Sleep Fragments

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An Uncommon Find in an Adult With Excessive Daytime Sleepiness and Morning Neck Pain

Contributed by Lourdes DelRosso, MD; Andrew L. Chesson, M.D. Louisiana State University Health Sciences Center, Shreveport Department of Neurology, Section of Sleep Medicine


A 23 year old man with history of Attention Deficit Hyperactivity Disorder (ADHD) and impulse control disorder presents to the sleep clinic with a chief complaint of excessive daytime sleepiness (EDS), headaches and neck pain upon awakening.

He takes Depakote for mood control. He denies any other medical conditions.

A nocturnal polysomnogram was performed as evaluation of possible Obstructive Sleep Apnea [OSA], producing the symptoms of EDS and morning headaches.


What significant finding is seen in the PSG tracings?

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Rhythmic Movement Disorder [Head Rolling]


In the PSG tracing we see episodes of 1 Hz. activity across the EEG and leg leads corresponding to movement in the EMG, EKG artifact and chest and abdomen with enhanced PTAF. The frequency corresponds to video monitoring showing head movement consistent with Rhythmic Movement Disorder.

Rhythmic movement disorders of sleep [RMD] are repetitive and stereotyped motor behaviors that involve large muscle groups. This group of disorders include: head rolling, body rocking, and head banging. They are more commonly seen in infants and have been associated with bed time self soothing behaviors. The incidence can range from 50% in the first months of life to about 5% at 5 years old. Rhythmic movements can also persist into adulthood. Some studies have shown that when persisting into adulthood, these disorders may be associated with ADHD1 or other psychiatric conditions. The movements have been seen in all stages of sleep. It has been postulated that the immaturity of the premotor and striatal circuits may be the common denominator in both RMD and ADHD2. It has been postulated that the sleep disruption by RMD may potentially cause the symptoms of ADHD. Treatment options are usually aimed at prevention of injuries.

In the current case the patient had a CPAP titration for management of mild OSA. He reported improvement of his symptoms after CPAP initiation.


  1. Iva Stepanova, M.D.; Sona Nevsimalova, M.D. DrS; Jaroslava Hanusova, M.D. Rhythmic movement disorder in sleep persisting into childhood and adulthood Sleep, volume 28, number 7, 2005

  2. Arthur S. Walters, M.D1; Rosalia Silvestri, M.D.2; Marco Zucconi, M.D.3; Ranju Chandrashekariah, M.D.1; Eric Konofal, Review of the Possible Relationship and Hypothetical Links Between Attention Deficit Hyperactivity Disorder [ADHD] and the Simple Sleep Related Movement Disorders, Parasomnias, Hypersomnias, and Circadian Rhythm Disorders
    Journal of Clinical Sleep Medicine, Volume 4, Number 6, 2008