The Electromyographic Diagnosis of REM Sleep Without Atonia and REM Sleep Behavior Disorder

  • Monica PulighedduEmail author
  • Patrizia Congiu
  • Raffaele Ferri


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.


REM 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. (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. (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.


  1. 1.
    Boeve BF. REM sleep behavior disorder: updated review of the core features, the REM sleep behavior disorder-neurodegenerative disease association, evolving concepts, controversies, and future directions. Ann N Y Acad Sci. 2010;1184:15–54.CrossRefGoogle Scholar
  2. 2.
    Fulda S, Plazzi G, Ferri R. Scoring atonia during normal and pathological rapid eye movement sleep: visual and automatic quantification methods. Sleep Biol Rhythms. 2013;11(Suppl 1):40–51.CrossRefGoogle Scholar
  3. 3.
    Schenck CH, Bundlie SR, Ettinger MG, Mahowald MW. Chronic behavioral disorders of human REM sleep: a new category of parasomnia. Sleep. 1986;9(2):293–308.CrossRefGoogle Scholar
  4. 4.
    Schenck CH, Bundlie SR, Patterson AL, Mahowald MW. Rapid eye movement sleep behavior disorder. A treatable parasomnia affecting older adults. JAMA [Internet]. 1987;257(13):1786–9. Available from: Scholar
  5. 5.
    Schenck CH, Milner DM, Hurwitz TD, Bundlie SR, Mahowald MW. A polysomnographic and clinical report on sleep-related injury in 100 adult patients. Am J Psychiatry [Internet]. 1989;146(9):1166–73. Available from: Scholar
  6. 6.
    Schenck CH, Mahowald MW. REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in SLEEP. Sleep [Internet]. 2002;25(2):120–38. Available from: Scholar
  7. 7.
    Schenck CH, Hurwitz TD, Mahowald MW. Symposium: normal and abnormal REM sleep regulation: REM sleep behaviour disorder: an update on a series of 96 patients and a review of the world literature. J Sleep Res [Internet]. 1993;2(4):224–31. Available from: Scholar
  8. 8.
    Olson EJ, Boeve BF, Silber MH. Rapid eye movement sleep behaviour disorder: demographic, clinical and laboratory findings in 93 cases. Brain [Internet]. 2000;123(Pt 2):331–9. Available from: Scholar
  9. 9.
    American Academy of Sleep Medicine. International classification of sleep disorders. 3rd ed. Darien, Illinois: American Academy of Sleep Medicine; 2014.Google Scholar
  10. 10.
    Brunner DP, Dijk DJ, Borbély AA. A quantitative analysis of phasic and tonic submental EMG activity in human sleep. Physiol Behav [Internet]. 1990;48(5):741–8. Available from: Scholar
  11. 11.
    Bliwise DL, He L, Ansari FP, Rye DB. Quantification of electromyographic activity during sleep: a phasic electromyographic metric. J Clin Neurophysiol [Internet]. 2006;23(1):59–67. Available from: Scholar
  12. 12.
    Consens FB, Chervin RD, Koeppe RA, Little R, Liu S, Junck L, et al. Validation of a polysomnographic score for REM sleep behavior disorder. Sleep [Internet]. 2005;28(8):993–7. Available from: Scholar
  13. 13.
    Lapierre O, Montplaisir J. Polysomnographic features of REM sleep behavior disorder: development of a scoring method. Neurology [Internet]. 1992;42(7):1371–4. Available from: Scholar
  14. 14.
    Bliwise DL, Rye DB. Elevated PEM (phasic electromyographic metric) rates identify rapid eye movement behavior disorder patients on nights without behavioral abnormalities. Sleep. 2008;31(6):853–7.CrossRefGoogle Scholar
  15. 15.
    Eisensehr I, Linke R, Tatsch K, Kharraz B, Gildehaus JF, Wetter CT, et al. Increased muscle activity during rapid eye movement sleep correlates with decrease of striatal presynaptic dopamine transporters. IPT and IBZM SPECT imaging in subclinical and clinically disorder, Parkinson’s disease, and manifest idiopathic REM sleep behavior disorder, Parkinson’s disease, and controls. Sleep. 2003;26(5):507–12.CrossRefGoogle Scholar
  16. 16.
    Frauscher B, Iranzo A, Högl B, Casanova-Molla J, Salamero M, Gschliesser V, et al. Quantification of electromyographic activity during REM sleep in multiple muscles in REM sleep behavior disorder. Sleep [Internet]. 2008;31(5):724–31. Available from: Scholar
