult (increasing with age) • 2 times higher in women then men RLS and Sleep Impact

• DIMS • 60-90% of patients report poor sleep quality • Daytime fatigue and sleepiness What Causes RLS?

• Positive Family History • Iron Deficiency (ferritin below 50 ug/L) – Brain Iron Deficiency • Medications – antihistamines, antipsychotics and antidepressants – CNS dopamine regulation • Pregnancy (prevalence 2 -3 times higher) • Chronic Renal Failure - Uremia (40% under hemodialysis) • Strong relationship between RLS, PLMS, and ADHD (44% children) Treatment for RLS

• Behavioral Modification – regular exercise, , avoid exacerbating medications. • Medication - Sinement, Mirapex, Requip • The use of Opiods and Benzodiazepines – Oxycodone or Klonopin • Neurontin (anticonvulsant) Periodic Limb Movement Disorder (PLMD)

• Periodic episodes of repetitive limb movements • Occur mostly in the lower extremities • Extension of the great toe (Big), partial flexion of the ankle, occasionally with knee and hip involvement • Can cause EEG arousal Sleep Related Movement Disorder - PLMD

• Exact prevalence is unknown • Report in both children and adults • Increasing in prevalence with advancing age PLMD Impact on Sleep

• Sleep Maintenance • Daytime Sleepiness • Fatigue • Increased Nocturnal Blood Pressure • Can appear immediately with sleep onset N1 • Frequent in Stage N2 • Decrease in N3 and typically no factor during REM

PLMD What Causes PLMD?

• Questionable family history – increase risk • Iron Deficiency (Low Brain Iron) • Metabolic Disorders – such as Diabetes • Spinal Cord Injury – multiple system atrophy • Medications – SSRI and Tricyclic antidepressants • Medication withdrawal – anticonvulsants and benzodiazepines • Strong relationship between RLS, PLMS, and ADHD (44% children) Treatment for PLMD

• Behavioral Modification – Exercise and stretching • Avoid caffeine, nicotine, and alcohol • Avoid antihistamines • Medication - Dopaminergic (Carbidopa/Levodopa), Anticonvulsants (Neurontin), Narcotics (Oxycodone, Methadone) Sleep Related Bruxism

• Repetitive jaw – muscle activity (clenching or grinding) • Rhythmic Masticatory Muscle Activity (RMMA) • Repetitive Activity – Phasic • Sustained jaw clenching - Tonic Sleep Related Movement Disorder - Bruxism

• Highest prevalence in children (estimated up to 17%) • Decreasing over time • Teenager 12% • Middle Adulthood 8% • Older 3% Bruxism and Sleep Impact

• Slight change in autonomic – cardiac sympathetic (increase) and parasympathetic (decrease) balance • Most common in N1 and N2 • Rise in EEG alpha and delta activity • May trigger sleep arousals • Jaw pain in the AM • in the AM

Bruxism What Causes Bruxism

• Positive family history (20% - 50%) • Associated with exacerbating psychosocial factors • Medical or psychiatric conditions • Drug use – cocaine, ecstasy, amphetamines Treatment of Bruxism

• Behavior modifications – relaxation, stress reduction, biofeedback • Mouth guards • Medications – Buspirone, Lorazepam, Trazodone Sleep Related Rhythmic Movement Disorder

• Repetitive and rhythmic motor • Body Rocking – rocking while behaviors of large muscle on hands and knees groups during drowsiness or • Head Banging – head striking sleep an object • Head Rolling – head moving laterally • Body Rolling – full-body movement from side-to-side Sleep Related Rhythmic Movement Disorder

• Typically in early childhood • Historically resolve during the second or third year of life • Rare in adolescence and adulthood What Causes Rhythmic Movement Disorder?

• Environmental Stress • Lack of environmental stimulation • Intellectual disability – Autism • Calming technique for insomnia in children • Blindness • GERD (in children) Sleep Impact in Rhythmic Movement Disorder

• Associated in N1 and N2 Sleep • Can occur during REM Sleep (more often in adults) • Significant impairment in daytime function • Interference with normal sleep • Self-inflicted bodily injury Head Banging Head Banging Body Rolling Body Rolling Body Rocking Body Rocking with head banging Head Rolling Head Rolling Treatment for Sleep Related Movement Disorders

• Remits spontaneously in younger patients • Environmental protection • Behavior management – avoiding emotional stress • Severe cases – hypnotic medication or benzodiazepines Isolate Symptoms and Normal Variants

• Excessive Fragmentary Myoclonus (EFM) – small movement at the corner of mouth, fingers, toes (think of a baby sleeping) • Hypnagogic Foot Tremor – rhythmic movements of toes and feet during transitions from wakefulness to N1 • Alternating Leg Muscle Activation (ALMA) anterior tibialis activation from one leg to the other during sleep • – contraction of the body that occurs during sleep onset Hypnic Jerk with Summary

• Distressing for the patient(s) and the people involved in the event ( partner, parents, care givers, etc…) • Primary complaint of may overlap with other disorders • Potential for self injury • Impacts health and wellbeing • Very difficult to replicate in the clinical setting – Sleep Center • Very little understanding of the movement disorders in sleep. Further research needs to be conducted. References

• American Academy of . International Classification of Sleep Disorder 3rd ed. Darien, IL: American Academy of Sleep Medicine, 2014 • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders : DSM-5(5th ed.). Arlington, VA: American Psychiatric Association. • Berry, Richard. Fundamentals of Sleep Medicine. Philadelphia, PA: Elsevier, 2012 • Kryger, Avidan,and Berry. Atlas of Clinical Sleep Medicine 2nd ed. Philadelphia, PA: Elsevier, 2014 Contact Information – [email protected]

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