From the Guidelines
Limb movements during sleep, such as those experienced in Periodic Limb Movement Disorder (PLMD) or Restless Legs Syndrome (RLS), should be treated with dopamine agonists like pramipexole (0.125-0.5 mg) or ropinirole (0.25-4 mg) taken 1-2 hours before bedtime, as they are the first-line treatments for moderate to severe cases, according to the American Academy of Sleep Medicine clinical practice guideline 1. When diagnosing and treating limb movements in sleep, it is essential to consider the frequency and severity of the movements, as well as their impact on sleep quality and daytime functioning.
- The diagnosis of PLMD requires frequent periodic limb movements during sleep (PLMS) (> 15 events/h in adults and > 5 events/h in children), coexisting clinically significant sleep disturbance and/or daytime dysfunction, and the absence of other sleep disorders that may be associated with high rates of PLMS 1.
- Treatment options for PLMD and RLS include lifestyle changes, such as reducing caffeine, alcohol, and nicotine, establishing a regular sleep schedule, and exercising regularly during the day.
- For moderate to severe cases, medications like dopamine agonists, gabapentin (300-1200 mg at bedtime), gabapentin enacarbil (600 mg daily), or low-dose clonazepam (0.5-2 mg at bedtime) may be prescribed, with the goal of reducing PLMS and improving sleep quality and daytime functioning 1.
- It is crucial to start with the lowest effective dose to minimize side effects and to be aware that finding the right treatment may require trying different approaches, as the treatment of RLS and PLMD is highly individualized 1.
From the Research
Limb Movements in Sleep
- Limb movements in sleep can be associated with various sleep disorders, including Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD) 2, 3, 4, 5.
- RLS is a common sleep disorder with a prevalence of 5% to 15% in the general population, and can be idiopathic or secondary to iron deficiency, chronic renal failure, peripheral neuropathy, and certain medications 2.
- Periodic limb movements of sleep are an electrophysiologic finding commonly accompanying RLS, but most individuals with periodic limb movements of sleep do not have RLS 2.
- The clinical significance of periodic limb movements of sleep has been argued, and PLMD is a distinct sleep disorder that arises in individuals without RLS and is a diagnosis of exclusion 2, 4.
Prevalence and Clinical Significance
- The prevalence of periodic leg movements in sleep (PLMS) is estimated to be 4-11% in adults, and PLMS are found most frequently in RLS and often occur in narcolepsy, sleep apnea syndrome, and REM sleep behavior disorder 4.
- PLMD is estimated to occur in 5-8% of the pediatric population and 4-11% of the general adult population, and can lead to functional impairment, including hyperactivity and delayed language development in children, and poor concentration and work performance in adults 5.
- Longitudinal data demonstrate that those with PLMD are at greater risk of depression and anxiety, and a 4-fold greater risk of developing dementia 5.
Treatment and Management
- Management of RLS and PLMD includes pharmacologic agents, such as dopaminergic agents, alpha-2 delta calcium channel ligands, opioids, and benzodiazepines, as well as nonpharmacologic therapies, such as iron supplementation and behavioral management 2, 3.
- IV iron can improve RLS symptoms even in those whose serum ferritin level is between 75 ng/mL and 100 ng/mL, and oral iron will likely have minimal absorption or little effect on the improvement of RLS at serum ferritin levels greater than 75 ng/mL 3.
- Dopaminergic medications, such as ropinirole and pramipexole, can be effective in treating RLS and PLMD, but may have side effects and require slow titration or the addition of domperidone in sensitive patients 6.