PATIENT 28

A Child with Repeated Movements

During Sleep
A 5-year-old male was evaluated for snoring and daytime behavior problems. His mother also reported
that he was observed to have repeated movements during sleep. The child was not taking any
medications. A 30-second tracing is shown in Figure P28-1.

1 sec

FIGURE P28-1 n A 30-second tracing during stage W.

QUESTION
1. What does the 30-second tracing show?

ANSWER
1. Answer: Rhythmic movements (RMs) during sleep
Discussion: The sleep related rhythmic movement disorder (RMD) is characterized by repetitive,
stereotypical, and rhythmic motor behaviors (not tremors) that occur predominantly during drows-
iness or sleep and involve large muscle groups. The occurrence of significant clinical consequences
differentiates RMD from developmentally normal sleep-related movements. Diagnostic criteria for

178
 PATIENT 28 A CHILD WITH REPEATED MOVEMENTS DURING SLEEP 179

BOX P28-1 Sleep Related Rhythmic Movement Disorder: Diagnostic Criteria ICSD-31
Criterial A to D must be met
A. The patient exhibits repetitive, stereotypical, and
rhythmic motor behaviors involving large muscle
groups.
B. The movements are predominantly sleep related,
occurring near nap or bedtime, or when the indi-
vidual appears drowsy or asleep.
C. The behaviors result in a significant complaint as
manifest by at least one of the following:*
1. Interference with normal sleep
2. Significant impairment in daytime function
3. Self-inflicted bodily injury or likelihood of
injury if preventive measures are not taken
D. The rhythmic movements are not better
explained by another movement disorder or
epilepsy.

*When no clinical consequences of the rhythmic movements are present, the rhythmic movements are simply noted, but the term
rhythmic movement disorder is not used.

the sleep-related RMD are listed in Box P28-1. A diagnosis of RMD versus RMs implies clinical
consequences (or potential consequences), including evidence of bodily injury or the potential for
injury if preventative measures are not applied. A number of types of RMD have been described:
1. Body rocking type: The whole body is rocked while on the hands and knees.
2. Head banging type: The head is forcibly moved, striking an object.
3. Head rolling type: The head is moved laterally, typically while the patient is in a supine position.
4. Other type: Includes body rolling, leg rolling, and leg banging.
Rhythmic humming or inarticulate sounds often accompany the body, head, or limb movements
and may be quite loud. Head banging often occurs in the prone position, with repeated lifting of the
head or the entire upper torso, and forcible banging of the head back down into the pillow or
mattress.
At 9 months of age, 59% of all infants have been reported to exhibit one or more of the following
sleep-related RMs: body rocking (43%), head banging (22%), or head rolling (24%). At 18 months,
the overall prevalence has been reported to decline to 33% and by 5 years to only 5%. Most pedi-
atric studies have found no gender difference in the prevalence of RMD.1–3 The disorder can persist
into childhood and adulthood. In some studies, an association between RMD and attention deficit
disorder was observed. Over 50 cases of RMD have been reported in adolescents and adults, with a
male preponderance found in adults.4,5
RMs have been reported in association with restless legs syndrome (RLS), obstructive sleep
apnea (OSA), narcolepsy,6 REM sleep behavior disorder (RBD),5–7 and attention-deficit-
hyperactivity disorder (ADHD). RMs may be used as conscious strategy to relieve the urge to move
or the uncomfortable sensations associated with RLS. With continuous positive airway pressure
(CPAP), obstructive sleep apnea (OSA)–associated RMD often improves.8–9 Individuals with nar-
colepsy may initiate RM to terminate episodes of sleep paralysis.6
Video-polysomnography (PSG) studies have shown RMs to occur most often in association with
stages N1 and N2 sleep. In one study, 46% occurred while the subject was falling asleep (stage W)
or during NREM sleep; 30% during both NREM and REM sleep; and 24% only during REM
sleep. The exclusively REM-related RMs occur more frequently in adults.
The AASM Scoring Manual rules for scoring the PSG features of RMD are listed in Box P28-2. In
most patients, electroencephalography (EEG) shows normal activity between episodes of rhythmic
behavior (although often obscured by movement artifact). A frequency of 0.5 to 2 Hz corresponds
to a duration between movements of 0.5 to 2 seconds.

BOX P28-2 AASM Scoring Manual Rules for Scoring the Polysomnography Features
of Rhythmic Movement Disorder
1. The following define the polysomnographic c. The minimum number of individual move-
characteristics of rhythmic movement disorder: ments required to make a cluster of rhythmic
a. The minimum frequency for scoring rhythmic movements is four movements.
movements is 0.5 hertz (Hz). d. The minimum amplitude of an individual
b. The maximum frequency for scoring rhythmic rhythmic burst is two times the background
movements is 2.0 Hz. electromyography (EMG) activity.

Note: Time-synchronized video-polysomnography (PSG), in addition to PSG is needed to make the diagnosis.
180 FUNDAMENTALS 16 MONITORING LIMB AND OTHER MOVEMENTS DURING SLEEP

Often no treatment is needed for the RMD unless a risk of self-injury or the potential for self-
injury exists. In others with violent movements, bed padding may be necessary.
In the present patient, the video showed head banging. In Figure P28-1, the RMs are seen as
rhythmic activity in multiple channels—especially prominent in the leg tracings—but also in chan-
nels recording respiration. RM artifact is noted in the EEG and electrooculography (EOG) chan-
nels. The frequency of RMs in this patient is about 1 hertz (Hz). The chief consequence was
parental concern about the child injuring himself. However, no injury had been noted because
the banging occurred against a soft mattress. A diagnosis of rhythmic movements but not the rhyth-
mic movement disorder was made. Parental reassurance was given. The PSG showed snoring but
no OSA.

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