Normative EMG values during REM sleep for the diagnosis of REM sleep behavior disorder

Abstract

Background: Correct diagnosis of rapid eye movement sleep behavior disorder (RBD) is important because it can be the first manifestation of a neurodegenerative disease, it may lead to serious injury, and it is a well-treatable disorder. We evaluated the electromyographic (EMG) activity in the Sleep Innsbruck Barcelona (SINBAR) montage (mentalis, flexor digitorum superficialis, extensor digitorum brevis) and other muscles to obtain normative values for the correct diagnosis of RBD for clinical practice.

Setting: Two university hospital sleep disorder centers.

Participants: Thirty RBD patients (15 idiopathic [iRBD], 15 with Parkinson disease [PD]) and 30 matched controls recruited from patients with effectively treated sleep related breathing disorders.

Interventions: Not applicable.

Methods and results: Participants underwent video-polysomnography, including registration of 11 body muscles. Tonic, phasic, and "any" (any type of EMG activity, irrespective of whether it consisted of tonic, phasic or a combination of both) EMG activity was blindly quantified for each muscle. When choosing a specificity of 100%, the 3-sec miniepoch cutoff for a diagnosis of RBD was 18% for "any" EMG activity in the mentalis muscle (area under the curve [AUC] 0.990). Discriminative power was higher in upper limb (100% specificity, AUC 0.987-9.997) than in lower limb muscles (100% specificity, AUC 0.813-0.852). The combination of "any" EMG activity in the mentalis muscle with both phasic flexor digitorum superficialis muscles yielded a cutoff of 32% (AUC 0.998) for patients with iRBD and with PD-RBD.

Conclusion: For the diagnosis of iRBD and RBD associated with PD, we recommend a polysomnographic montage quantifying "any" (any type of EMG activity, irrespective of whether it consisted of tonic, phasic or a combination of both) EMG activity in the mentalis muscle and phasic EMG activity in the right and left flexor digitorum superficialis muscles in the upper limbs with a cutoff of 32%, when using 3-sec miniepochs.

Keywords: EMG activity; SINBAR EMG montage; cutoff; movement disorders; normal values; quantification.

Figure 1

Boxplot representation of the percentages of different types of mentalis muscle EMG activity (tonic, phasic, “any”) measured in 3-sec miniepochs in patients with RBD and controls, and corresponding receiver operating characteristic curves. AUC, area under the curve; Ment, mentalis muscle; Phas, phasic EMG activity.

Figure 2

Boxplot representation of the percentages of different types of phasic EMG activity measured in 3-sec miniepochs in the 4 bilateral limb muscles of the upper and lower limbs in patients with RBD and controls, and corresponding receiver operating characteristic curves. All muscles were evaluated bilaterally. AT, anterior tibialis muscle; AUC, area under the curve; Bic, biceps brachii muscle; Ext, extensor digitorum brevis muscle; Flex, flexor digitorum superficialis muscle.

Figure 3

Boxplot representation and the corresponding receiver operating characteristic curves of the mentalis muscle EMG activity values measured in 30-sec epochs. AUC, area under the curve; Ment, mentalis muscle; Phas, phasic EMG activity.

Figure 4

Boxplot representation of the percentages of different types of 30-sec epochs with phasic EMG activity in the 4 muscles of the upper and lower limbs in RBD patients and controls and corresponding receiver operating characteristic curves. Muscles are presented bilaterally. AT, anterior tibialis muscle; AUC, area under the curve; Bic, biceps brachii muscle; Flex, flexor digitorum superficialis muscle; phas, phasic EMG activity.