Movement Disorders

Movement disorders are stereotypic movements noted during sleep that are non-purposeful.

Katy's Story

Katy’s mother brings her in for a well child visit. During the course of the visit, she mentions that Katy’s grandmother is concerned about some funny movements she noted during Katy's sleep when Katy was spending the night at her house over the summer. Grandmother reports that she has noted that Katy’s entire body seems to jump shortly after she falls asleep. Grandmother has raised concerns that Katy may be having a seizure during sleep.

Katy’s mother reports she has not noticed these movements because Katy sleeps in her own room and falls asleep without anyone being present. Katy is well rested in the mornings and doing well in school.

Expert Insights

BEARS Screening for Movement Disorders

As part of the clinic’s routine protocols all patients are screened with a BEARS assessment tool. Open the categories below to review some of the history that was obtained from Katy's and her family.

Bedtime Problems

Katy has no difficulty falling asleep by herself at home. While staying with her grandmother during the summer, she likes her grandmother to stay in the room until she falls asleep. Her grandmother has noted a jerking movement involving her entire body shortly after Katy falls asleep. Katy has no memory of these events and describes no leg discomfort or motor restlessness.

Expert Insights
  • Sleep starts occur shortly after sleep onset. Patients usually have no recollection of the movements but there may be associated sensations such as falling, vivid dreams or some sort of noise appreciated by the patient.
  • RLS may cause leg discomfort and motor restlessness worsened in the evening and at rest. This may delay sleep onset.
Excessive Daytime Sleepiness

Katy is well rested during in the morning without issues of daytime sleepiness.

Expert Insights
  • Sleep starts do not typically result in daytime sleepiness unless the patient is having severe or intense events that lead to sleep avoidance or sleep onset insomnia.
  • PLMs/RLS may result in daytime sleepiness if sleep is sufficiently disrupted (see previous case).

Katy does not have problematic awakenings during the night.

Expert Insights
  • Sleep starts may occur during sleep onset after awakenings.
  • RLS may result in difficulty returning to sleep after awakenings during the night leading to prolonged awakenings and difficulty returning to sleep.
Regularity & Duration

Katy has a consistent bedtime and wake time. She has a regular bedtime routine with enough time in bed to obtain adequate sleep.

Expert Insights
  • This history is important to determine diagnosis particularly if symptoms of non-restorative sleep and daytime sleepiness are felt to be an issue. It is important to determine if a child has adequate sleep duration based on age related needs before attributing daytime sleepiness to an underlying sleep disorder.
Sleep-Disordered Breathing / Snoring

Katy has no signs or symptoms of sleep disordered breathing such as snoring, difficulty breathing during sleep or sleep apnea.

Expert Insights
  • Screening for obstructive sleep apnea is important as leg movements during sleep can be noted at the termination of respiratory events. Knowing the cause of the leg movements (ie PLMs versus OSA) is important for determining the appropriate treatment.

Katy's Evaluation & Diagnosis

What evaluation & diagnostic protocol should the provider use to diagnose Katy’s funny movements and sleep onset?.
Check all that apply:

The evaluation protocol strategies we recommend for Katy's case are:

  • Determine child’s sleep history.
    • Delineate timing of symptoms (e.g., at sleep onset) as well as exacerbating/relieving factors.
  • Perform a physical exam.
    • Evaluate for signs of neuropathy or spinal cord injury that might contribute to leg movements.
  • Complete a Sleep Diary.
    • Document adequate sleep and timing of events noted at home.
  • Refer to a specialist.
    • Consider a psychosocial evaluation by a nurse, social work staff or clinical psychologist. Determine if emotional, family or environmental issues are contributing to Katy’s problems or family’s reaction to problems.
  • Have family videotape events.
    • Characterize movements noted by family and help determine if they are consistent with sleep starts. This can be very important in determine if additional testing is necessary.
  • Obtain a Pediatric Epworth Sleepiness Scale Score.
    • Determine if Katy is having symptoms of daytime sleepiness which have not been appreciated by her parents.

