Criteria in diagnosing nocturnal leg cramps: a systematic review.

BACKGROUND: Up to 33% of the general population over 50 years of age are affected by nocturnal leg cramps. Currently there are no generally accepted clinical characteristics, which identify nocturnal leg cramps. This study aims to identify these clinical characteristics and to differentiate between them and the characteristics of restless leg syndrome and periodic limb disorder. METHOD: A systematic literature study was executed from December 2015 to May 2016. This study comprised of a systematic literature review of randomized clinical trials, observational studies on nocturnal and rest cramps of legs and other muscles, and other systematic and narrative reviews. Two researchers independently extracted literature data and analyzed this using a standardized reviewing protocol. Modified versions of the Cochrane Collaboration tools assessed the risk of bias. A Delphi study was conducted to assess agreement on the characteristics of nocturnal leg cramps. RESULTS: After systematic and manual searches, eight randomized trials and ten observational studies were included. On the basis of these we identified seven diagnostic characteristics of nocturnal leg cramps: intense pain, period of duration from seconds to maximum 10 minutes, location in calf or foot, location seldom in thigh or hamstrings, persistent subsequent pain, sleep disruption and distress. CONCLUSION: The seven above characteristics will enhance recognition of the condition, and help clinicians make a clear distinction between NLC and other sleep-related musculoskeletal disorder among older adults.

A review of nocturnal leg cramps in older people.

Nocturnal leg cramps are common and troublesome, especially in later life, and have a significant impact on quality of life, particularly sleep quality. This article reviews the current state of knowledge regarding the diagnosis, frequency, pathophysiology and management of cramps. Recent evidence suggests that diuretic and long-acting beta-agonist therapy predispose to leg cramps. There is conflicting evidence regarding the efficacy of prophylactic stretching exercises in preventing cramps. Quinine remains the only medication proven to reduce the frequency and intensity of leg cramps. However, the degree of benefit from quinine is modest and the risks include rare but serious immune-mediated reactions and, especially in older people, dose-related side effects. Quinine treatment should be restricted to those with severe symptoms, should be subject to regular review and requires discussion of the risks and benefits with patients.

Sexsomnia: sleep sex research and its legal implications.

"Sleep sex," also known as sexsomnia, is a sleep disorder characterized by sexual behaviors committed while asleep. There has recently been increased interest in sexsomnia due to controversies arising in legal trials that have been widely publicized in the social and public media. This article attempts to marshal the current information about sexsomnia from the forensic literature and provides an overview of sexsomnia including common features, precipitating factors, prevalence rates, diagnostic procedures, and treatment. As sexsomnia represents a condition in which sexual acts are committed without awareness or intention, this paper also reviews the development of sexsomnia as a legal defense and summarizes Canadian case law on the topic. It provides an overview of the hurdles presented to defense attorneys attempting to utilize the defense and examines popular public notions surrounding the legitimacy of sexsomnia and the possibility of malingering. We conclude that sexsomnia is a legitimate sleep disorder for which case law now exists to support its use in legal defenses based on automatism. The question of whether it is an example of "sane" or "insane" automatism remains to be determined by the courts. Regardless of whether or not sexsomnia is determined to be a mental disorder by the courts, it is now a recognized and well-described sleep disorder that can be safely treated and managed by knowledgeable clinicians.

Persistent combined type sleep-related rhythmic movement disorder into adolescence: a case report.

Sleep-related rhythmic movement disorder is characterized by repetitive, stereotyped, rhythmic movements of large muscle groups, primarily occurring at the onset of sleep and during sleep. Common in infancy and early childhood, its persistence into adolescence or adulthood is rare. Combined type is rare. This article reviews and analyzes the diagnosis and treatment of a case with combined type sleep-related rhythmic movement disorder persisting for 15 years aimed at enhancing the level of diagnosis and treatment of the disorder, and reducing misdiagnosis and missed diagnosis. CITATION: Zhao Y, Wang F, Wang X, Zhao W, Liu Z. Persistent combined type sleep-related rhythmic movement disorder into adolescence: a case report. J Clin Sleep Med. 2024;20(8):1391-1394.

Factors associated with night-time calf muscle cramps: a case-control study.

