When gender matters: Restless legs syndrome. Report of the “RLS and woman” workshop endorsed by the European RLS Study Group

The Relationship of Restless Legs Syndrome to History of Pregnancy-Induced Hypertension

BACKGROUND

Restless legs syndrome (RLS), a burdensome sleep disorder, has been associated with cardiovascular disease (CVD), hypertension, diabetes, and related disorders. However, the relationship of RLS to history of pregnancy-induced hypertension (PIH), a predictor of subsequent CVD, diabetes, and associated conditions, remains little explored. In this study, we investigated the relationship of RLS to history of PIH in a sample of primary care patients.

METHODS

Participants were women aged ≥40 years drawn from an anonymous survey study of West Virginia primary care patients. Data collected included detailed information on demographics, lifestyle factors, sleep patterns, and reproductive/medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or unsure about their pregnancy status were excluded from the analyses.

RESULTS

Of the 498 participants in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms ≥once/week, 11.9% with symptoms ≥3 times/week); 73 (16.5% of parous women) reported a history of PIH, defined as physician-diagnosed preeclampsia or gestational hypertension. After adjustment for demographics, lifestyle characteristics, obesity, reproductive history, health conditions, and other factors, those reporting a history of PIH were approximately twice as likely to meet criteria for RLS (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.1, 3.6). These associations increased in magnitude with increasing symptom frequency (adjusted OR for RLS with symptoms ≥3 times/week = 3.8; CI 1.9, 7.6; p for trend = 0.003).

CONCLUSIONS

History of PIH was strongly and positively related to current RLS in this study of primary care patients; these findings further support a possible role for metabolic dysregulation in RLS etiology.

The Association of Restless Legs Syndrome to History of Gestational Diabetes in an Appalachian Primary Care Population

OBJECTIVES

Restless legs syndrome (RLS) is a burdensome sensorimotor disorder that has been linked to diabetes and obesity. However, the relationship of RLS to gestational diabetes mellitus (GDM), a common pregnancy complication strongly associated with obesity and a harbinger of diabetes, remains unknown. In this study, we examined the association of RLS to history of GDM in a sample of older female primary care patients.

METHODS

Participants were community-dwelling women aged ≥ 40 years drawn from an anonymous survey study of West Virginia adult primary care patients. Data gathered included detailed information on demographics, lifestyle factors, reproductive history, sleep patterns, and medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or had missing data on key variables were excluded from the analyses.

RESULTS

Of the 498 participants included in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms at least once/week). After adjustment for demographics, lifestyle characteristics, body mass index, diabetes and other comorbid conditions, parity, and other factors, those reporting history of GDM were almost three times as likely to meet criteria for RLS (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.3, 5.3). This association increased in magnitude with increasing symptom frequency (adjusted OR for RLS symptoms ≥ 3×/week = 4.8, CI 2.1, 11.2, p for trend = 0.004).

CONCLUSIONS

History of GDM was strongly and positively related to RLS in this study of older female primary care patients, offering further support for a possible role of metabolic dysregulation in RLS development.

Effect of long-term sleep restriction and subsequent recovery sleep on the diurnal rhythms of white blood cell subpopulations

While acute modifications of sleep duration induces a wide array of immune function alterations, less is known of how longer periods with insufficient sleep affect immune functions and how they return to normal once recovery sleep is obtained. The purpose of the present study was to investigate the effects of five days of restricted sleep and a subsequent 7-day period of sleep recovery on white blood cell (WBC) subpopulation count and diurnal rhythms. Nine healthy males participated in a sleep protocol consisting of two baseline days (8h of sleep/night), five nights with restricted sleep (4h of sleep/night) and seven days of recovery sleep (8h of sleep/night). During nine of these days, blood was drawn hourly during night-time end every third hour during daytime, and differential WBC count was analyzed. Gradual increase across the days of sleep restriction was observed for total WBC (p<.001), monocytes (p<.001), neutrophils (p<.001) and lymphocytes (p<.05). Subsequent recovery sleep resulted in a gradual decrease in monocytes (p<.001) and lymphocytes (p=.001), but not in neutrophils that remained elevated over baseline level at the end of the 7-day recovery period. These effects were associated with altered diurnal rhythms of total WBC and neutrophils, restricted sleep being associated with higher levels during the night and at awakening, resulting in a flattening of the rhythm. The diurnal alterations were reversed when recovery sleep was allowed, although the amplitude of total WBC, neutrophils and monocytes was increased at the end of the recovery period in comparison to baseline. Altogether, these data show that long-term sleep restriction leads to a gradual increase of circulating WBC subpopulations and alterations of the respective diurnal rhythms. Although some of the effects caused by five days of restricted sleep were restored within the first days of recovery, some parameters were not back to baseline even after a period of seven recovery days.

