Body jerks occurring only in drowsiness--when first falling
asleep:
-In
most cases are “sleep starts” or “hypnic jerks”--
a harmless phenomenon experienced by nearly everyone on occasion when
first dozing off, sometimes with a sensation of falling. Can be
aggravated by stress, fatigue and caffeine. While they usually
require no treatment, they rarely can occur repeatedly to the point of
making it difficult to fall asleep.
-Occasionally
can be due to epileptic seizures or a type of non-epileptic movement
disorder called myoclonus (which involves abrupt, shock-like muscle contractions
due to various non-epileptic causes) when these occur primarily in drowsiness
and light sleep. In such cases, the resulting body jerks may occur
repeatedly, and they may appear virtually identical each time that they
happen.
-Periodic
limb movement syndrome (PLMS) usually occurs throughout a good part of
sleep-- particularly stage 2 sleep, but it may be noticed by the patient
only when drowsy (see below).
-Breathing
problems such as sleep apnea may arouse drowsy patients with an abrupt
start--they may jerk awake because they had stopped breathing while dozing
off. Look for: snoring, restless sleep, arousals with snores/ gasps/
shortness of breath/ chest discomfort/ headache/ dry throat, worsening
with weight gain, nasal congestion and after consumption of alcohol,
or such daytime complaints as sleepiness, irritability, trouble concentrating
and memory problems. At the same time, realize that some people
with sleep apnea have none of these symptoms.
-Rhythmic
movement disorders before sleep onset are common in infants and toddlers. May
involve repetitive headbanging, headrolling, body rocking, and body rolling--sometimes
with humming or chanting. While affected youngsters are usually quite
normal and outgrow it by age four, occurrence in late childhood is sometimes
associated with retardation and other problems. It rarely is mimicked
by seizure activity. While usually benign, injuries have followed
violent headbanging.
-Periodic
limb movement syndrome (PLMS) and Restless Legs Syndrome
[RLS]
PLMS is extremely
common, particularly in older individuals. It
involves jerks usually beginning in the feet and ankle: the toes
fan out and move upward, with “cocking
up” of the ankle (dorsiflexion). In some cases, the knees and
hips may flex abruptly and occasionally, the arms will also jerk.
PLMS
most often occurs primarily in non-REM sleep--particularly stages 1
and 2--and has an unusual periodicity--with a jerk occurring at nearly
predictable intervals of roughly 15-40 seconds. It is not a form of
seizure.
Most patients
with restless legs syndrome (RLS--defined by a restless, “antsy” uncomfortable
sensation in the legs, that compels people to get up and walk about to
get relief--and which tend to occur particularly when they try to go
to bed) have PLMS. However, the majority of people with PLMS don’t
suffer from RLS.
Both
PLMS and RLS can “run in families”. Sometimes,
underlying causes can be found. Some cases
may be due to iron deficiency, deficiencies of certain vitamins like
folic acid, kidney failure, and damage to the nerves in the legs.
Certain
medications--particularly antidepressants--can make these problems
much worse, and excessive exercise and even small amounts of caffeine
may aggravate them.
Many
people with PLMS do not experience awakenings as a consequence, feel
their sleep is good, and require no treatment--although the repeated
jerking (or even kicking!) of their legs can be a problem
for their bedpartners.
Treatment
of PLMS and RLS may be required, however, in cases in which severe
sleep fragmentation and insomnia complaints result. Medications include:
-drugs
acting on dopamine receptors in the brain that are used to treat
Parkinson’s
disease such
as L-DOPA containing preparations [Sinemet®], ropinirole
[Requip®]
and pramipexole [Mirapex®] and a similar agent, cabergoline
[Dostinex®] which is used in the United States to treat prolactin-secreting
pituitary tumors.
Sinemet®,
Requip® and Mirapex® can markedly decrease the actual leg
jerks and RLS symptoms-- at least initially. Unfortunately,
in many cases, they may lose their effectiveness and ultimately may
cause worsening of symptoms: with occurrence of more intense restless
legs symptoms earlier in the day and with spread into the arms. This
phenomenon, called augmentation, may be less likely to occur with
Dostinex.
-narcotic
medications like codeine, oxycodone [Percodan®] and methadone
-anti-epileptic
drugs like gabapentin [Neurontin®] and clonazepam [Klonopin®]
-Many
other drugs also have been tried--some with anecdotal reports of
success, but generally without much scientific
proof that they would help most people.
-Some
of these treatments do not suppress the leg jerks, but instead may help
people sleep through them better.
The
limitations and possible side effects of current drug treatments for
PLMS and RLS render it all the more important to identify and avoid any
factors that are making them worse.
-Sleep
apnea.
Sleep
apnea can cause jerking, thrashing, flinging of the arms, sitting up,
jumping up onto one’s feet or even falling out of bed-- as a consequence
of violent struggling to overcome throat collapse and smothering. Snoring
is usually present. Other possible clues (not present in all cases)
include: night sweats, headaches/ dry throat on awakening, arousals with
shortness of breath, gasps or snorts, daytime sleepiness, irritability
or memory difficulties, occurrence in obese individuals, and worsening
with nasal congestion and after alcohol consumption.
-Sleep-related
seizures.
Sleep-related
epileptic seizures can involve repetitive twitches and jerks that are
usually rhythmic and which may involve either one or both sides of the
body and/or face. If observers are available-- ask them to turn
on bedroom lights immediately during onset of the episodes and look for
the following:
-Does the
jerking start on one side? If so, always on the
same side? Is there head turning or drawing
of the face to that side?
-Are
the eyes open? If so, do they turn to one side (which side?),
or roll up? Do the pupils look
large or dilated?
-Any
sign of breathing difficulty? Any cyanosis (lips or face appear
bluish)? Or, does the face look pale?
-Any
rigid stiffening or posturing? Clenching of the teeth? Biting
of the tongue? Loss of urine? -Difficulty
awakening thereafter? Lethargy and confusion following these
episodes?
Sleep-related
seizures are rather common and in most cases, quite readily treated. Often, no underlying cause is found. However, they
may “run in families” or result from various medical and
neurological disorders-- including sleep-related abnormal heart rhythms
or breathing disorders with resulting lack of oxygen: particularly if
no seizural symptoms have ever been experienced during wakefulness.
-Nocturnal
paroxysmal dystonia.
A r elatively
uncommon syndrome of repeated body stiffening, eye opening and sometimes
violent posturing in sleep. Attacks
may occur almost nightly and may respond to certain anti-seizure medications. Many
cases appear to represent a form of epilepsy.