INTRODUCTION: Although highly prevalent and painful, night-time calf muscle cramping is poorly understood, and no treatment has shown consistent efficacy or safety. METHODS: One hundred sixty adults were recruited from New South Wales, Australia, including 80 who had night-time calf cramping at least once per week and 80 age- and gender-matched adults who did not. Participants were assessed using reliable tests of lower limb strength, flexibility, morphometrics, circulation, and sensation, and were questioned about health and lifestyle factors, diet, medications, exercise, symptomatology, sleeping habits, and footwear. RESULTS: Conditional logistic regression identified 3 factors independently associated with night-time calf muscle cramps: muscle twitching (OR 4.6, 95% CI 1.6-15.5, P = 0.01); lower limb tingling (OR 4.1, 95% CI 1.6-10.3, P = 0.003); and foot dorsiflexion weakness (OR 1.02, 95% CI 1.01-1.03, P = 0.002), which represented other measures of lower limb weakness in the model. CONCLUSIONS: Night-time calf muscle cramps were associated with markers of neurological dysfunction and potential musculoskeletal therapeutic targets.

The usefulness of monitoring sleep talking for the diagnosis of Dementia with Lewy bodies.

BACKGROUND: Dementia with Lewy bodies (DLB) is the second most common type of neurodegenerative dementia. It is frequently difficult to differentiate DLB from Alzheimer's disease (AD) and other types of dementia. This study examined the usefulness of monitoring sleep talking for the diagnosis of DLB. METHODS: A total of 317 patients with dementia were selected from a consecutive series at the Dementia Clinic of Kumamoto University Hospital. Diagnostic categories consisted of probable DLB (n = 55), probable AD (n = 191), frontotemporal lobar degeneration (FTLD) (n = 16), vascular dementia (VaD) (n = 18), and other/unspecified dementia (n = 37). We evaluated sleep talking in all dementia patients and normal elderly subjects (n = 32) using an originally designed sleep talking questionnaire. RESULTS: Sleep talking occurred most frequently in the DLB group (61.8%), followed by the VaD group (33.3%), other/unspecified dementia group (27.0%), AD group (18.8%), FTLD group (12.5%), and normal elderly subjects group (6.3%). The prevalence of sleep talking in the DLB group was significantly higher than in other groups, except in the VaD group. The sleep talking yielded high specificity (81.2%) and some sensitivity (61.8%) for the differential diagnosis of DLB from AD. Furthermore, loud sleep talking may improve the specificity (96.9%). For the differentiation of DLB from all other dementia types, the specificity of sleep talking and loud sleep talking was also high (79.4% and 95.8% respectively). CONCLUSIONS: Assessing sleep talking, especially the volume of sleep talking, may be useful in the clinical discrimination of DLB from not only AD but also from all other types of dementia.

Nocturnal leg cramps.

Up to 60 percent of adults report that they have had nocturnal leg cramps. The recurrent, painful tightening usually occurs in the calf muscles and can cause severe insomnia. The exact mechanism is unknown, but the cramps are probably caused by muscle fatigue and nerve dysfunction rather than electrolyte or other abnormalities. Nocturnal leg cramps are associated with vascular disease, lumbar canal stenosis, cirrhosis, hemodialysis, pregnancy, and other medical conditions. Medications that are strongly associated with leg cramps include intravenous iron sucrose, conjugated estrogens, raloxifene, naproxen, and teriparatide. A history and physical examination are usually sufficient to differentiate nocturnal leg cramps from other conditions, such as restless legs syndrome, claudication, myositis, and peripheral neuropathy. Laboratory evaluation and specialized testing usually are unnecessary to confirm the diagnosis. Limited evidence supports treating nocturnal leg cramps with exercise and stretching, or with medications such as magnesium, calcium channel blockers, carisoprodol, or vitamin B(12). Quinine is no longer recommended to treat leg cramps.

Nocturnal leg cramps.

Nocturnal leg cramps are a frequent cause of sleep disturbance among the general population, especially among the elderly. These painful episodes can delay sleep onset and awaken the patient from sleep, as well as delay subsequent return to sleep. Different mechanisms have been proposed to explain this phenomenon. Although most cases of leg cramps are idiopathic, multiple secondary causes of sleep-related leg cramps have been identified as well. In this article, we review the epidemiology, pathophysiology, and risk factors and discuss the salient features of the diagnosis and workup. Finally, we review the wide array of behavioral and pharmacologic treatments that have been studied for nocturnal leg cramps.