Sleep disturbances in menopausal women: Aetiology and practical aspects

Sleep deteriorates with age. The menopause is often a turning point for women's sleep, as complaints of insomnia increase significantly thereafter. Insomnia can occur as a secondary disorder to hot flashes, mood disorders, medical conditions, psychosocial factors, underlying intrinsic sleep disorders, such as obstructive sleep apnoea (OSA) or restless legs syndrome (RLS), or it can be a primary disorder. Since unrecognized OSA can have dramatic health-related consequences, menopausal women complaining of persisting sleep disturbances suggesting primary insomnia or intrinsic sleep disorders should be referred to a sleep specialist for a comprehensive sleep assessment. Patients suffering from primary insomnia will be preferentially treated with non-benzodiazepine hypnotics or melatonin, or with cognitive behavioural therapy. Insomnia related to vasomotor symptoms can be improved with hormone replacement therapy. Gabapentin and isoflavones have also shown efficacy in small series but their precise role has yet to be established. In patients suffering from OSA, non-pharmacological therapy will be applied: continuous positive airway pressure or an oral appliance, according to the severity of the disorder. In the case of RLS, triggering factors must be avoided; dopaminergic agonists are the first-line treatment for moderate to severe disease. In conclusion, persisting sleep complaints should be addressed in menopausal women, in order to correctly diagnose the specific causal disorder and to prescribe treatments that have been shown to improve sleep quality, quality of life and long-term health status.

An update on restless legs syndrome (Willis-Ekbom disease): clinical features, pathogenesis and treatment

PURPOSE OF REVIEW

In recent years, there have been a number of advances in the field of restless legs syndrome (RLS) or Willis-Ekbom disease (WED). Here, we review recent studies pertaining to the diagnosis and clinical features, pathogenesis, and treatment of RLS/WED.

RECENT FINDINGS

Recent studies have added a temporal dimension to RLS/WED epidemiology by examining both the incidence and persistence rates in different populations. Diagnostic criteria have been modified to increase sensitivity, and new guidelines take into account recently published studies of different drug classes.

SUMMARY

Recent epidemiological findings have shown that RLS/WED is a common neurological disorder that affects up to 5% of the adult population in Western countries. In moderate and severe cases, RLS/WED has a strong impact on sleep and quality of life and can involve an increased cardiovascular risk. Diagnosis is made clinically by confirming the presence of the five essential criteria. However, in difficult cases objective tests such as the multiple suggested immobilization test (m-SIT) can be used. The pathophysiology is partially known, with several risk polymorphisms (BTBD-9 (BTB (POZ) domain containing 9), MEIS-1 (Meis homeobox 1), protein tyrosine phosphatase, receptor type, D, and others) playing an important role, along with dopaminergic and iron dysfunctions. The disorder frequently requires long-term treatment with low-dose dopamine agonists or α2δ ligands. Dopamine agonists are usually effective but the main complication, RLS/WED augmentation, can arise.

Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis-Ekbom disease during pregnancy and lactation

Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is common during pregnancy, affecting approximately one in five pregnant women in Western countries. Many report moderate or severe symptoms and negative impact on sleep. There is very little information in the medical literature for practitioners on the management of this condition during pregnancy. Accordingly, a task force was chosen by the International RLS Study Group (IRLSSG) to develop guidelines for the diagnosis and treatment of RLS/WED during pregnancy and lactation. A committee of nine experts in RLS/WED and/or obstetrics developed a set of 12 consensus questions, conducted a literature search, and extensively discussed potential guidelines. Recommendations were approved by the IRLSSG executive committee, reviewed by IRLSSG membership, and approved by the WED Foundation Medical Advisory Board. These guidelines address diagnosis, differential diagnosis, clinical course, and severity assessment of RLS/WED during pregnancy and lactation. Nonpharmacologic approaches, including reassurance, exercise and avoidance of exacerbating factors, are outlined. A rationale for iron supplementation is presented. Medications for RLS/WED are risk/benefit rated for use during pregnancy and lactation. A few are rated "may be considered" when RLS/WED is refractory to more conservative approaches. An algorithm summarizes the recommendations. These guidelines are intended to improve clinical practice and promote further research.

