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Monday, September 1, 2014
Shaking and leg cramps
I often get a bad leg cramp while sleeping that will hurt to the point that it will wake me from a deep sleep and I will have to get up and walk it off. It seems like I have had these since I had back surgery to remove some material from one of the discs in my back. I had the surgery about 8 years ago. Recently, my wife has complained about my leg shaking during the night and I`m not sure if it may be the cramp and just not quite bad enough to wake me up or something else. I have other sleep disorder symptoms, such as, sleepiness sometimes during the day, but I also have allergy problems that I`m now getting treatment for that may be contributing. I`m really not sure if I should see a sleep specialist at this point or first give some of the medications from the allergist time to do their job. I do have some Sleep Apnea in the family. My mother, an uncle, and a cousin (all on my mother`s side of the family) are all undergoing treatment for Sleep Apnea. My wife has monitored me while I am sleeping, but doesn`t think that there is any interruption in my breathing. I don`t really know if Sleep Apnea can be genetic, or if it is something that I should be worried about. I`m concerned that I may have too many other health issues to accurately determine if I have a legitimate sleep disorder as well.
You are describing two (and possibly three) sets of symptoms; leg cramps, leg “shaking” at night and symptoms suggestive of possible obstructive sleep apnea (OSA).While the leg cramps may be more related to your back surgery and not a primary sleep disorder, the leg shaking in your sleep and the daytime sleepiness are likely due to one and, maybe two, sleep disorders that may or may not be related. Since you are curious about sleep apnea, we’ll discuss that first. OSA is a common condition, affecting roughly 5% of middle aged adults in America. Most individuals with this condition are still not diagnosed and, of those that are diagnosed, many have had it for many years prior to undergoing appropriate testing. OSA is a condition where the airway partially or completely collapses during sleep. This results in fragmentation of sleep and, in some individuals, low oxygen level during sleep. Symptoms may include waking up choking or gasping at night, very loud snoring, poor and unrefreshing sleep, morning headaches and daytime sleepiness (as you describe). For some individuals, the fragmentation of sleep due to recurrent arousals can also manifest itself as recurrent leg jerks in sleep, which could be an explanation for the leg shakes your wife describes. The consequences of this condition can be serious and range from a poor quality of life (morning headaches, disabling sleepiness, poor concentration, irritability, etc) to increasing problems with blood pressure control, heart disease and strokes. Increased weight and having a family history, as you do, predispose individuals to this disorder. For some individuals, certain features of their airway anatomy, such as large tonsils or blocked nasal passages (which could be related to allergies), may increase their risk of developing OSA. The diagnosis of sleep apnea usually depends on an overnight sleep study performed in a sleep laboratory, where your breathing during sleep can be monitored. The primary treatment for OSA is the use of CPAP, which is very effective at keeping the airway open during sleep. It does this by “pressurizing” the airway to prevent it from collapsing. In some cases, surgery or oral appliances can be effective treatment for OSA, though this is in the minority of patients.
Now let’s discuss the leg shakes. It’s possible these could be related to your leg cramps or to OSA (as noted above). Another possibility for this symptom is periodic limb movement disorder, PLMD, a disease where people move their limbs rhythmically throughout the night. This may occur in the setting of back problems, nerve disorders (such as compressed nerves or diseases that affect the nerves, like diabetes), anemia and other less common conditions. PLMD may or may not cause arousals that can sometimes be associated with a full awakening. If fragmentation of sleep occurs, this can lead to daytime sleepiness. PLMD is again usually diagnosed by a sleep study as monitoring of the legs is required. If PLMD is present, it is usually successfully treated with medications.
To truly determine the underlying cause of your problems, additional information (history and examination) and possible testing will be required. In general, testing can be done regardless of the number of “health issues” an individual has. In addition, it’s certainly conceivable that if you do have a primary sleep disorder, it may be affecting your other medical problems. Given the numerous risk factors you have for possible sleep apnea (male, allergies, family history of sleep apnea), coupled with the symptoms you describe (leg shakes, sleepiness), you should certainly discuss these with your primary care physician. Depending on other specific features in your history and examination, referral to a Sleep Specialist may be necessary to determine how best to evaluate and treat your problems
If you have other specific questions about sleep apnea, sleep paralysis or other sleep disorders, please visit the American Academy of Sleep Medicine. In addition to information, the website contains a list of Sleep Centers and Sleep Specialists across the country so that you may locate one near you. The website sleepeducation.com also contains plenty of consumer friendly information about sleep and sleep apnea.Good luck and here's to better sleep!
Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University