History is essential in the evaluation of Katy’s symptoms. If the movements noted are consistent with sleep starts and occur at sleep onset without affecting her daytime performance, her family can be reassured that these movements are a normal phenomenon and do not have long term effects. The Epworth Sleepiness Scale can help evaluate whether or not she has daytime sleepiness not appreciated by her family that might prompt additional evaluation. Home video taping can help confirm the diagnosis so that additional testing by sleep study is not required. Psychosocial evaluation may reveal additional emotional, family or environmental issues.

Elements of Katy's Sleep History

Sleep History Case Specific Information Katy's Evaluation Results

What the child does at night

What happens at sleep onset?

Katy reports going to sleep, by her report without incident. She does occasionally report having the sensation of falling at sleep onset but it does not frighten her.  Grandmother reports seeing Katy’s body have one jerking motion shortly after sleep onset.  It does not recur during the night that Grandmother reports.  Katy does not cry out and does not express any concern about going to sleep. Katy has no leg complaints.

Does the movement involve the entire body?

Is there any associated sensory component such as popping/banging noise, sensation of falling, flashing lights or a vivid dream?

Does the child cry out?

Is the child afraid to fall asleep?

Does the child complain of leg discomfort?

Review timing of events at night (bedtime/wake time)

Does it only occur at sleep onset?

Does the same movement occur during sleep onset after awakenings during the night?

Jerking movement occurs only once at sleep onset by the family’s report. Movements do not seem to increase with stress or decreased sleep; however, mom is not present at sleep onset so movements have only been noted by Grandmother.

Do these events occur more frequently with stress or sleep deprivation?

Screen for other sleep issues (OSA, restless leg syndrome)

Is there snoring or apnea associated with movements?

No snoring, restlessness, kicking or breath holding reported by the family.

Review of medications (antidepressants, seizure medications, and antihistamines all have impacts on sleep)

What medications is the patient taking that might affect sleep onset and movements during sleep? Does the patient drink caffeinated beverages?

Katy is taking no medications at this time. Katy is only allowed to drink caffeinated beverages when staying at her Grandmother’s house.

Assess for family history of sleep disorders

Is there a family history of RLS, seizures or OSA?

The family reports no family history of sleep disorders other than mild snoring in Grandfather. While meeting with the social worker, Grandmother reports that a family member died suddenly in sleep and Grandmother believes cause of death was a seizure.

Perform a Physical Exam

Information to obtain includes: Case Evaluation Results

A physical exam should include vital signs, HEENT exam, cardiovascular exam, and a neurologic exam. The neurologic exam is important to evaluate for potential causes of movements including neuropathy, spinal cord injury or seizure disorder.

Katy has a normal physical exam with normal vital signs and growth parameters. Her HEENT exam shows a Mallampati of 1 with no nasal obstruction and 1+ tonsils. Her neurological exam is also normal with no signs of neuropathy.

Complete a Sleep Diary

Information to obtain includes: Case Evaluation Results

Time in bed, sleep onset time, sleep offset time, awakenings during the night including frequency and duration, timing of movements noted after sleep onset and occurrence at other times during the night.

Katy typically goes to bed at 8:30 pm and falls asleep within 15 minutes. No prolonged awakenings are reported during the nights and sleep offset is at 7:30 am. When at Grandmother’s she goes to bed at 9:30, falls asleep quickly with jerking movements noted only within the first 10 minutes of sleep onset. Rise time at Grandmother’s house is 8:30 am.

Refer to a specialist

Information to obtain includes: Case Evaluation Results

Probably not indicated in Katy’s case unless she develops additional symptoms such as:

  • extreme daytime sleepiness.
  • episodes of nocturnal activity.
  • hallucinations associated with the movements described.

However, if social work services are not available in clinic, formal referral may be needed to evaluate additional components of case especially if referral to community resources seems likely.

