Sleep-related rhythmic movement disorder …

Federica Provini MD

Sleep Disorders

Updated 01.23.2026
Released 08.16.1995
Expires For CME 01.23.2029

Sleep-related rhythmic movement disorder

Author: Federica Provini MD

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Editor: Antonio Culebras MD FAAN FAHA FAASM

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Sleep-related rhythmic movement disorder

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Introduction

Overview

In this article, the author describes the clinical and polysomnographic features of sleep-related rhythmic movement disorder. Sleep-related rhythmic movements are common in infants and children. However, due to the development of sleep medicine there has been an increase in the number of adults appealing for diagnosis and management of sleep-related movement disorders. The pathogenesis of sleep-related rhythmic disorder is likely to be multifactorial, possibly involving emotional, vestibular, and sleep-related emergence of archaic motor pattern activity through the activation of the central motor pattern generators in the brainstem. These factors may prevail over one another in the different forms of sleep-related rhythmic movement disorder and with respect to the stage during which the disorder arises (sleep/wake transition, NREM sleep, or REM sleep).

At times, these movements are excessive and may disrupt sleep, resulting in daytime sleepiness or injury. In these cases, the movements are classified by the International Classification of Sleep Disorders, 3rd edition (ICSD-3-TR), as a sleep-related rhythmic movement disorder (03).

Key points

	• Sleep-related rhythmic movement disorder consists of repetitive, stereotyped, and rhythmic motor behaviors (not tremor) that involve large muscle groups, such as in head banging and rocking or rolling of the head or body, with a rate range of 0.5 to 2 per second.
	• Sleep-related rhythmic movement disorder is distinguished from developmentally normal sleep-related rhythmic movements by the presence of associated sleep disturbance, impairment of daytime function, or self-inflicted bodily injury.
	• The movements occur at bedtime or near naptime when the patient is drowsy or may occur during any stage of sleep, including REM sleep.
	• Sleep-related movements usually occur in infants and young children. However, cases of sleep-related rhythmic movement disorder have also been reported in adults, both as adult-onset forms or relapse forms of prior infantile sleep-related rhythmic movement disorder.
	• Although there are no well-established therapies, there are case reports of significant improvement of rhythmic movements and sleep quality with the use of benzodiazepines, antidepressants, behavioral interventions, hypnosis, and/or sleep restriction.

Historical note and terminology

Repetitive head banging during sleep was first described by Zappert in 1905 and termed “jactatio capitis nocturna.” At the same time, Cruchet of France termed it “rhythmie du sommeil.” The terms “head banging,” ‘head rolling,” body rocking,” “body rolling,” and jactatio corporis nocturna” have also been applied to describe the movements. This condition was named “rhythmic movement disorder” by the International Classification of Sleep Disorders (ICSD) in 1990 to include the different rhythmic movements that occur in sleep (05). It was initially classified in the parasomnia section under the subcategory of sleep-wake transition disorders because the movements were thought to occur exclusively during the transition between wake and sleep.

In 2005, the International Classification of Sleep Disorders, 2nd edition (ICSD-2) renamed the condition “sleep-related rhythmic movement disorder” or “RMD” to stress that these movements are associated with sleep and to avoid confusion with the stereotypic rhythmic movements or “stereotypic movement disorder” (DSM 4 and proposed DSM 5) that occur during the daytime (04; 02).

Interestingly, in 1937, almost 60 years before sleep-related rhythmic movement disorder was recognized by the ICSD, it was depicted in Walt Disney’s film Snow White and the Seven Dwarfs (19). One of the seven dwarfs, Dopey, is noted to have repeated rhythmic back-and-forth myoclonus-like thrusting movements of the head, accompanied by soft vocalizations, after laying down to sleep. When he is touched, the movement subsides as he opens his eyes, and he goes back to sleep with a happy sigh.

Clinical manifestations

Presentation and course

Sleep-related rhythmic movement disorder is characterized by repetitive, stereotyped, and rhythmic motor behaviors (not tremor) of large muscle groups with a rate of 0.5 to 2 per second, which occur during drowsiness or sleep. These movements are very common in infants and young children and are thought to be related to the soothing effect of vestibular stimulation caused by the rhythmic movements. The presence of significant clinical consequences such as interference with normal sleep, significant impairment in daytime function, or self-inflicted bodily injury that requires medical treatment (or would result in injury if preventable measures were not used) is what differentiates sleep-related rhythmic movement disorder from normal sleep-related movements (03).

Subtypes of movements include the following:

	• Body rocking usually involves the entire body with the subject on hands and knees, or it may involve only the torso with the subject sitting and rocking back and forth.
	• Head banging usually occurs with the subject lying prone and involves lifting of the head and, at times, the upper torso and then forcibly banging the head down on the pillow or mattress. The subject may also sit with his back to the wall or headboard and repeatedly bang the occiput back and forth.
	• Head rolling consists of side-to-side head movements, usually with the subject lying supine.
	• The combined type involves two or more of the individual types. For example, body rocking and head banging may also be combined so that the subject rocks back and forth and bangs the head simultaneously.
	• Other movements include body rolling, leg banging, or leg rolling. Hand banging has also been reported but is less common. Different types of rhythmic movements may occasionally occur in the same individual during the same night (18).

Atypical forms of sleep-related rhythmic movement disorder consisting of head banging with punching or slapping the head with a hand, recurrent nocturnal tongue biting associated with rhythmic jaw movements, mandibular rhythmic movements, and severe rhythmic flexion movements of the neck in Hirayama disease have been reported (39).

The episodes usually last less than 15 minutes, but the duration may vary from a few minutes to an hour, with a frequency of 0.5 to 2 per second. Rhythmic humming may be heard along with movement. The movements and the associated sounds may be loud. Environmental noise or distractions during the movements may lead to cessation of the event. The patient is usually unresponsive during the events and may have no recollection on awakening.

Episodes of sleep-related rhythmic movements were initially reported to occur when drowsy near sleep onset and during transitions between sleep and wake. However, this was before polysomnographic studies were done. It is now known that movements associated with sleep-related rhythmic movement disorder may occur during quiet wakeful activities, such as listening to music or riding in a vehicle, and during any stage of sleep independently of age (03). Sleep-related movements arising from an unstable, difficult-to-define NREM stage were reported in a case of rhythmic movement disorder and sleep terror comorbidity in a 3-year-old boy (28).

Sleep-related rhythmic movement disorder has also been strongly linked with the A phase of cyclic alternating pattern during NREM sleep stage N2 (26).

Typical cases of sleep-related rhythmic movement disorder in infants and toddlers are not associated with a significant risk of injury. When injury occurs, it is noted mostly in headbangers and can be variable in type.

Most individuals with sleep-related rhythmic movement disorder are otherwise normal children and adults. However, sleep-related rhythmic movement disorder has been found to be associated with sleepwalking and daytime sleepiness in school-aged children and in adults. There are reports of an increased association of sleep-related rhythmic movement disorder with temper tantrums and attention deficit disorder in school-aged children, especially those with low ferritin levels and headaches (37; 11). Several studies link sleep-related rhythmic movement disorder persisting into adulthood with attention deficit hyperactivity disorder, restless legs syndrome, and sleep apnea (33; 35). Sleep-related rhythmic movements could occur in association with obstructive respiratory events, especially during REM sleep stages, disappearing after continuous positive airway pressure therapy (10). The hypothesis was that sleep apneas may trigger rhythmic motor events through a respiratory-related arousal mechanism in genetically predisposed subjects.

In a retrospective study of 50 patients with rhythmic movement disorder, Laganière and colleagues reported a high rate of complaints of disturbed nocturnal sleep (82%) as well as comorbidities (92%) (22). Polysomnography documented altered sleep continuity, low sleep efficiency, increased wake time after sleep onset, and frequent periodic leg movements and apnea events, with the severity of rhythmic movements being associated with the degree of disrupted nighttime sleep after controlling for comorbid motor and respiratory events.

There are also reports of sleep-related rhythmic movement disorder associated with REM sleep behavior disorder persisting despite successful treatment of REM sleep behavior disorder with clonazepam. In the other two cases, rhythmic movements in REM sleep were observed in two adults as an integral part of motor manifestations of REM sleep behavior disorder episodes (25). Although the association is unclear, the mesencephalon, pons, and spinal cord are the sites of loss of muscle control seen in REM sleep behavior disorder. This is also the site of the so-called central pattern generators (14). Central pattern generators are a genetically programmed network of neurons that may be involved in generating motor patterns seen in sleep-related rhythmic movement disorder.

In a questionnaire-based and 3-night home video polysomnographic plus 5-night actigraphic study, Kose and colleagues found a significantly higher prevalence of sleep-related rhythmic movement disorder in Down syndrome subjects compared to healthy controls (20). In Down syndrome with sleep-related rhythmic movement disorder, sleep proved to be of poor quality and low efficiency. The link between sleep-related rhythmic movement disorder and Down syndrome is of uncertain origin, though neurocognitive impairment and developmental delay are thought to play a role.

Prognosis and complications

Sleep-related rhythmic movement disorder typically occurs in infants and toddlers, and it usually resolves in the second or third year of life with a prevalence of 5% by 5 years of age (03). Even when the disorder persists into adolescence or adulthood, complications are rare, other than embarrassment. However, sleep-related rhythmic movement disorder has been found to be associated with sleep-onset insomnia, sleepwalking, and daytime sleepiness in both children and adults. As described earlier, injuries have also been reported, especially in headbangers, including minor head trauma, headbanger tumor, tongue injury, odontoid fracture, and Hirayama disease. Recurrent subdural hematoma was reported to occur in a case of headbanging (30).

In a systematic review, Michalek-Zrabkowska and colleagues reported that clinical manifestations of body or head rolling predominated in most of the cases and that insomnia, restless legs syndrome, obstructive sleep apnea, ischemic stroke, epilepsy, hypertension, alcohol and drug dependency, mild depression, and diabetes mellitus were not infrequently comorbid with rhythmic movement disorder (29).

Clinical vignette

A 5-year-old boy presented to the sleep medicine clinic with complaints of restless sleep, irritability, growing pains, and body rolling. The mother stated that the movements started with head rolling at 6 months of age, occurred during sleep onset, and occurred 10 to 12 times throughout the night. More recently, body rocking and rolling movements occurred during sleep onset for up to an hour, with nocturnal awakenings. The movements had resulted in bruising in the past; subsequently, the mother routinely put extra pillows around his bed so that he would not injure himself against the wall or headboard. The mother was concerned that her son was sleep-deprived, and the grandmother was concerned about epilepsy.

The child was born full-term and did not have other medical problems. He was developmentally on track, socially appropriate, and growing well with a normal appetite. On further questioning, he described leg and arm discomfort (“feels like soda”) at night, which was relieved with movement.

His vitals were normal. His height and weight were at the 50th percentile for age. The physical exam was normal, including an absence of bruising or signs of injury. Neurologic examination was normal.

Laboratory findings included a ferritin level of 28 ng/mL (low, but within laboratory normal range). Polysomnogram revealed an absence of sleep-disordered breathing, the presence of periodic limb movements with frequent awakenings, an absence of EEG abnormalities, and repeated episodes of body rocking.

Sleep-related rhythmic movement disorder in a 5-year-old boy (PSG)

(Contributed by Dr. Pallavi P Patwari.)
Sleep-related rhythmic movement disorder in a 5-year-old boy

(Contributed by Dr. Pallavi P Patwari.)

The patient was diagnosed with restless legs syndrome and sleep-related rhythmic movement disorder because of daytime impairment and a history of injury. He was given supplemental iron treatment for the restless legs syndrome. The family was given reassurance that he did not have a seizure disorder. Treatment options, including a short course of benzodiazepine therapy, were discussed with the family.

At follow-up, the mother reported an improvement in the child’s sleep, including improved sleep onset within 15 minutes and fewer nocturnal awakenings. The patient also reported an improvement in his symptoms of restless legs. His daytime irritability had also improved. He continued to have body rocking, which was of shorter duration and occurred less frequently. The mother was reassured that the body rocking would continue to resolve with increasing age.

Biological basis

Etiology and pathogenesis

Although the exact cause of rhythmic movement disorder is unknown, it has been suggested that it may be a part of normal development. Other suggested etiologies include a kinesthetic drive, tension-releasing maneuver, attention-seeking device, response to restricted activity, a consequence of emotional deprivation, and the result of acute illness. Developmental disorders and perinatal risk factors have been reported in association with both sleep-related rhythmic movements and rhythmic movement disorder in children and young adults; when sleep-related rhythmic movements significantly interfere with sleep or affect daytime functioning, potentially resulting in injury, rhythmic movement disorder is diagnosed.

A familial history, although uncommon, has been reported (27; 06).

The role of genetic factors has been suspected in some cases. Hayward-Koennecke and colleagues reported monozygotic female triplets affected by cystic fibrosis who presented with a rolling subtype of rhythmic movement disorder (17).