Sleep regulation and sex hormones exposure in men and women across adulthood

This review aims to discuss how endogenous and exogenous testosterone exposures in men and estrogens/progesterone exposures in women interact with sleep regulation. In young men, testosterone secretion peaks during sleep and is linked to sleep architecture. Animal and human studies support the notion that sleep loss suppresses testosterone secretion. Testosterone levels decline slowly throughout the aging process, but relatively few studies investigate its impact on age-related sleep modifications. Results suggest that poorer sleep quality is associated with lower testosterone concentrations and that sleep loss may have a more prominent effect on testosterone levels in older individuals. In women, sex steroid levels are characterized by a marked monthly cycle and reproductive milestones such as pregnancy and menopause. Animal models indicate that estrogens and progesterone influence sleep. Most studies do not show any clear effects of the menstrual cycle on sleep, but sample sizes are too low, and research designs often inhibit definitive conclusions. The effects of hormonal contraceptives on sleep are currently unknown. Pregnancy and the postpartum period are associated with increased sleep disturbances, but their relation to the hormonal milieu still needs to be determined. Finally, studies suggest that menopausal transition and the hormonal changes associated with it are linked to lower subjective sleep quality, but results concerning objective sleep measures are less conclusive. More research is necessary to unravel the effects of vasomotor symptoms on sleep. Hormone therapy seems to induce positive effects on sleep, but key concerns are still unresolved, including the long-term effects and efficacy of different hormonal regimens.

Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria--history, rationale, description, and significance

BACKGROUND

In 2003, following a workshop at the National Institutes of Health, the International Restless Legs Syndrome Study Group (IRLSSG) developed updated diagnostic criteria for restless legs syndrome/Willis-Ekbom disease (RLS/WED). These criteria were integral to major advances in research, notably in epidemiology, biology, and treatment of RLS/WED. However, extensive review of accumulating literature based on the 2003 NIH/IRLSSG criteria led to efforts to improve the diagnostic criteria further.

METHODS

The clinical standards workshop, sponsored by the WED Foundation and IRLSSG in 2008, started a four-year process for updating the diagnostic criteria. That process included a rigorous review of research advances and input from clinical experts across multiple disciplines. After broad consensus was attained, the criteria were formally approved by the IRLSSG executive committee and membership.

RESULTS

Major changes are: (i) addition of a fifth essential criterion, differential diagnosis, to improve specificity by requiring that RLS/WED symptoms not be confused with similar symptoms from other conditions; (ii) addition of a specifier to delineate clinically significant RLS/WED; (iii) addition of course specifiers to classify RLS/WED as chronic-persistent or intermittent; and (iv) merging of the pediatric with the adult diagnostic criteria. Also discussed are supportive features and clinical aspects that are important in the diagnostic evaluation.

CONCLUSIONS

The IRLSSG consensus criteria for RLS/WED represent an international, interdisciplinary, and collaborative effort intended to improve clinical practice and promote further research.

Pre-pregnancy restless legs syndrome (Willis-Ekbom Disease) is associated with perinatal depression

OBJECTIVES

Both restless legs syndrome ([RLS], also known as Willis-Ekbom Disease [WED]) and depression are common during pregnancy. However, no prior studies have assessed if pregnant women with RLS have an elevated risk of depression during and/or after pregnancy.

METHODS

1,428 women who were pregnant in gestational week 16-17 were asked to participate in a longitudinal survey. They were followed by web-based questionnaires in gestational week 17 and 32, and 6 weeks after delivery. Data were also retrieved from prenatal and birth records. Two different sets of criteria were used to examine the prevalence of RLS in the cohort (International Restless Legs Syndrome Society Group standard criteria and the later developed CH-RLSQ11 questionnaire). The latter questionnaire attempts to exclude those with common "mimics" of RLS.