  17. 17.
    McCarter SJ, St. Louis EK, Duwell EJ, Timm PC, Sandness DJ, Boeve BF, et al. Diagnostic thresholds for quantitative REM sleep phasic burst duration, phasic and tonic muscle activity, and REM atonia index in REM sleep behavior disorder with and without comorbid obstructive sleep apnea. Sleep [Internet]. 2014;37(10):1649–62. Available from: Scholar
  18. 18.
    Iranzo A, Frauscher B, Santos H, Gschliesser V, Ratti L, Falkenstetter T, et al. Usefulness of the SINBAR electromyographic montage to detect the motor and vocal manifestations occurring in REM sleep behavior disorder. Sleep Med [Internet]. 2011;12(3):284–8. Available from: Scholar
  19. 19.
    Frauscher B, Iranzo A, Gaig C, Gschliesser V, Guaita M, Raffelseder V, et al. Normative EMG values during REM sleep for the diagnosis of REM sleep behavior disorder. Sleep [Internet]. 2012;35(6):835–47. Available from: Scholar
  20. 20.
    Frauscher B, Ehrmann L, Högl B. Defining muscle activities for assessment of rapid eye movement sleep behavior disorder: from a qualitative to a quantitative diagnostic level. Sleep Med [Internet]. 2013;14(8):729–33. Available from: Scholar
  21. 21.
    Figorilli M, Ferri R, Zibetti M, Beudin P, Puligheddu M, Lopiano L, et al. Comparison between automatic and visual scorings of REM sleep without atonia for the diagnosis of REM sleep behavior disorder in Parkinson disease. Sleep [Internet]. 2016.; Available from:
  22. 22.
    Ferri R, Manconi M, Plazzi G, Bruni O, Vandi S, Montagna P, et al. A quantitative statistical analysis of the submentalis muscle EMG amplitude during sleep in normal controls and patients with REM sleep behavior disorder. J Sleep Res [Internet]. 2008;17(1):89–100. Available from: Scholar
  23. 23.
    Ferri R, Rundo F, Manconi M, Plazzi G, Bruni O, Oldani A, et al. Improved computation of the atonia index in normal controls and patients with REM sleep behavior disorder. Sleep Med [Internet]. 2010;11(9):947–9. Available from: Scholar
  24. 24.
    Burns JW, Consens FB, Little RJ, Angell KJ, Gilman S, Chervin RD. EMG variance during polysomnography as an assessment for REM sleep behavior disorder. Sleep [Internet]. 2007;30(12):1771–8. Available from: Scholar
  25. 25.
    Zhang J, Lam SP, Ho CKW, Li AM, Tsoh J, Mok V, et al. Diagnosis of REM sleep behavior disorder by video-polysomnographic study: is one night enough? Sleep [Internet]. 2008;31(8):1179–85. Available from: Scholar
  26. 26.
    Kempfner J, Jennum P, Nikolic M, Christensen JA, Sorensen HB. Automatic detection of REM sleep in subjects without atonia. Conf Proc IEEE Eng Med Biol Soc [Internet]. 2012;2012:4242–5. Available from: Scholar
  27. 27.
    Frauscher B, Gabelia D, Biermayr M, Stefani A, Hackner H, Mitterling T, et al. Validation of an integrated software for the detection of rapid eye movement sleep behavior disorder. Sleep [Internet]. 2014;37(10):1663–71. Available from: Scholar
  28. 28.
    Frandsen R, Nikolic M, Zoetmulder M, Kempfner L, Jennum P. Analysis of automated quantification of motor activity in REM sleep behaviour disorder. J Sleep Res [Internet]. 2015;24(5):583–90. Available from: Scholar
  29. 29.
    Berry R, Brooks R, Gamaldo C, Harding S, Lloyd R, Marcus C, et al. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, version 2.4. J Clin Sleep Med. 2017;13(5):665–6. CrossRefGoogle Scholar
  30. 30.
    Rechtschaffen A, Kales A. A manual of standardized terminology, techniques and scoring system for sleep stages of human subjects. Los Angeles Brain Inf Serv Res Institute, Univ Calif; 1986.Google Scholar
  31. 31.
    Montplaisir J, Gagnon JF, Fantini ML, Postuma RB, Dauvilliers Y, Desautels A, et al. Polysomnographic diagnosis of idiopathic REM sleep behavior disorder. Mov Disord. 2010;25(13):2044–51.CrossRefGoogle Scholar
  32. 32.
    Ferri R, Gagnon J-F, Postuma RB, Rundo F, Montplaisir JY. Comparison between an automatic and a visual scoring method of the chin muscle tone during rapid eye movement sleep. Sleep Med [Internet]. 2014;15(6):661–5. Available from: Scholar
  33. 33.
