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Periodic Limb Movement Disorder (PLMD)

Periodic Limb Movement Disorder (PLMD) is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Sleep-related movement disorder with episodes of periodic limb movements (PLMs) occurring during sleep (1)[A]
    • Periodic limb movements of sleep (PLMS) demonstrated during polysomnography combined with clinical symptoms
    • Clinical history of significant sleep disturbance or functional impairment is necessary for diagnosis.
    • PLMS are repetitive contractions of the tibialis anterior muscles occurring mainly in non-rapid eye movement (NREM) sleep.
    • Movements consist of unilateral or bilateral, simultaneous or not, rhythmical extension of the big toe and ankle dorsiflexion.
    • Sometimes, knee and hip flexion is noted.
    • Arm movements or more generalized movements occur less commonly.
    • Movements might be associated with cortical arousals from sleep unbeknownst to the patient (PLMs with Arousals—PLMA).
    • Complaints include insomnia, nonrestorative sleep, daytime fatigue, and/or somnolence.
    • Bed partner may complain of patient’s movements.
    • Another sleep disorders: Obstructive sleep apnea, narcolepsy, restless legs syndrome do not explain the PLMS (2)[A].
  • No wakeful perception of the PLMS or associated restlessness
    • If there is wakeful perception, the diagnosis is not periodic limb movement disorder (PLMD) but possibly RLS.
  • System(s) affected: musculoskeletal, nervous
  • Synonym(s): nocturnal myoclonus; sleep myoclonus; periodic leg movements of sleep

Epidemiology

Incidence
  • PLMD is rare, reported in both children and adults (1).
  • PLMS occurs in at least 15% of insomnia patients.
  • PLMS is frequent in rapid eye movement (REM) sleep behavior disorder (RBD) occurring during REM sleep.
  • PLMS is frequent in narcolepsy, in OSA, and during initiation of continuous positive airway pressure (CPAP).

Prevalence
  • No predominant sex preference; male = female
  • PLMS >5/hr is uncommon before age 40 years.
  • PLMS increases with age: 45% of patients >65 years exhibit PLMS >5/hr but not necessarily PLMD.
  • PLMD is much less common: <5% of adults but is underdiagnosed (1)
  • 85% of RLS patients have PLMS (3).

Etiology and Pathophysiology

  • Understudied; most data pertain to PLMS in RLS.
  • Brain iron deficiency
  • Supra-segmental disinhibition at the brainstem and spinal cord levels
  • Spinal cord excitability
  • CNS dopamine dysregulation supported by increased incidence of PLMS in untreated Parkinson disease (PD) patients
  • Decreased incidence of PLMS in schizophrenia patients
  • Triggering and exacerbating factors:
    • Peripheral neuropathy
    • Arthritis
    • Renal failure
    • Synucleinopathies (multiple-system atrophy)
    • Spinal cord injury
    • Pregnancy
    • Medications:
      • Most antidepressants (except bupropion or desipramine) and lithium
      • Some antipsychotic and anti-dementia medications
      • Antiemetics (metoclopramide)
      • Antihistamines

Genetics
BTBD9 on chromosome 6p associated with PLMS in patients with or without RLS, but not in RLS patients without PLMS

Risk Factors

  • Family history of RLS
  • Iron deficiency and associated conditions
  • Peripheral neuropathy
  • Arthritis, orthopedic problems
  • Chronic limb pain or discomfort

General Prevention

  • Adequate nightly sleep
  • Avoid PLMS triggers such as iron deficiency, frequently observed in children.
  • Awareness, including family history

Commonly Associated Conditions

  • Narcolepsy
  • Iron deficiency
  • End-stage renal disease (ESRD)
  • Cardiovascular disease; stroke
  • Gastric surgery
  • Pregnancy
  • Arthritis
  • Synucleinopathies (multiple-system atrophy)
  • Lumbar spine disease; spinal cord injury
  • Peripheral neuropathy
  • Insomnia, insufficient sleep, parasomnias
  • ADHD
  • Mood disorders, anxiety, oppositional behaviors
Pediatric Considerations
  • PLMD may precede overt RLS by years.
  • Association with RLS is more common than in adults.
  • Symptoms may be more consequential than in adults (4)[B].
  • Association and differential diagnosis with ADHD, oppositional behaviors, mood disorders, growing pains
Pregnancy Considerations
  • May be secondary to iron or folate deficiency
  • Most severe in the 3rd trimester
  • Usually subsides after delivery
Geriatric Considerations
  • May become a significant source of sleep disturbance
  • May cause or exacerbate circadian disruption and “sundowning”
  • Many medications given to the elderly may trigger or exacerbate PLMs, which can lead to PLMD or RLS.

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Citation

Stephens, Mark B., et al., editors. "Periodic Limb Movement Disorder (PLMD)." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117564/all/Periodic_Limb_Movement_Disorder__PLMD_.
Periodic Limb Movement Disorder (PLMD). In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117564/all/Periodic_Limb_Movement_Disorder__PLMD_. Accessed April 26, 2019.
Periodic Limb Movement Disorder (PLMD). (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117564/all/Periodic_Limb_Movement_Disorder__PLMD_
Periodic Limb Movement Disorder (PLMD) [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 26]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117564/all/Periodic_Limb_Movement_Disorder__PLMD_.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Periodic Limb Movement Disorder (PLMD) ID - 117564 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117564/all/Periodic_Limb_Movement_Disorder__PLMD_ PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -