Periodic Limb Movement Disorder (PLMD) is characterized by repetitive, stereotyped leg movements during sleep that resemble a slow version of the peripheral withdrawal reflex. PLMs are commonly seen in patients with Restless Legs Syndrome (RLS) and can negatively impact sleep quality. PLMD is diagnosed when leg movements cause sleep or wakefulness issues and no other sleep disorder is present. Management of PLMD focuses on treating underlying iron deficiency or RLS with iron supplementation, dopamine agonists, opioids, or gabapentin depending on symptoms. Dopamine agonists are first-line but require monitoring for augmentation.

1. Periodic Limb Movement Disorder
(PLMD)
Ade Wijaya, MD
August 2018

2. Introduction
• Commonly coexist with RLS
• Repetitive, usually stereotyped leg movements, most often bilateral, that
resemble a slow version of the peripheral withdrawal reflex
• Clinical consequence on sleep quality or daytime wakefulness caused by the
leg movements, not attributable to any other sleep disorder.
American Academy of Sleep Medicine. The International Classification of Sleep Disorders: diagnostic and coding manual, 2nd edition. Westchester, IL: American Academy of Sleep Medicine; 2005.

3. Epidemiology
• A PLM index >5 can be found in up to 45% of subjects older than 60 years
• A PLM index >5 is present in 80–90% of RLS patients
• PLMs with symptomatic sleep disruption, is thought to be relatively rare (3,9%)
• Also found, possibly incidentally, in a large variety of sleep disorders including
insomnia, sleep apnea, narcolepsy, parkinsonism, and REM sleep behavior
disorder
Ancoli-Israel S, Kripke DF, Klauber MR et al. Periodic limb movements in sleep in community-dwelling elderly. Sleep 1991; 14:496–500.
Ohayon MM, Roth T. Prevalence of restless legs syndrome and periodic limb movement disorder in the general population. J Psychosom Res 2002; 53:547–554.

4. Diagnostic Criteria
American Academy of Sleep Medicine. The International Classification of Sleep Disorders: diagnostic and coding manual, 2nd edition. Westchester, IL: American Academy of Sleep Medicine; 2005.

6. Management
• Similar to RLS.
• Empirical trial of iron replacement if ferritin levels < 45 mg/l even in the
absence of anemia. (ferrous sulphate 365 mg + Vitamin C; 3 times daily)
• Folic acid replacement has also been shown to be of benefit in pregnancy or,
obviously, in folic acid deficiency.
• Magnesium supplementation
Hornyak M, Feige B, Riemann D et al. Periodic leg movements in sleep and periodic limb movement disorder: prevalence, clinical significance and treatment. Sleep Med Rev 2006; 10:169–177.

7. Management
Hornyak M, Feige B, Riemann D et al. Periodic leg movements in sleep and periodic limb movement disorder: prevalence, clinical significance and treatment. Sleep Med Rev 2006; 10:169–177.

8. Augmentation
García-Borreguero D, Allen RP, Kohnen R et al. Diagnostic standards for dopaminergic augmentation of restless legs syndrome: Report from a World Association of Sleep Medicine –
International Restless Legs Syndrome Study Group consensus conference at the Max Planck Institute. Sleep Med 2007; 8:520–530.

9. Dopamine Agonists
Fulda S, Wetter TC. Dopamine agonists for the treatment of restless legs syndrome. Expert Opin Pharmacother 2005; 6:2655–2666.

10. Opioids
Silber MH, Ehrenberg BL, Allen RP et al. An algorithm for the management of restless legs syndrome. Mayo Clin Proc 2004; 79:916–922

11. Summary
• Periodic limb movements are very often present in patients with RLS but their clinical
relevance is often unclear
• Check for ferritin
• dopamine agonists are regarded as first-line therapy.
• Augmentation is an important “side-effect” of dopaminergic agents, and sometimes difficult
to treat.
• Opioid drugs are useful as second-line therapy, often in combination with dopaminergic
supplementation.
• If sensory symptoms predominate, anecdotal evidence suggests that pregabalin or
gabapentin are helpful.

12. THANK YOU