Normative and isolated rapid eye movement sleep without atonia in adults without REM sleep behavior disorder

John C. Feemster, Youngsin Jung, Paul C. Timm, Sarah M. Westerland, Thomas R. Gossard, Luke N. Teigen, Lauren A. Buchal, Elena F.D. Cattaneo, Charlotte A. Imlach, Stuart J. McCarter, Kevin L. Smith, Bradley F. Boeve, Michael H. Silber, Erik K.St Louis

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Study Objectives: Values for normative REM sleep without atonia (RSWA) remain unclear. Older age and male sex are associated with greater RSWA, and isolated elevated RSWA has been reported. We aimed to describe normative RSWA and characterize isolated RSWA frequency in adults without REM sleep behavior disorder (RBD). Methods: We visually quantified phasic, "any," and tonic RSWA in the submentalis (SM) and anterior tibialis (AT) muscles, and the automated Ferri REM Atonia Index during polysomnography in adults without RBD aged 21-88. We calculated RSWA percentiles across age and sex deciles and compared RSWA in older (≥ 65) versus younger (<65) men and women. Isolated RSWA (exceeding diagnostic RBD cutoffs, or >95th percentile) frequency was also determined. Results: Overall, 95th percentile RSWA percentages were SM phasic, any, tonic = 8.6%, 9.1%, 0.99%; AT phasic and "any" = 17.0%; combined SM/AT phasic, "any" = 22.3%, 25.5%; and RAI = 0.85. Most phasic RSWA burst durations were ≤1.0 s (85th percentiles: SM = 1.07, AT = 0.86 seconds). Older men had significantly higher AT RSWA than older women and younger patients (all p < 0.04). Twenty-nine (25%, 18 men) had RSWA exceeding the cohort 95th percentile, while 17 (14%, 12 men) fulfilled diagnostic cutoffs for phasic or automated RBD RSWA thresholds. Conclusions: RSWA levels are highest in older men, mirroring the demographic characteristics of RBD, suggesting that older men frequently have altered REM sleep atonia control. These data establish normative adult RSWA values and thresholds for determination of isolated RSWA elevation, potentially aiding RBD diagnosis and discussions concerning incidental RSWA in clinical sleep medicine practice.

Original languageEnglish (US)
Article numberzsz124
Issue number10
StatePublished - Oct 1 2019


  • Isolated REM sleep without atonia
  • Normative values
  • Polysomnogram
  • REM sleep behavior disorder

ASJC Scopus subject areas

  • Clinical Neurology
  • Physiology (medical)


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