periodic leg movement

[sheepless]

I thought I'd start a thread for discussing our experiences with periodic leg movements (plm).  initially I was going to reply to an allanri thread in which Cpapian quoted Dr. Barry Krakow on the subject, but decided the topic might be better served in it's own thread.  

I've seen it called plm syndrome, plm disorder and plm in sleep. I've seen it mentioned in a few threads but not in much detail. because it's often associated with apnea, and is a potential cause of arousals, I'm hoping this thread will stimulate enough conversation that we might learn something from each other about this ailment. 

first we need to distinguish between restless legs syndrome (rls) and plm.  my understanding is rls and plm are entirely different.  some people have one or the other; apparently it's common to have both.  

rls occurs while awake.  I usually fall asleep the minute my head hits the pillow, but when I have rls, it can be very difficult to get to sleep.  it occurs most often just before and while trying to go to sleep. leg movements are voluntary: squirming, moving the legs around, clenching and unclenching leg muscles to try to ease the agitated feelings in those muscles.  for example, I had a bout with rls that kept me awake for the first couple hours of my in-lab titration.  the tech commented that I seemed restless but did not mention rls.

plm occurs while asleep.  I am completely unaware of them but my wife tells me about them.  I had 24/hr during my home sleep study.  I don't know if that's a lot or a little.  the movements are involuntary and occur at regular intervals, often a count of about 16 or 18 apart.  following one recent middle of the night awakening I wondered aloud what had wakened me.  my wife happened to be lying awake herself, trying to sleep by counting through the interval between my leg jerks.  she told me I was having plm immediately before waking, so I have reason to suspect they can and do cause arousals. looking at my flow rate graph the following day, I saw a distinct pattern coinciding with the time in question.  it's a pattern that occurs intermittently throughout most nights.  flow rate often varies with physical movement so it is not beyond the realm of possibility that plm is visible in that graph.  however, I'll have to get a camera to confirm it.

I become completely awake at least 5 times and as many as 19 times between roughly 10-11pm and 6-8am.  awake enough that I stop the machine and remove the mask to 'regroup' for a few minutes to an hour or so before feeling able to go back to sleep.  I have long suspected disordered breathing like flow limitations to be part of the problem.  now that I'm aware of the plm and the coincident but uncomfirmed pattern in the flow rate, I now suspect plm to be part of the problem as well.

I plan to experiment with the supplements mentioned in the Krakow article (maybe Cpapian can provide the citation or link?), including L-tyrosine, iron, vitamin d, maybe some magnesium.  I'm not going to get my hopes up but I'd be ecstatic if I could extend my sleep sessions to longer than the few minutes to 1.5 hours at a time that's typical for me now.

I don't know if plm is common or rare among apnea board members so I'm curious to see if there's enough interest to sustain the thread.  ultimately I hope to learn how plm affects others and what they've done about it.      

[greatunclebill]

there are medications your doc can prescribe for this.

[allanri]

My sleep doctor thought that mine might be related to the fact that I take Paxil. Apparently there is a known connection between SSRIs and PLM.  He suggested switching to another anti-depressant (personally, I'd like to get off them entirely), but (a) I've been on this medication SO long, getting off of it is murder, and (b) the doctor who prescribed the Paxil didn't think the Paxil was the problem.  That doctor suggested that if the PLMs were an issue, it should be treated as  separate issue. Not that I like the idea of having to take another daily medication.

The prescribing doctor looked this up while I was in his office recently, and he said that the point at which PLMs were considered an issue was when the PLM index exceeded 5 (or 15, depending on the source).

In my initial sleep study, the PLM index was 6; I'm not sure what it was during my titration study, but it was definitely higher.

[Cpapian]

Not sure if I can provide links.  So instead here the site names without the dot com 


Dr Krakow's website is sleeptreatment.  He has some information and videos that can be helpful to someone trying to sort through breathing issues as they relate to xPAP.

The article I posted is at the bottom right of his homepage entitled a new approach to restlessleg syndrome and periodic limb disorder .  The link goes to  Sleepdynamictherapy

The study referred to in the article is entitled.   Efficacy of Tyrosine in Restless Leg Syndrome

FWIW my sleep doctor tested my iron levels and found them to be low.  He recommended iron and 250 mg vitamin c for best absorption.  This was to help RLS.

My DME recommended calcium and magnesium 1/2 hour before bedtime for better sleep.  I have a glass of milk (I don't take calcium supplements) and magnesium citrate before bed.  I can't say if it helps or not because I am an intermittent insomniac 2 days on 1 off 1 day on 2 off.   Mostly about a 2 hr shift.  Never had 5 days in a row of falling asleep easily.  (still trying to work that out).  But, when I sleep, I sleep very well.

I hope the articles above help in your journey.

Allanri, there are some who claim depression is caused or increases by untreated OSA.  Dr. Steven Parks for one, in his book sleep interrupted.  Explanation, the apnea events cause the body stress moving to fight or flight mode, hundreds of times each night; eventually causing or worsening depression.  So, best case scenario, once you nail down your xPAP treatment, you could, eventually be able to lower the dose of your SSRI.

In the meantime, if you have 2 doctors disagreeing on Paxil's effect on your limbs, why not get a referral to CAMH.  The doctors there are much more knowledgeable about the side effects/interactions of the various drugs.