RESULTS

Adjusted odds ratio for depression in gestational week 17, 32, and postpartum week 6 in relation to pre-pregnancy RLS onset and moderate to severe symptom severity were 4.74 (2.30 - 9.76), 3.67 (1.85 - 7.28), and 2.58 (1.28 - 5.21), respectively. No significant associations were seen in pregnant women with de novo RLS during pregnancy. When using the standard diagnostic RLS criteria and frequency of symptoms more than 2-3 days per week, the prevalence of RLS was 12.3%. With the CH-RLSQ11 questionnaire and the same threshold for frequency of symptoms the prevalence was 6.5%.

CONCLUSION

Women with RLS onset before pregnancy with moderate or severe symptoms had an increased risk of both antenatal and postnatal depression. The self-reported prevalence of RLS during pregnancy is lower when a questionnaire dealing with "mimics" is used.

Restless legs symptoms in adolescents: epidemiology, heritability, and pubertal effects

AIMS

We aimed to determine the prevalence, pubertal effect, familial aggregation, and heritability of restless legs (RLS) symptoms in Chinese adolescents. In addition, the correlates and consequences of RLS symptoms were examined.

METHODS

This was a population-based family study that involved 1549 adolescents (probands), their parents and siblings. RLS symptoms were assessed by a single question measuring the core features of RLS. Subjects with RLS symptoms for at least once per week were considered as abnormal. Impairment of daytime functions, behavioral problems, health status, and lifestyle practice were also documented.

RESULTS

The prevalence of RLS symptoms was 2.8% in adolescents and 7.4% in their parents with female preponderance. Gender difference of RLS symptoms emerged in mid-pubertal adolescents (Tanner stage 3 or above). RLS symptoms were closely associated with various sleep problems (range of ORs=2.24 to 32.5, p<0.05), except habitual snoring. They were also independently associated with impairment of daytime functions, poor general health and frequent temper outbursts but not caffeine or alcohol intake or cigarette smoking after adjustment for age, sex, and other comorbid sleep problems. RLS symptoms presented with a modest familial aggregation and heritability (h²±SE=0.17±0.04, p<0.001).

INTERPRETATION

RLS symptoms are common in Chinese adolescents with significant health repercussions. Puberty plays a critical role in the emergence of gender difference of RLS symptoms, which are accounted for by both genetic and environmental factors.

Diagnostic and management approach to common sleep disorders during pregnancy

The significance for maternal and fetal health of gestational obstructive sleep apnea, primary insomnia, restless legs syndrome, and narcolepsy are summarized. The pathophysiology, signs, symptoms, and basic Sleep Medicine concepts that assist the obstetrician in suspecting these 4 conditions are described. Where appropriate, initial management options are also outlined. Referral guidelines to a Sleep Medicine specialist are included when further diagnostic, severity assessment, and management suggestions are needed.

Restless legs syndrome: impact on sleep-related breathing disorders

Restless legs syndrome (RLS) is a common chronic sensory-motor neurological disorder that remains a clinical diagnosis. Most RLS patients present with sleep complaints in the form of initiation and/or maintenance insomnia as RLS has a circadian rhythmicity. An increased number of periodic leg movements during sleep (PLMS) is a supportive criterion in the diagnosis of RLS. Abnormalities in the central dopaminergic and iron systems are involved in the physiopathology of RLS. There is a higher prevalence of RLS and PLMS in sleep-disordered breathing patients, particularly those with obstructive sleep apnoea (OSA), the most common sleep disorder in western societies. The complex mechanisms underlying the association between OSA, RLS and PLMS remain unclear. Untreated OSA can lead to adverse cardiovascular consequences due to cardio-metabolic dysfunction. It remains controversial whether RLS could further adversely impact the cardiovascular consequences of OSA. The PLMS do not have an additive effect on the hypersomnia experienced by some sleep-disordered breathing patients. Continuous positive airway pressure (CPAP) therapy is the most effective therapy for OSA. The presence of PLMS during CPAP treatment could be a marker of an incomplete resolution of sleep-disordered breathing in the form of increased upper airway resistance syndrome, despite treatment. Dopaminergic agonists are the preferred agent for the treatment of RLS, and are indicated when RLS symptoms are frequent and affect quality of life. PLMS and RLS do not seem to contribute to the residual hypersomnia that can be observed in some sleep-disordered breathing patients despite adequate compliance and effective CPAP therapy.

