CASE CONFERENCES

Sleep Fragments
Section Editors: Mihaela Teodorescu, M.D., and Bernie Sunwoo, M.D.

A Young Man Who Rocks and Rolls at Night

Sameh S. Morkous1, O’Dene H. Lewis1, and Dennis Auckley2
1
Department of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals, Case Medical Center, Cleveland, Ohio; and 2Division
of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio

In Brief A nocturnal polysomnogram was

performed. Total sleep time was
A 9-year-old boy presented to the sleep 350 minutes, sleep latency 51 minutes,
clinic for evaluation of abnormal behavior sleep efficiency 76.6%, and wake after
during sleep. The referring physician was sleep onset time was 55.5 minutes. The
concerned about a possible underlying apnea–hypopnea index was 1.9 events/h,
sleep disorder versus a neurological and the arousal index was 6.9/h. The lowest
problem. Polysomnography provided the oxygen saturation was 92%, and the
answer. mean end-tidal CO2 was 31 mm Hg.
The periodic limb movement index was
0.9 events/h. There were 46 episodes of
whole-body rocking behavior during
transitions to sleep, with the longest episode
Case Vignette being 187 seconds. Three representative
30-second epochs from the patient’s
A 9-year-old boy presented with polysomnogram are shown in Figure 1.
nonrestorative sleep and abnormal
behaviors during sleep. There were no
reports of snoring, witnessed apneas,
sleepwalking, or sleep talking, but the Questions
parents reported episodes of thrashing in
bed at night, since the age of 2 years. 1. What is the most likely diagnosis?
These spells typically occurred 45 to
2. What is the most appropriate next step in
60 minutes after the patient went to bed.
the management of this patient?
The abnormal activity, described as
whole-body rocking, would last for up to [Continue onto next page for answers]
30 minutes. The child would then fall back
asleep. There was no event recall and no
report of tongue biting or bladder or bowel
incontinence. He was otherwise well
except for generalized anxiety. His only
medication was a daily multivitamin.
The child did not use caffeinated beverages.
His body mass index was 15.7 kg/m2
(35th percentile BMI for age). Examination
revealed a Mallampati score of 2,
and 1 to 21 tonsil size. The remainder
of the physical examination was normal.

(Received in original form March 30, 2015; accepted in final form June 3, 2015 )
Correspondence and requests for reprints should be addressed to Sameh S. Morkous, M.D., University Hospital, Pulmonary and Sleep Medicine, 11100 Euclid
Avenue, Cleveland OH 44106. E-mail: samehserry20@hotmail.com
Ann Am Thorac Soc Vol 12, No 9, pp 1413–1415, Sep 2015
Copyright © 2015 by the American Thoracic Society
DOI: 10.1513/AnnalsATS.201503-181CC
Internet address: www.atsjournals.org

Case Conferences: Sleep Fragments 1413

 CASE CONFERENCES

Discussion
The patient described in this report met
the diagnostic criteria for rhythmic
movement disorder. This condition is
sometimes also referred to as body rocking,
head banging, or head or body rolling.
According to the third edition of the
International Classification of Sleep
Disorders, the diagnosis of rhythmic
movement disorder requires all of the
following be met (1):
A. The patient exhibits repetitive,
stereotyped, and rhythmic motor
behaviors involving large muscle groups.
B. The movements are predominantly
sleep related, occurring near naps or
bedtime, or when the patient appears
drowsy or asleep.
C. The behaviors result in a significant
complaint characterized by at least one
of the following:
1. Interference with normal sleep;
2. Significant impairment of daytime
functioning;
3. Self-inflicted body injury.
D. The rhythmic movements are not better
explained by another movement
disorder or epilepsy.
“Significant clinical consequence” is
what differentiates rhythmic movement
disorder from sleep-related movements
that are part of normal development (59%
of 9-month-old infants exhibit some sleep-
related rhythmic movements, which
decreases to 5% by 5 years of age [2]).
Polysomnography is often performed to
verify the diagnosis and rule out other causes
of the behavior. Characteristic findings include
a minimum and maximum movement
frequency of 0.5 and 2 Hz, respectively;
a minimum of four rhythmic movements in
a cluster; and minimum amplitude on the
EMG of a rhythmic burst twice the
background EMG activity (3). Time-
synchronized video polysomnography is
recommended to help make the diagnosis (4).
Rhythmic movements occur most
often during N1 and N2 sleep, although they
can occur with drowsiness (1). In the
patient described here, almost all of the
rhythmic movements occurred during
wake–sleep transitions or N2 sleep and
were not associated with respiratory events.
The soothing effect of vestibular
stimulation has been proposed as the
Figure 1. Thirty-second epochs recorded during wakefulness in the supine position. (A) Onset, (B) reason infants and toddlers exhibit
continuation, and (C) termination of a typical event. this behavior, possibly to promote