[sheepless]

thanks for the comments so far. I'd rather not drift too far off topic but I'll go along with wherever the comments take us.

so, re depression: there may be a solid relationship between apnea and depression; I don't want to minimize or discount that. however:

I have been asked many times over the years if perhaps I'm depressed. pre cpap, I went so far as to try at least a half dozen antidepressant Rx's with no improvement, leading me to conclude what I thought I already knew, that I'm not depressed.

OTOH, I have been sleep deprived and exhausted for decades. feeling sick, like being hungover. little drive, lacking motivation, lacking perseverance, difficulty concentrating, memory problems, sleep disturbances, moodiness, etc, etc.; all can easily be attributed to apnea & sleep deprivation. and yes, if/when I indulge myself, I can be depressed, as in really bummed about all that, but for me at least, (exhausted and) bummed is not depression, as in clinical depression.

the stress of stuggling to breathe can produce anxiety. so too, difficulty performing life's tasks as a result of sleep deprivation can also trigger anxiety, which in turn can contribute to insomnia. anxiety, like depression, can be 'ordinary' or rise to the level of a clinically recognized problem.

apap didn't relieve those symptoms for me but asv has helped enormously. I don't feel as sick anymore and I do have a bit more energy, but fragmented sleep continues to wear me down. I think I'm making some progress in reducing the duration of my middle of the night gaps in sleep but even so, multiple awakenings, even for just a minute or two, take a toll.

it's one of the reasons I'm interested in periodic leg movement.

[PaulaO2]

There's been a recent turn of the tide that believes RLS happens in sleep. The line between the two is thinning.

For OSA folks, the leg movements often occur at the same time as an event. It is our body trying to wake us up.

Anyone who has RLS or PLMD should have a full blood chemistry done to see if any levels are off. Like iron or potassium. It is a good starting point and rules out a plethora of other causes.

I use potassium (in foods) to treat a bad day with RLS. And my PLMD dropped significantly once I started CPAP. Mine were quite violent. I once kicked my 80lb Rottie up and over the footboard. She was not amused. When I was in college, room mates hated to let me go to sleep first. I was on big twitch, apparently.

And to get the scoop on a medication as the cause, talk to your pharmacist.

[sheepless]

yeah, before cpap I monitored my sleep with a pretty elaborate phone app. the audio recordings were of a tortured soul. as I've mentioned, lots of thrashing, including kicking and leg rolling. I know this via the combination of recordings, actigraphy, my wife's comments and my own experience as these things woke me up. I assumed the leg action was rls but now realize the kicking and leg rolling were just 2 of the many ways I physically struggled against asphyxiation. in my case I'm pretty sure these actions were not rls or plm. it's not my place to defend or argue the definition of rls, particularly since I'm not very informed on the subject, but I will say that the leg movements you describe as our body's way of waking us during apnea seem more like fighting to breathe than rls. in addition, to my knowledge plm does not respond to cpap so I wonder if now that you're being treated you are not forced to struggle for your life the way you might have had to before cpap. my understanding is rls and plm are distinctly different from the instinctive fight for breath. but what do I know? edit: not meaning to discount your input re rls by any means, PaulaO2; just a bit of counterpoint for the sake of discussion.

[foxfire]

The prescribing doctor looked this up while I was in his office recently, and he said that the point at which PLMs were considered an issue was when the PLM index exceeded 5 (or 15, depending on the source).

In my initial sleep study, the PLM index was 6; I'm not sure what it was during my titration study, but it was definitely higher.

At my last titration study my PLM index was 50 and my PLM arousal index was 25, when I went over the study results with my doctor his comment was that other than checking ferritin level "we don't treat that". My ferritin came back at 100.

[sheepless]

foxfire: does the plm arousal index mean 25/hr? versus 50/hr plm's?, meaning half your plm's produce some measure of arousal?

is 100 ferritin level low? if so, are you getting treatment for that?

are you aware of the plm? are you aware of it waking you? do you think it disrupts your sleep?

"we don't treat that". sleep labs, sleep doctors, sleep medicine - wouldn't you think they'd treat all sleep problems? don't want to take the lid off that can of worms but it does seem that many just churn cpap and it's a battle to get help for anything else. I hope your doc gave you a referral or otherwise suggested what to do about plm? seems irresponsible if they ignored it.

[foxfire]

foxfire: does the plm arousal index mean 25/hr?  versus 50/hr plm's?, meaning half your plm's produce some measure of arousal?

 
I'm no expert, but that is my guess.

is 100 ferritin level low?  if so, are you getting treatment for that?  

 
Levels below 50 are associated with increased leg movements, so at 100 I'm pretty good.

are you aware of the plm?  are you aware of it waking you?  do you think it disrupts your sleep?
 

 
My calf muscles definitely feel sore by the end of the day, which would be more of an RLS symptom. I am definitely aware of multiple arousals during the course of a typical night which has been pretty much the case my whole life. I kind of joke that I have go through a "dying fish routine" at night. It feels like I'm constantly flopping around. Although with recent changes to my meds and xPAP therapy things do seem to have calmed down.

"we don't treat that".  sleep labs, sleep doctors, sleep medicine - wouldn't you think they'd treat all sleep problems?  don't want to take the lid off that can of worms but it does seem that many just churn cpap and it's a battle to get help for anything else.  I hope your doc gave you a referral or otherwise suggested what to do about plm?  seems irresponsible if they ignored it.

I think what he meant was that the existing treatments aren't very good and come with side effects and he would rather not go down that path. Either that or he felt I had bigger issues to deal with first. I was OK with this approach since my previous sleep doc had prescribed ropinirole which did nothing to improve my sleep quality, even is it did reduce the leg movements.