    Fernández-Arcos A, Iranzo A, Serradell M, Gaig C, Guaita M, Salamero M, Santamaria J. Diagnostic value of isolated mentalis versus mentalis plus upper limb electromyography in idiopathic REM sleep behavior disorder patients eventually developing a neurodegenerative syndrome. Sleep. 2017;40(4).
  34. 34.
    McCarter SJ, St Louis EK, Sandness DJ, Duwell EJ, Timm PC, Boeve BF, Silber MH. Diagnostic REM sleep muscle activity thresholds in patients with idiopathic REM sleep behavior disorder with and without obstructive sleep apnea. Sleep Med. 2017;33:23–9.CrossRefGoogle Scholar
  35. 35.
    Bliwise DL, Trotti LM, Greer SA, Juncos JJ, Rye DB. Phasic muscle activity in sleep and clinical features of Parkinson disease. Ann Neurol. 2010;68(3):353–9.CrossRefGoogle Scholar
  36. 36.
    Fairley JA, Georgoulas G, Stylios CD, Vachtsevanos G, Rye DB, Bliwise DL. Phasic Electromyographic Metric detection based on wavelet analysis. Mediterr Conf Control Automation. 2011. doi: 10.1109/MED.2011.5983202. Available from:
  37. 37.
    Ferri R, Fulda S, Cosentino FII, Pizza F, Plazzi G. A preliminary quantitative analysis of REM sleep chin EMG in Parkinson’s disease with or without REM sleep behavior disorder. Sleep Med [Internet]. 2012;13(6):707–13. Available from: Scholar
  38. 38.
    Ferri R, Bruni O, Fulda S, Zucconi M, Plazzi G. A quantitative analysis of the submentalis muscle electromyographic amplitude during rapid eye movement sleep across the lifespan. J Sleep Res [Internet]. 2012;21(3):257–63. Available from: Scholar
  39. 39.
    Sasai-Sakuma T, Frauscher B, Mitterling T, Ehrmann L, Gabelia D, Brandauer E, et al. Quantitative assessment of isolated rapid eye movement (REM) sleep without atonia without clinical REM sleep behavior disorder: clinical and research implications. Sleep Med [Internet]. 2014;15(9):1009–15. Available from: Scholar
  40. 40.
    Stefani A, Gabelia D, Högl B, Mitterling T, Mahlknecht P, Stockner H, et al. Long-term follow-up investigation of isolated rapid eye movement sleep without atonia without rapid eye movement sleep behavior disorder: a pilot study. J Clin Sleep Med [Internet]. 2015;11(11):1273–9. Available from: Scholar
  41. 41.
    Peever J, Luppi PH, Montplaisir J. Breakdown in REM sleep circuitry underlies REM sleep behavior disorder. Trends Neurosci. 2014;37(5):279–88.CrossRefGoogle Scholar
  42. 42.
    Puligheddu M, Congiu P, Aricò D, Rundo F, Borghero G, Marrosu F, et al. Isolated rapid eye movement sleep without atonia in amyotrophic lateral sclerosis. Sleep Med [Internet]. 2016;26:16–22. Available from:, Scholar
  43. 43.
    Winkelman JW. Periodic limb movements in sleep—endophenotype for restless legs syndrome? N Engl J Med [Internet]. 2007;357(7):703–5. Available from: Scholar
  44. 44.
    Mayer G, Kesper K, Ploch T, Canisius S, Penzel T, Oertel W, et al. Quantification of tonic and phasic muscle activity in REM sleep behavior disorder. J Clin Neurophysiol. 2008;25(1):48–55.CrossRefGoogle Scholar
  45. 45.
    Cygan F, Oudiette D, Leclair-Visonneau L, Leu-Semenescu S, Arnulf I. Night-to-night variability of muscle tone, movements, and vocalizations in patients with REM sleep behavior disorder. J Clin Sleep Med [Internet]. 2010;6(6):551–5. Available from: Scholar
  46. 46.
    Ferri R, Marelli S, Cosentino FII, Rundo F, Ferini-Strambi L, Zucconi M. Night-to-night variability of automatic quantitative parameters of the chin EMG amplitude (Atonia Index) in REM sleep behavior disorder. J Clin Sleep Med [Internet]. 2013;9(3):253–8. Available from: Scholar
  47. 47.
    Jeppesen J, Otto M, Frederiksen Y, et al. Observations on muscle activity in REM sleep behavior disorder assessed with a semi-automated scoring algorithm. Clin Neurophysiol. 2017;129(3):541–7.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Monica Puligheddu
    • 1
    Email author
  • Patrizia Congiu
    • 1
  • Raffaele Ferri
    • 2
  1. 1.Sleep Disorders Centre, University of CagliariMonserrato-CagliariItaly
  2. 2.Sleep Research Centre, Oasi Research Institute IRCCSTroinaItaly

Personalised recommendations