Have family videotape events

Information to obtain includes: Case Evaluation Results

Capturing video of the movement event in the home setting via a camera or cellphone

Grandmother was able to videotape one of the jerking events that she had previously reported. The recording showed Katy with a brief jerk of her arms and legs shortly after she appeard to fall asleep.

Obtain an Epworth Sleepiness Scale Score

Information to obtain includes: Case Evaluation Results

Family and patient’s response to PESS questions.

Katy’s mother's responses resulted in a score of 2, Katy’s response resulted in a score of 1. Both of these scores suggested that Katy does not experience daytime sleepiness.

Options that are Not Recommended

Complete a Sleep Study

Completing a Sleep Study would not be informative in this situation.

Red Flags

  • Repeated generalized movement - consider nocturnal seizures if generalized movement occurs repeatedly during the night. Have caregivers observe and videotape the movements to determine the timing and extent of activity.
  • Bedtime anxiety or fears - additional evaluation and/or treatment is warranted.

When evaluating a child for possible parasomnias, consider how other health care providers may also need to be involved.

Expert Insights:
Triggers for Sleep Starts of Hypnic Jerks

Evaluation & Diagnosis

What evaluation & diagnostic is consistent with Katy's night time behaviors?
Check all that apply:

Katy's signs and symptoms are consistent with:

  • Sleep Starts

In this case, Restless Leg Syndrome, seizure disorder, or Periodic Leg Movement Disorder (PLMD) are not consistent with the information provided.

Katy's Treatment & Referrals

Now it’s time to recommend treatment options for Katy.
Check all that apply:

The following treatment strategies are recommended for Katy's sleep starts:

  • Reassurance.
  • Avoid caffeine intake.
  • Good sleep hygiene practices.
  • Screen for other sleep disorders.

Treatment Strategies for Movement Disorders

  • Reassue the family that sleep starts are normal phenomenon that do not result in long term issues.
  • Eliminate caffeine intake. Help family identify sources of caffeine intake and suggest alternative foods and beverages.
  • Stress the importance of good sleep hygiene practices including enough time in bed for the child to obtain adequate sleep.
  • Screen for OSA as a cause of nocturnal kicking.

When to consult a sleep specialist or refer to another discipline:

  • Social workers and/or clinical psychologist are very helpful if sleep starts cause anxiety or fear about going to sleep. They can evaluate other factors that may be the cause of sleep onset issues.
  • If movements are occurring throughout the night, referral to sleep specialist and evaluation by sleep study is indicated to determine if another sleep disorder is present.
  • Family representatives may be helpful if family having a difficult time with reassurance about the benign nature of sleep starts. They can help determine if the family members have cultural issues which may be playing a role in their concerns.
  • Consider referral to sleep specialist if other sleep disorders are suspected. If excessive daytime sleepiness is an issue despite adequate treatment and adequate sleep, an intrinsic disorder of sleepiness may be co-existing with the movement disorder.
  • Consider referral to pediatric neurologist if there is a concern for seizures.

Interdisciplinary Treatment Components

Katy's Results:

Good news! Katy’s sleep starts are occurring less frequently and causing less concern in her grandmother once she has understood that they occur normally and are not linked to long term problems. Additional information obtained about the family member who died helped reassure Grandmother that seizures were not to blame.

Treatment strategies for and results for Katy’s PLMD:

  • Family reassurance that sleep starts are normal. Grandmother stopped staying in the room during sleep onset when Katy is visiting. Katy continues to be well rested and doing well in school.
  • Eliminate caffeine intake. Katy replaced her intake of sweet tea with water while visiting Grandmother.
  • Continuation of good sleep habits with adequate time for sleep. Katy’s family was congratulated on her excellent sleep practices and encouraged to continue those. They were reminded that sleep starts may occur more commonly with sleep deprivation.
  • Screen for OSA. Katy did not have symptoms of snoring, apnea or choking during sleep.