Movement Disorders

Introduction & Background Scenario Activities Resources & Clinical Tools CME Certification for Module

Sleep related bruxism is increased in children with a family history of bruxism

Periodic leg movements during sleep are associated with certain medications and medical conditions

As many as

60 %
of infants will exhibit some form of rhythmic movement disorder (head banging, body rocking or head rolling) by 9 months of age

By the end of this module, you will be able to:

Recognize that Rhythmic Movement Disorder (RMD) can be seen in normal children and share this with the family.
Describe what happens in RMD.
Recognize that sleep disruption by Periodic Leg Movement During Sleep (PLMS) can have adverse daytime consequences.
Recognize that PLMS can lead to difficulty initiating and maintaining sleep (DIMS).
Identify approaches to the treatment for PLMS.

Movement disorders are stereotypic movements noted during sleep that are non-purposeful. These movements may be noted at sleep onset, during sleep wake transitions during the night or during any stage of sleep. They may disrupt sleep or cause concern for caregivers who observe the behavior during sleep. Most are self-limited and do not require specific intervention.

Different types of sleep related movement disorders include rhythmic movement disorder, bruxism, benign sleep myoclonus of infancy, sleep starts, periodic limb movements, hypnagogic foot tremor (HFT), alternating leg muscle activation (ALMA), sleep related leg cramps and excessive fragmentary myoclonus. Restless leg syndrome is another disorder with daytime manifestations which can resulting in kicking during sleep.

Different types of sleep related movement disorders include:

Rhythmic movement disorder.
Bruxism.
Benign sleep myoclonus of infancy.
Sleep starts.
Periodic limb movements.
Hypnagogic foot tremor (HFT).
Alternating leg muscle activation (ALMA).
Sleep related leg cramps.
Excessive fragmentary myoclonus.
Restless leg syndrome may manifest as kicking during sleep (and daytime manifestations).

Movement disorders that primarily occur at sleep onset or after awakenings:

Rhythmic movements.
Sleep starts.
Hypnagogic foot tremor (HFT).
Alternating leg muscle activation (ALMA).

1 Rhythmic Movement Disorders (RMD)

Rhythmic movement disorders (RMD) are movements that occur at sleep onset and after sleep wake transitions often involving large muscles in stereotypic and repeated movements. The most common RMDs include head banging (also known as jactatio capitis nocturna), body rocking, body rolling and head rolling. Additional less common types include leg rolling and leg banging. The intensity of the movements may be subtle or more violent and the frequency of these movements is usually 0.5 to 2 per second. These types of movements are very common in childhood with up to 60% of infants demonstrating at least one of these by 9 months of age. The movements are more common in males and usually decrease with age but can persist into adulthood.

2 Sleep-Related Bruxism

In sleep-related bruxism there is grinding or clenching of teeth in a rhythmic fashion during sleep which results in an audible sound. These events occur with involuntary contractions of muscles about the jaw including the masseter and temporalis muscle. The child may report headaches, muscle tenderness or jaw pain upon awakening. It is considered a disorder if it results in abnormal tooth wear, jaw muscle discomfort, or fatigue and masseter muscle hypertrophy noted during wakefulness with voluntary jaw clenching. This occurs equally in males and females, decreases with age, and is associated with a family pattern of bruxism.

3 Periodic Limb Movements (PLMs)

Periodic limb movements (PLMs) are repetitive, stereotyped movements of the limbs that occur during sleep. Although both arms and legs can be affected, they are most commonly noted in legs with the most common movement comprising extension of the big toe and dorsiflexion of the foot. Evaluation by polysomnography shows repetitive movements that occur in a series of at least four movements with movements lasting 0.5 to 10 seconds and occurring every 5 to 90 seconds. The child or adolescent is usually unaware of these movements but they are often observed by caregivers especially with co-sleeping. Such movements during sleep can result in sleep disruption and arousals.

