Spasticity or periodic limb movements?

Background: Spasticity and spasms are distressing features of the upper motor neuron syndrome (UMNS) following spinal cord injuries (SCI) or multiple sclerosis (MS), and have common therapeutic implications. Despite an increase of antispastic drugs and strategies, sometimes up to the surgical implant of intrathecal baclofen pump, some patients still complain of disabling spasms, which poses diagnostic and therapeutic challenges. Although clinically similar, flexor spasms due to pyramidal tract disruption must be clearly differentiated from periodic limb movements (PLM), often accompanying restless leg syndrome (RLS) and occurring during sleep. We raised the hypothesis of this differential as a diagnostic confusion in this particular population.

Aim: The aim of this study was twofold: 1) to search for RLS with PLM in consecutive patients referred for uncontrolled disabling spasms despite treatment, by nocturnal polysomnography (PSG); 2) to report the efficacy of dopaminergic agonists on PLM in this population.

Design: Observational prospective study.

Setting: Spasticity Clinic at the Raymond-Poincaré University Hospital, Garches, France.

Population: All consecutive patients with MS or SCI, referred to our spasticity clinic from March 2014 to July 2016 for the management of persistent and disabling spasms despite treatment. Obvious daytime spasticity or flexor spasms were not considered. When spasms prevailed at evening, night, or in supine position, patients underwent a nocturnal PSG.

Methods: Patients were assessed for RLS by clinical interview and for PLM by PSG. Patients with confirmed PLM (≥15 per hour of sleep) were treated with low dosage of pramipexole (after an iron deficiency was ruled out) and reassessed by PSG the following night.

Results: Forty-five patients were included. All fulfilled RLS criteria, and PLMs were confirmed in 39 patients. Median PLM index, and related arousals were 45.9 (19.8-76.2) and 5.1 (1.5-15) events per hour respectively. Nine patients treated with pramipexole underwent an early second PSG which showed an improvement of PLM index and arousals (P=0.0007 and P=0.01, respectively).

Conclusions: In this princeps study, we demonstrated that in SCI and MS patients, "persistent spasms" inefficiently treated by antispastic drugs could in fact be PLM. Furthermore, we first reported the efficacy of dopaminergic agonists for PLM in an MS and SCI population.

Clinical Rehabilitation Impact: This study brings new insights on abnormal movements, often misinterpreted as spasticity, and their management. We suggest to include a PSG in the diagnostic approach of uncontrolled spasms prevailing at night or in supine position, to search for PLM, which are easily treatable.