Is time elapsed between cannabis use and sleep start time associated with sleep continuity? An experience sampling method.

BACKGROUND: A substantial proportion of people using cannabis report using it to improve sleep. Yet, little research exists on the associations between the timing of cannabis use and sleep. This study examines the time elapsed between cannabis use and sleep start time and its association with two of the main indicators of sleep continuity: (1) sleep onset latency (SOL) and (2) number of awakenings (NOA) throughout the night. METHODS: Each morning, for 7 consecutive days, daily cannabis users (n = 54) reported on the timing of previous night's cannabis use and sleep indicators on their smartphones. Mixed effects models examined the relations of within- and between-subjects' time elapsed between previous night cannabis use and sleep start time, with (1) SOL and (2) NOA. RESULTS: Within subjects, shorter time elapsed between cannabis use and sleep start time was associated with shorter SOL (ß = 0.519, p = 0.010), but not NOA (ß = -0.030, p = 0.535). Furthermore, between individuals, the time gap between the previous night cannabis use and sleep start time was not associated with SOL or NOA (p > 0.05). CONCLUSIONS: It is possible that cannabis use proximal to bedtime is associated with shorted sleep onset latency but not nighttime awakenings. Cannabis users should be informed about both the potential sleep aid effects of cannabis and its limitations. Pending further evidence of the effects of cannabis on sleep, cannabis users experiencing sleep problems should be provided with evidence-based alternatives to improve sleep, e.g., pharmacological and behavioral treatments.

Quality of sleep in patients with nocturnal leg cramps and validity of a single-item measure of cramp-related sleep disturbance: an observational study.

OBJECTIVE: Only a few studies have addressed the impact of nocturnal leg cramps on sleep quality. We investigated the association between nocturnal leg cramps and sleep disturbance using the Pittsburgh Sleep Quality Index (PSQI), and assessed the criterion validity of a single-item daily measure of cramp-related sleep disturbance. METHODS: In this prospective observational study conducted in Western Switzerland from January 2015 to June 2016, 20 primary care physicians recruited up to 20 consecutive patients aged >50 years. During a 2-week period, patients recorded on a daily basis the number of cramps and their level of sleep disturbance using a single item measure (10-point visual analogue scale from 0 to 10). They also completed the PSQI questionnaire on day 14. Patients were considered as “poor sleepers” if the PSQI score was >5/21. The criterion validity of the single-item measure (averaged over the 2-week period) was assessed using Spearman’s rank correlation coefficient to determine the correlation with the PSQI. RESULTS: 129 patients participated (women 67%, mean age 70 years). The single-item and the PSQI mean scores were 2.6/10 (standard deviation 2.5) and 6.1/21 (SD 3.9), respectively. Being a “poor sleeper” (47% of patients) was not statistically significantly associated with patients’ characteristics and number of cramps. The averaged single-item measure was not correlated with the PSQI score (Spearman’s rank correlation 0.08, p-value 0.51). CONCLUSIONS: In this primary care sample, poor sleep quality was not associated with suffering from a higher number of nocturnal cramps, and a single-item mean score was not a valid instrument to screen for sleep disturbance among these patients.

Motor-behavioral episodes in REM sleep behavior disorder and phasic events during REM sleep.

STUDY OBJECTIVES: To investigate if sudden-onset motor-behavioral episodes in REM sleep behavior disorder (RBD) are associated with phasic events of REM sleep, and to explore the potential meaning of such an association. DESIGN: Observational review analysis. SETTING: Tertiary sleep center. PATIENTS: Twelve individuals (11 males; mean age 67.6 +/- 7.4 years) affected by idiopathic RBD, displaying a total of 978 motor-behavioral episodes during nocturnal in-laboratory video-PSG. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: The motor activity displayed was primitive in 69.1% and purposeful/semi-purposeful in 30.9% of the motor-behavioral episodes recorded. Sleeptalking was significantly more associated with purposeful/semi-purposeful motor activity than crying and/or incomprehensible muttering (71.0% versus 21.4%, P<0.005). In 58.2% of the motor-behavioral episodes, phasic EEG-EOG events (rapid eye movements [REMs], alpha bursts, or sawtooth waves [STWs]) occurred simultaneously. Each variable (REMs, STWs, alpha bursts) was associated more with purposefullsemi-purposeful than with primitive movements (P<0.05). CONCLUSIONS: Motor-behavioral episodes in RBD were significantly more likely to occur in association with phasic than with tonic periods of REM sleep. The presence of REMs, alpha bursts and STWs was found to be more frequent in more complex episodes. We hypothesize that motor-behavioral episodes in RBD are likely to occur when the brain, during REM sleep, is in a state of increased instability (presence of alpha bursts) and experiencing stronger stimulation of visual areas (REMs).

Sleep-related rhythmic movements and rhythmic movement disorder beyond early childhood.

INTRODUCTION: Sleep-related rhythmic movements (SRRMs) are common in young children and become less prevalent with increasing age. When SRRMs significantly interfere with sleep and/or affect daytime functioning, potentially resulting in injury, rhythmic movement disorder (SRRMD) is diagnosed. OBJECTIVE: The aim of our study was to assess clinical comorbidities, types of SRRMs, sleep stage/wakefulness distribution during night, and age-dependence of these parameters. MATERIAL AND METHODS: In sum, 45 patients (age range 1-26 years, mean age 10.56 ± 6.4 years, 29 men) were clinically examined for SRRMs or SRRMD. Nocturnal polysomnography (PSG) was recorded in 38 patients. To evaluate clinical and sleep comorbidity, the cohort of 38 patients was divided according to age into four groups: (1) younger than 5 years (N = 7), (2) 5-9 years (N = 12), (3) 10-14 years (N = 11), and (4) ≥ 15 years (N = 8). RESULTS: A clear relationship between perinatal risk factors and developmental disorders (attention deficit hyperactivity disorder - ADHD, specific learning disability) was found which extended population prevalence at least five times. A total of 62 recordings were evaluated in 38 patients; SRRMs were found in PSG in 31 of 38 patients (82%). No age-dependent correlation between type of SRRMs and sleep stage/wakefulness distribution during the night was observed. However, when all recordings were correlated together, rolling stereotypes occurred more frequently in REM sleep, and rocking stereotypes in superficial NREM sleep. CONCLUSION: Developmental disorders and perinatal risk factors were connected with SRRMs and SRRMD in children and young adults. Rolling movements were significantly associated with REM stage and rocking stereotypes with superficial NREM sleep, independent of age.

Objectively confirmed prevalence of sleep-related rhythmic movement disorder in pre-school children.

OBJECTIVE: Childhood sleep-related rhythmic movement disorder (RMD) (ie, sleep-related repetitive movements involving large muscle groups) can impair sleep quality, cause local injury, and disturb household members. Previous parental reports indicate prevalence rates in children under three years of age between 5.5 and 67%. We studied the prevalence of RMD with objective home videosomnography. METHODS: Parents of 707 children having their one-year routine health check (357 male), 740 children having their two-year health check (395 male), and 17 children of unknown age (nine male), were asked if their child showed sleep-related rhythmic movements. If telephone interview confirmed likely RMD, parents completed a standardised clinical questionnaire and three nights of home videosomnography. RESULTS: At the one-year health check, 31/707 possible cases of RMD were identified [maximal prevalence: 4.38%; 95% CI (2.81, 5.89)] compared to 11/740 at the two-year check [maximal prevalence: 1.49%, 95% CI (0.61, 2.36)]. Of 42 possible cases, nine had resolved; 14 were uncontactable, or did not wish to participate, and four did not complete the study protocol. In four of 10 remaining one-year olds and four of five remaining two-year olds parental report was objectively confirmed by videosomnography. Minimal prevalence based on objective observation was therefore 0.28% [95% CI (0.08, 1.30)] at one-year check and 0.41% [95% CI (0.08, 1.24)] at two-year check. CONCLUSIONS: Prevalence of RMD in a large population of infants and toddlers was lower than previously reported (maximum prevalence 2.87%, minimum prevalence 0.34%). It is important to confirm parental report using objective measures.

Association of body rolling, leg rolling, and rhythmic feet movements in a young adult: A video-polysomnographic study performed before and after one night of clonazepam.

We report clinical and polysomnographic data of a young adult affected by several forms of rhythmic movement disorder (RMD), present in the same night, including a new kind of it, known as rhythmic feet movements. The patient was monitored by means of three consecutive video-polysomnographic recordings, the first two performed to confirm the presence of the sleep disorder and the last one to observe the acute effectiveness of clonazepam on rhythmic movements. We discuss the characteristics of the RMD and the response to the first administration of pharmacological treatment, observed in our patient.

Maternal separation anxiety as a regulator of infants' sleep.

BACKGROUND: The regulation of infants' sleep is determined not only by biological factors but by relational aspects too. This study focused on maternal separation anxiety and examined its association with sleep-wake regulation at 10 months of age. METHOD: In a community sample comprising 52 infants and their mothers, sleep was measured objectively with an activity monitor, as well as through questionnaires. The mothers reported on their own separation anxiety and on the child's perceived distress. RESULTS: The main finding was that maternal separation anxiety was linked to settling to sleep routines and to night-waking. The contribution of the mothers' own separation anxiety to their infants' night-waking remained significant after controlling for the child's fussiness. CONCLUSIONS: Consistent with the transactional perspective, the current research documented an interplay between maternal separation anxiety and aspects of the child's sleep-wake transitions.

Sexsomnia as a Defense in Repeated Sex Crimes.

Sexsomnia and related sexual behaviors during sleep may be diagnosed in individuals accused of sex crimes. Although sexsomnia is now formally recognized in the DSM-5, the variable presentation of such behaviors and the possibility of malingering in medicolegal situations can cause challenges for forensic evaluators and legal professionals alike. Review of the literature reveals a paucity of cases involving allegations of repeated incidents due to abnormal sexual behaviors or experiences in sleep. It is important for experts involved in such cases to understand how the courts have responded to sexsomnia defenses involving diverse alleged incidents. The authors review the case law and discuss methods of examining evaluees with suspected sexsomnia in cases of alleged sexual assault.

REM sleep behavior disorder in patients with guadeloupean parkinsonism, a tauopathy.

STUDY OBJECTIVE: To describe sleep characteristics and rapid eye movement (REM) sleep behavior disorder in patients with Guadeloupean atypical parkinsonism (Gd-PSP), a tauopathy resembling progressive supranuclear palsy that mainly affects the midbrain. It is possibly caused by the ingestion of sour sop (corossol), a tropical fruit containing acetogenins, which are mitochondrial poisons. DESIGN: Sleep interview, motor and cognitive tests, and overnight videopolysomnography. PATIENTS: Thirty-six age-, sex-, disease-duration- and disability-matched patients with Gd-PSP (n = 9), progressive supranuclear palsy (a tauopathy, n = 9), Parkinson disease (a synucleinopathy, n = 9) and controls (n = 9). SETTINGS: Tertiary-care academic hospital. RESULTS: REM sleep behavior disorder was found in 78% patients with Gd-PSP (43% of patients reported having this disorder several years before the onset of parkinsonism), 44% of patients with idiopathic Parkinson disease, 33% of patients with progressive supranuclear palsy, and no controls. The percentage of muscle activity during REM sleep was greater in patients with Gd-PSP than in controls (limb muscle activity, 8.3%+/-8.7% vs 0.1%+/- 0.2%; chin muscle activity, 24.3%+/- 23.7% vs 0.7%+/-2.0%) but similar to that of other patient groups. The latency and percentage of REM sleep were similar in patients with Gd-PSP, patients with Parkinson disease, and controls, whereas patients with progressive supranuclear palsy had delayed and shortened REM sleep. CONCLUSION: Although Gd-PSP is a tauopathy, most patients experience REM sleep behavior disorder. This suggests that the location of neuronal loss or dysfunction in the midbrain, rather than the protein comprising the histologic lesions (synuclein versus tau aggregation), is responsible for suppressing muscle atonia during REM sleep. Subjects with idiopathic REM sleep behavior disorder should avoid eating sour sop.