Iron deficiency alters expression of dopamine-related genes in the ventral midbrain in mice

A clear link exists between iron deficiency (ID) and nigrostriatal dopamine malfunction. This link appears to play an important role in at least restless legs syndrome (RLS) if not several other neurological diseases. Yet, the underlying mechanisms remain unclear. The effects of ID on gene expression in the brain have not been studied extensively. Here, to better understand how exactly ID alters dopamine functioning, we investigated the effects of ID on gene expression in the brain, seeking to identify any potential transcription-based mechanisms. We used six strains of recombinant inbred mice (BXD type) known to differ in susceptibility to ID in the brain. Upon weaning, we subjected mice from each strain to either an iron-deficient or iron-adequate diet. After 100 days of dietary treatment, we measured the effects of ID on gene expression in the ventral midbrain, a region containing the substantia nigra. The substantia nigra is the base of the nigrostriatal dopamine pathway and a region particularly affected by iron loss in RLS. We screened for ID-induced changes in expression, including changes in that of both iron-regulating and dopamine-related genes. Results revealed a number of expression changes occurring in ID, with large strain-dependent differences in the genes involved and number of expression changes occurring. In terms of dopamine-related genes, results revealed ID-induced expression changes in three genes with direct ties to nigrostriatal dopamine functioning, two of which have never before been implicated in an iron-dopamine pathway. These were stromal cell-derived factor 1 (Cxcl12, or SDF-1), a ferritin regulator and potent dopamine neuromodulator, and hemoglobin, beta adult chain 1 (Hbb-b1), a gene recently shown to play a functional role in dopaminergic neurons. The extent of up-regulation of these genes varied by strain. This work not only demonstrates a wide genetic variation in the transcriptional response to ID in the brain, but also reveals two novel biochemical pathways by which iron may potentially alter dopamine function.

Is preeclampsia associated with restless legs syndrome?

OBJECTIVE

Restless legs syndrome (RLS) is a common neurologic disorder. Secondary RLS includes pregnancy and iron deficiency. Prevalence of RLS in pregnancy ranges from 11% to 27%. We aimed to assess the frequency and characteristics of RLS in pregnancy in a Peruvian population and to evaluate the possible pregnancy or delivery complications due to RLS.

METHODS

We assessed 218 consecutive expectant mothers at the inpatient clinic of the Hospital San Bartolome in Lima, Peru. Assessment was performed by using the standard diagnostic criteria for RLS and by using a clinical and diagnostic interview. Questionnaires for RLS severity, idiopathic RLS (IRLS), and excessive daytime sleepiness (EDS) according to the Epworth sleepiness scale (ESS) were used. Blood examination was performed for hemoglobin and hematocrit. For comparison, RLS patients were matched for age and body mass index (BMI) with pregnant women without RLS.

RESULTS

Out of 218 patients, 40 (18.4%) fulfilled diagnostic criteria for RLS. In RLS patients, prophylactic iron supplementation therapy during pregnancy was less frequently taken (P=.02). Pregnant women with RLS had a higher ESS score than pregnant controls (10.6 +/- 3.1 vs 7.6. +/- 3.6; P<.001). Preeclampsia was more frequent in RLS (7/40 vs 1/39; P=.03).

CONCLUSIONS

In our study, RLS was frequent in pregnant Peruvian women, especially in those without prophylactic iron supplementation. RLS patients described more EDS. Preeclampsia was more common in RLS. Our study is the first study to indicate a possible association between RLS and preeclampsia.

The relationship between depressive symptoms and restless legs syndrome in two prospective cohort studies

OBJECTIVE

Cross-sectional studies suggest a strong association between depression and restless legs syndrome (RLS); however, the temporal relationship between the two disorders remains unknown. We tested whether the presence of clinically relevant depressive symptoms (CRDS) is a risk factor for subsequent RLS in the general population. The relationship between prevalent RLS and incident CRDS was also examined.