No neuropathologic lesion has been described, although an abnormality of the basal ganglia has been suggested. Motor stereotypies generally seem dependent on some kind of basal ganglia circuitry involving the striatum or the substantia nigra (08; 12). Stereotypic behaviors performed by captive and domesticated animals housed in barren environments resemble rhythmic movement disorder and are thought to reflect disinhibition of the behavioral control mechanisms of the dorsal basal ganglia (13). The release of a central pattern generator has also been suggested to account for the occurrence of rhythmic movements in both physiological and pathological conditions (24). The presence of subcortical central pattern generators has been proposed to account for the similarities in movements observed between frontolimbic epileptic seizures, parasomnias, and sleep-related rhythmic movement disorder (34). In addition, the presence of a central pattern generator in the mesencephalic, pontine, and spinal cord regions has also been suggested to explain the case reports of rhythmic movements seen in cases of idiopathic REM sleep behavior disorder (14).

Some authors have proposed different pathogenetic mechanisms for the rhythmic movements seen in NREM versus REM sleep. Manni and colleagues reported the association between sleep-related rhythmic movement disorder and cyclic alternating pattern (CAP) (26).

Differential diagnosis

Confusing conditions

Even though sleep-related rhythmic movement disorder is easily diagnosed based on clinical history in most cases, a few sleep-related disorders may be misdiagnosed as rhythmic movement disorder. These include seizures, periodic limb movements, self-stimulatory behavior (masturbation), hypnagogic foot tremor, alternating leg movements of sleep, or hypnic jerk (sleep start) (32). In addition, sleep-related rhythmic movement disorder may be confused with bruxism, thumb sucking, rhythmic sucking of a pacifier, and other such movements. The limb movements seen with periodic limb movement disorder or restless legs syndrome may sometimes appear rhythmic. Patients with restless legs syndrome will usually report discomfort in their body and other classic symptoms of restless legs syndrome. Autoerotic or masturbatory behavior in sleep may appear rhythmic but is primarily focused on the genital area and should not be termed as sleep-related rhythmic movement disorder (31). Hypnagogic foot tremor is a rhythmic movement of the feet occurring every second or so for several minutes (38). It is seen before sleep onset or during light sleep. Alternating leg movements of sleep may represent that same disorder and involve brief contraction of the anterior tibialis in one leg alternating with the other during sleep (09). It is unclear if these two conditions are separate entities or a variant of sleep-related rhythmic movement disorder. Sleep starts are brief jerks that occur during sleep-wake transitions and, when recurrent, may appear rhythmic.

Although the movements seen in patients with REM sleep behavior disorder and NREM parasomnias are complex, the associated movements may sometimes appear rhythmic and should also be differentiated from sleep-related rhythmic movement disorder.

Media

References

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Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Federica Provini MD

Dr. Provini of the University of Bologna and IRCCS Institute of Neurological Sciences of Bologna received speakers' fees from Idorsia and Italfarmaco.
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Editor

Antonio Culebras MD FAAN FAHA FAASM

Dr. Culebras of SUNY Upstate Medical University at Syracuse has no relevant financial relationships to disclose.
See Profile

Former Authors

Michael J Thorpy MD
Daniel Rifkin MD
Pasquale Montagna MD
Pallavi P Patwari MD
Ramadevi Gourineni MD
Raffaele Manni MD

Patient Profile

Age range of presentation: 0 month to 65+ years
Sex preponderance: Male>female for adults (no gender difference in pediatric studies)
Heredity: none
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

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Sleep-related rhythmic movement disorder

Associated Disorders

Attention deficit disorder
Autism
Headache
Developmental delay
Myoclonus
- Obstructive sleep apnea syndrome
- REM sleep behavior disorder
- Restless legs syndrome

Differential Diagnosis

epilepsy
nocturnal epilepsy
seizures
periodic limb movements
self-stimulatory behavior (masturbation)
- hypnagogic foot tremor
- alternating leg movements of sleep
- hypnic jerk (sleep start)
- bruxism
- thumb sucking
- rhythmic sucking of a pacifier
- restless legs syndrome
- akathisia
- rhythmic feet movements
- sexsomnia
- sleep sex
- hypnagogic behavior disorder

Also Relevant

Attention deficit hyperactivity disorder
Autism spectrum disorder
Intellectual disability
Periodic limb movements
Restless legs syndrome
- Sleep disorders
- Sleep-related leg cramps
- Stereotypies
- Tourette syndrome

Clinical Categories

Patient Handouts

Sleep

Sleep-related rhythmic movement disorder

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Special considerations

Pregnancy

Anesthesia

Media

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

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