4 Restless Leg Syndrome

Restless legs syndrome (RLS) is a clinical diagnosis with motor and sensory complaints. The components of RLS include an urge to move legs or the body, uncomfortable sensations in legs or arms, worsening of sensations with rest or in the evening and improvement in the sensations with movement.

The diagnosis of RLS in children is more difficult if they are unable to articulate the urge to move and/or the discomfort experienced. RLS can result in the child being fidgety during the day, overly active and having difficulty settling down to sleep at night.
These feelings can be exacerbated by long period of inactivity (sitting in car or at school desk for long period of time). Difficulty settling down to sleep can be perceived as bedtime resistance by caregivers or medical professionals.
The official name of RLS was changed to Willis-Ekbom disease in 2013. Studies in adults show that 70-90% of adults with RLS will have PLMs during sleep. Similar studies are not yet available in children. Population estimates suggest the prevalence of RLS in children ranges from 1-6%.

Additional less common movement disorders include:

Other Movement Disorders	Description
Sleep Starts	Sleep starts are also called hypnic jerks and comprise a brief involuntary sudden muscle contraction involving legs, arms or head that only occur at sleep onset. These are normal and may be associated with a sensation of falling.
Hypnagogic foot tremor (HFT) Alternating leg muscle activation (ALMA)	HFT and ALMA are benign leg movements that occur at sleep wake transitions and during light sleep. They consist of rhythmic movements with rapid frequency, every second or so, distinguishing them from PLMs. HFT involves one foot moving. ALMA involves alternating movements between both feet. These are considered benign phenomenon not specifically requiring treatment and have been associated with antidepressant use. ALMA has also been noted to co-exist in patients with obstructive sleep apnea and PLMs.
Benign sleep myoclonus of infancy (BSMI)	BSMI occurs only in infants and usually resolves by age 6 months. It consists of repetitive myoclonic jerks affecting the entire body, the trunk or the limbs. Additional evaluation may be required to distinguish BSMI from sleep related epilepsy.
Sleep related leg cramps	Sleep related leg cramps are painful muscle contractions involving the calf or foot during the sleep period. They may last for a few seconds to several minutes and may result in sleep disruption and awakenings. They can occur at any age and can be associated with peripheral neuropathy or metabolic derangements (hypokalemia, dehydration). Treatment initially involves targeting the underlying condition.
Excessive fragmentary myoclonus (EFM)	EFM is manifested by brief asymmetric muscle contractions during NREM sleep involving many possible areas including face, arms, fingers, legs or toes. These are similar to muscle twitches often noted during REM sleep, are uncommon in children and may result in daytime sleepiness.

Due to the many types of movement disorders noted during sleep, this module will focus on three common types: periodic leg movements, rhythmic movement disorders and sleep starts.

Medicine	Medical providers will perform a history and exam to determine next course of action including testing needed and possible treatment.
Nursing	Obtain additional information about medications (antihistamines, SSRIs) , activities and adherence to therapies that may affect outcome and course.
Nutrition	Review dietary intake that may exacerbate movement disorders (caffeine). Offer dietary suggestions to improve intake of nutrients that may treat the disorder especially for families that do not want to take medications. May review dietary history for suggestion of low iron intake.
Pharmacy	Determine what medications patient is taking that may worsen the underlying disorder and what alternatives are available. Help family find correct iron preparation and administration techniques to maximize absorption.
Respiratory Therapy	Respiratory therapists play a role in educating patients and families on proper techniques for respiratory equipment such as nebulizers, PAP (positive airway pressure) devices, ventilators, and many others. Respiratory health can play a role in overall sleep quality.
Social Work and Mental Health	Identify and respond to emotional and/or environmental stressors which may exacerbate the family’s perception of movement disorders, the disorders themselves, and barriers that may affect the family’s ability to adhere with recommended treatments.
Family Perspective and Leadership	Help determine if family’s concerns are being appreciated by the entire team and if recommendations are unrealistic for families to follow. The family representative can help determine if there are additional family issues exacerbating the sleep disorder and the barriers to execution of the treatment plan.