METHODS

Two independent, prospective cohort studies with representative, age-stratified random samples, the Dortmund Health Study (DHS; n = 1312/1122 [baseline/follow-up], median follow-up time = 2.1 years) and the Study of Health in Pomerania (SHIP; n = 4308/3300, median follow-up time = 5.0 years) were analyzed. RLS was assessed in both studies according to the RLS minimal criteria, at baseline and at follow-up. CRDS were assessed by the Center for Epidemiologic Studies-Depression scale (a score of ≥16) in DHS only at baseline and by the Munich-Composite International Diagnostic-Screener in SHIP at baseline and at follow-up.

RESULTS

Clinically relevant depressive symptoms at baseline were associated new-onset RLS in both studies (DHS: odds ratio [OR] = 1.94, 95% confidence interval [CI] = 1.09-3.44; SHIP: OR = 2.37, 95% CI = 1.65-3.40) after adjustment for age, sex, education, body mass index, smoking, physical activity, and the presence of various comorbidities. RLS at baseline was an independent risk factor of incident CRDS in SHIP (OR = 1.82, 95% CI = 1.10-3.00).

CONCLUSIONS

The presence of CRDS may be a risk factor for subsequent RLS. The relationship between the two disorders might be bidirectional because RLS also predicts incident depressive symptoms.

Intravenous iron given prior to pregnancy for restless legs syndrome is associated with remission of symptoms

Restless legs syndrome (RLS) is more common during pregnancy than in the general population, occurring at a 2-3 times higher prevalence. While iron, genetics, and central nervous system dopamine have been shown to play major roles in RLS unrelated to pregnancy, the etiology and treatment of RLS during pregnancy have not been adequately delineated. We describe a novel approach where a 23-year-old female was given intravenous iron prior to pregnancy, with complete remission of RLS symptoms until five months postpartum. Factors other than iron status that may have influenced the course of remission and relapse were oral contraceptive use, antidepressant use, and a strong family history of RLS.

Role of gabapentin enacarbil XR in restless legs syndrome

Gabapentin enacarbil XR is a new extended-release formulation which attempts to overcome the reduced efficacy of shorter-acting gabapentin, with sustained delivery over a 24-hour period. It is a gabapentin prodrug which is efficiently and rapidly converted to gabapentin during active transport throughout the length of the intestine via high-capacity monocarboxylate type 1 nutrient transporters unlike its predecessor, which is absorbed via low-capacity transporters largely confined to the upper intestinal region. Its lack of saturable absorption allows for dose-proportional absorption and hence increased bioavailability. Several clinical trials addressing its efficacy in moderate to severe restless legs syndrome (RLS) demonstrate improvements in the International RLS Rating Scale after a 2-week to 3-month period. Open-label studies of 52 weeks' duration showed maintenance of symptom reduction with once-daily administration of the extended-release formulation. The most commonly reported treatment-emergent adverse effects were somnolence and dizziness. Although the incidence of emergent adverse effects is high, it is comparable with that of gabapentin. No studies thus far have documented augmentation as an issue, unlike that observed with most dopaminergic agents. In addition, both dopamine precursors and agonists have not been shown to increase slow wave sleep or improve overall sleep architecture consistently despite improvement in the periodic leg movement index, in contrast with gabapentin enacarbil. Presently, gabapentin enacarbil has not been approved by the Therapeutic Goods Administration or Medsafe for use in RLS. The cost of this medication may also be a potential barrier for many patients. Future comparative efficacy studies with gabapentin, first-line dopaminergic agents, rotigotine, being the other once daily RLS medication, and pregabalin, the structural analog of gabapentin, will be necessary.

Sleep-related movement disorders

Several movement disorders may occur during nocturnal rest disrupting sleep. A part of these complaints is characterized by relatively simple, non-purposeful and usually stereotyped movements. The last version of the International Classification of Sleep Disorders includes these clinical conditions (i.e. restless legs syndrome, periodic limb movement disorder, sleep-related leg cramps, sleep-related bruxism and sleep-related rhythmic movement disorder) under the category entitled sleep-related movement disorders. Moreover, apparently physiological movements (e.g. alternating leg muscle activation and excessive hypnic fragmentary myoclonus) can show a high frequency and severity impairing sleep quality. Clinical and, in specific cases, neurophysiological assessments are required to detect the presence of nocturnal movement complaints. Patients reporting poor sleep due to these abnormal movements should undergo non-pharmacological or pharmacological treatments.