1414 AnnalsATS Volume 12 Number 9 | September 2015

 CASE CONFERENCES

development of the motor system. More
recently, the inhibitory control system of the
central motor pattern generator has been
suggested to play a role in both pediatric and
adult rhythmic movement disorder (5).
The differential diagnoses include
repetitive movements restricted to small
muscle groups (e.g., bruxism or rhythmic
thumb sucking) and sleep-related epilepsy.
In this patient, the activity involved large
muscle groups. Associated features of
sleep-related seizures were absent, and there
was no epileptiform activity noted on the
EEG. Also included in the differential
diagnosis are the more common varieties of
childhood parasomnias, such as sleep terrors,
sleepwalking, and confusional arousals.
Secondary rhythmic movements have been
reported in association with restless leg
syndrome, obstructive sleep apnea,
narcolepsy, REM behavioral disorder, and
attention deficit hyperactivity disorder (6).
This patient had mild obstructive sleep
apnea, although this was not believed to be
a contributing factor to his rhythmic movement
disorder. Of interest, the patient had a long
sleep latency and overall short duration of sleep
on the in-lab polysomnogram, and this was
believed to represent first night effect in the
sleep laboratory.
Children with mild or intermittent
symptoms do not require treatment, and the
majority will outgrow the condition.
Treatment is indicated if there is significant
daytime impairment or concern for bodily
injury. There are no evidence-based treatment
guidelines at present; however, a low dose
of a benzodiazepine or selective serotonin
reuptake inhibitors have been used. Other
treatment options include sleep restriction,
hypnosis, and behavioral modifications (7).
Answers
1. What is the most likely diagnosis?
The most likely diagnosis is sleep-related
rhythmic movement disorder.
2. What is the most appropriate next step in
the management of this patient?
The most appropriate next step in the
management of this patient was
reassurance and discussion of safety
measures.
Follow-Up
This patient was seen by a pediatric
neurologist who obtained a sleep-
deprived EEG to suggest any underlying
seizure tendencies. The EEG was
normal.
Reassurance, safety measures,
and improved sleep hygiene were
recommended. The patient’s sleep
apnea was very mild, and watchful
waiting was decided after a thorough
discussion with the family. n
Author disclosures are available with the text
of this article at www.atsjurnals.org.

References specifications. Version 2.1; Darien IL: American Academy of Sleep

1 American Academy of Sleep Medicine. International classification of
sleep disorders, 3rd ed. Darien, IL: American Academy of Sleep
Medicine; 2014.
2 Laberge L, Tremblay RE, Vitaro F, Montplaisir J. Development of
parasomnias from childhood to early adolescence. Pediatrics 2000;
106:67–74.
3 American Academy of Sleep Medicine. The AASM manual for scoring of
sleep and associated events: rules terminology and technical
Medicine; 2014.
4 Mayer G, Wilde-Frenz J, Kurella B. Sleep related rhythmic movement
disorder revisited. J Sleep Res 2007;16:110–116.
5 Dyken ME, Lin-Dyken DC, Yamada T. Diagnosing rhythmic movement
disorder with video-polysomnography. Pediatr Neurol 1997;16:37–41.
6 Manni R, Terzaghi M. Rhythmic movements during sleep: a physiological
and pathological profile. Neurol Sci 2005;26:s181–s185.
7 Manni R, Tartara A. Clonazepam treatment of rhythmic movement
disorders. Sleep 1997;20:812.

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