The Electromyographic Diagnosis of REM Sleep Without Atonia and REM Sleep Behavior Disorder
The inability to tonically inhibit muscle tone during REM sleep results in REM sleep without atonia (RWA, RSWA) that represents the polysomnographic (PSG) hallmark of REM sleep behavior disorder (RBD). Different visual/manual RWA scoring methods have been developed to establish cutoff values for normal atonia during REM sleep with the aim to exactly quantify REM sleep atonia. The first method for quantifying RWA was developed by Lapierre and Montplaisir (which will be called here the Montréal method) in 1992. Subsequently, other research groups introduced their scoring methods such as the SINBAR method (2008) proposed by the Barcelona and Innsbruck groups and the McCarter-St. Louis method (2014) that was adapted from previous methods. Furthermore, in order to obtain a more rapid and reproducible scoring method, in 2008, a computer-based quantitative automatic scoring algorithm, also known as REM sleep atonia index (RAI), was proposed. (Also, other automated algorithms have been proposed.) According to the current ICSD-3 criteria, for the diagnosis of RBD, PSG demonstration of RWA is required. Nevertheless, RWA and RBD can occur independently from each other, and there is a “gray zone” into which both RBD patients and normal controls can fall. Because of its potential prognostic value, an important but still unresolved issue is whether subjects without RBD but with RWA are at risk of developing RBD, and/or future parkinsonism, or not. In conclusion, the role of RWA in the diagnosis of RBD is certainly central, but not absolute in regard to cutoff values, and an appropriate clinical judgment should guide the diagnostic process of RBD, as encouraged in the ICSD-3.
KeywordsREM sleep without atonia REM sleep behavior disorder REM sleep atonia index Lapierre and Montplaisir method SINBAR method
Note Added in Proof:
Four pertinent studies have recently been published: (1) Guttowski D, Mayer G, Oertel WH, Kesper K, Rosenberg T. Validation of semiautomatic scoring of REM sleep without atonia in patients with RBD. Sleep Med. 2018; 46:107–13. (2) Cesari M, Christensen JAE, Kempfner L, et al. Comparison of computerized methods for REM sleep without atonia detection. Sleep. 2018 Jul 13. https://doi.org/10.1093/sleep/zsy133. (3) Bliwise DL, Fairley J, Hoff S, Rosenberg RS, Rye DB, Schulman DA, Trotti LM. Inter-rater agreement for visual discrimination of phasic and tonic electromyographic activity in sleep. Sleep. 2018. https://doi.org/10.1093/sleep/zsy080. (4) Olesen AN, Cesari M, Christensen JAE, Sorensen HBD, Mignot E, Jennum P. A comparative study of methods for automatic detection of rapid eye movement abnormal muscular activity in narcolepsy. Sleep Med. 2018;44:97–105.
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