Physician-diagnosed restless legs syndrome in a large sample of primary medical care patients in western Europe: Prevalence and characteristics

Restless Legs Syndrome and Poor Sleep Quality in Obese Children and Adolescents

OBJECTIVE

Adult epidemiological studies suggest that the rate of Restless Legs syndrome (RLS) in the general population may range from 5% to 15%. The aim of this study was to investigate the frequency of RLS in a community sample of obese adolescents aged 10-16 years and to assess the association with sleep quality and health-related glucose metabolism markers.

METHODS

The study group comprised 144 obese and overweight children aged 10-16 yearsand the control group consisted of 66 age-matched healthy children. The RLS Questionnaire devised by the International RLS Study and the Pittsburgh Sleep Quality Index (PSQI), where a score >5 indicates poor sleep quality, was used to assess sleep quality.

RESULTS

Mean body mass index (BMI) of the overweight/obese and control groups were 30.5±0.5 and 18.7±0.2, respectively. The frequency of RLS was higher in the obese group (21.7%) than the overweight (3.4%) and control (1.5%) (p<0.001) groups. The frequency of a poor PSQI score was significantly higher (p<0.001) in the obese group (37.3%) than the control group (24.2%). The obese with RLS group also had poorer sleep quality scores than the non-RLS obese group. Many symptoms of sleep disruption were more common in obese patients with RLS and RLS was independently correlated with a high PSQI score [odds ratio (OR): 2.25, confidence interval (Cl): 0.96-5.28, p<0.001)] and an increased BMI z-score (OR: 8.87, Cl: 2.04-38.61, p<0.001).

CONCLUSION

RLS is common in obese children and may be associated with altered sleep quality. Obese children with RLS need to be assessed since they may need support to improve their sleep quality.

Restless legs syndrome: a rarity in the Nigerian pregnant population?

OBJECTIVES

The prevalence of RLS in pregnancy is higher when compared with the general population however it remains unknown among indigenous black Africans. Available data indicate that RLS is uncommon in sub-Saharan Africa. We embarked on this study to determine the prevalence and characteristics of RLS in an antenatal clinic sample of Nigerian pregnant women compared with a primary care sample of non-pregnant women.

METHODS

A total of 310 pregnant women and non-pregnant women filled out a questionnaire which incorporated the 2014 minimal criteria of the International Restless Legs Syndrome Study Group. Demographic and clinical data, including sleep duration and samples for blood hemoglobin concentration and urinalysis were obtained.

RESULTS

The mean ages of the pregnant and non-pregnant women were 24.9 ± 5.6 years and 23.6 + 5.4 years, respectively (p = 0.003). There was no case of RLS found among pregnant women while five (1.6%) of the non-pregnant women fulfilled the criteria for RLS. Overall, the prevalence report of RLS symptoms was associated with lower mean habitual nocturnal sleep duration (p < 0.05) coffee (p = 0.013) and kola nut (0.023) consumption, report of leg cramps (p < 0.001) and proteinuria (p = 0.047), Report of leg cramps and proteinuria were independently associated with RLS.

CONCLUSION

The prevalence of restless legs syndrome is low among women of child-bearing age in the Nigerian population and may be lower in pregnancy. Report of leg cramps and proteinuria are independently associated with RLS.

Pivotal Role of Adenosine Neurotransmission in Restless Legs Syndrome

The symptomatology of Restless Legs Syndrome (RLS) includes periodic leg movements during sleep (PLMS), dysesthesias, and hyperarousal. Alterations in the dopaminergic system, a presynaptic hyperdopaminergic state, seem to be involved in PLMS, while alterations in glutamatergic neurotransmission, a presynaptic hyperglutamatergic state, seem to be involved in hyperarousal and also PLMS. Brain iron deficiency (BID) is well-recognized as a main initial pathophysiological mechanism of RLS. BID in rodents have provided a pathogenetic model of RLS that recapitulates the biochemical alterations of the dopaminergic system of RLS, although without PLMS-like motor abnormalities. On the other hand, BID in rodents reproduces the circadian sleep architecture of RLS, indicating the model could provide clues for the hyperglutamatergic state in RLS. We recently showed that BID in rodents is associated with changes in adenosinergic transmission, with downregulation of adenosine A₁ receptors (A1R) as the most sensitive biochemical finding. It was hypothesized that A1R downregulation leads to hypersensitive striatal glutamatergic terminals and facilitation of striatal dopamine release. Hypersensitivity of striatal glutamatergic terminals was demonstrated by an optogenetic-microdialysis approach in the rodent with BID, indicating that it could represent a main pathogenetic factor that leads to PLMS in RLS. In fact, the dopaminergic agonists pramipexole and ropinirole and the α₂δ ligand gabapentin, used in the initial symptomatic treatment of RLS, completely counteracted optogenetically-induced glutamate release from both normal and BID-induced hypersensitive corticostriatal glutamatergic terminals. It is a main tenet of this essay that, in RLS, a single alteration in the adenosinergic system, downregulation of A1R, disrupts the adenosine-dopamine-glutamate balance uniquely controlled by adenosine and dopamine receptor heteromers in the striatum and also the A1R-mediated inhibitory control of glutamatergic neurotransmission in the cortex and other non-striatal brain areas, which altogether determine both PLMS and hyperarousal. Since A1R agonists would be associated with severe cardiovascular effects, it was hypothesized that inhibitors of nucleoside equilibrative transporters, such as dipyridamole, by increasing the tonic A1R activation mediated by endogenous adenosine, could represent a new alternative therapeutic strategy for RLS. In fact, preliminary clinical data indicate that dipyridamole can significantly improve the symptomatology of RLS.

Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study

BACKGROUND

Restless legs syndrome is a sensorimotor disorder and it is associated with several other diseases especially mental illnesses.

AIMS

To analyze the relationship between the symptoms of restless legs syndrome and the severity of depressive symptoms and the prevalence of restless legs symptoms in depression subtypes.

METHODS

A cross-sectional study of primary care patients in the Central Finland Hospital District. The prevalence of restless legs symptoms was studied in 706 patients with increased depressive symptoms and 426 controls without a psychiatric diagnosis by using a structured questionnaire. The depressive symptoms were evaluated with the Beck Depression Inventory (BDI) and the psychiatric diagnosis was confirmed by means of a diagnostic interview (Mini-International Neuropsychiatric Interview). The subjects with increased depressive symptoms were divided into three groups (subjects with depressive symptoms without a depression diagnosis, melancholic depression and non-melancholic depression).

RESULTS

In the whole study population, the prevalence of restless legs symptoms increased with the severity of depressive symptoms. The prevalence of restless legs symptoms was highest in the melancholic and non-melancholic depressive patients (52 and 46%, respectively) and then in subjects with depressive symptoms without a depression diagnosis (43.4%), but the prevalence was also substantial (24.6%) in subjects without a psychiatric diagnosis.

CONCLUSIONS

Restless legs symptoms are very common in primary care among subjects with depression, regardless of the depression type. The prevalence of restless legs symptoms increased with increasing severity of depressive symptoms, regardless of the diagnosis. These findings should be considered in clinical evaluation and treatment of patients visiting their physician due to restless legs or depressive symptoms.

The Appropriate Use of Opioids in the Treatment of Refractory Restless Legs Syndrome

Restless legs syndrome (RLS) is a distinct disorder, differing from chronic pain in many ways. Refractory RLS is characterized by unresponsiveness to dopamine agonists or alpha-2-delta ligands due to inadequate efficacy, augmentation, or adverse effects. This may result in severely impaired quality of life, profound insomnia, and suicidal depression. Opioid therapy is a mainstay in the management of these patients. This article summarizes the basic science and clinical evidence in support of their use, including the positive result of a large controlled multicenter study of 306 subjects, and outlines an approach to their use in clinical practice. Treatable explanations for RLS refractoriness, such as low iron stores, and other therapeutic options, such as combination therapy, should be considered before prescribing opioids. The agents most commonly used are oxycodone and methadone, but tramadol, codeine, morphine, and hydrocodone can also be considered. Controlled-release medication should be used for evening dosage and short-acting drugs, if needed, during the day. Effective doses are considerably lower than used for chronic pain (oxycodone 10-30 mg daily; methadone 5-20 mg daily) and the risk of opioid use disorder is relatively low. However, sensible precautions should be undertaken, including assessing opioid risk with standard questionnaires, using an opioid contract, using urine drug screens, consulting state prescription drug monitoring programs, and frequent reevaluation of effectiveness and side effects. Opioid use in selected patients with refractory RLS may be life-transforming with favorable risk-benefit ratio.

Prospective study of restless legs syndrome and total and cardiovascular mortality among women

OBJECTIVE

We prospectively examined whether women with physician-diagnosed restless legs syndrome (RLS) had a higher risk of total and cardiovascular disease (CVD) mortality relative to those without RLS.

METHODS

The current study included 57,417 women (mean age 67 years) from the Nurses' Health Study without cancer, renal failure, and CVD at baseline (2002). Main outcomes were total and CVD mortality. We used the Cox proportional hazards model to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and CVD-specific mortality based on RLS status, adjusting for age, presence of major chronic diseases, and other potential confounders.

RESULTS

We documented 6,448 deaths during 10 years of follow-up. We did not observe a significant association between presence of physician-diagnosed RLS and high risk of total mortality (adjusted HR 1.15, 95% CI 0.98-1.34). When cause-specific mortality was studied, participants with RLS had a significantly higher risk of CVD mortality (adjusted HR 1.43, 95% CI 1.02-2.00) relative to those without RLS after adjustment for potential confounders. Longer duration of RLS diagnosis was significantly associated with a higher risk of CVD mortality (p for trend = 0.04). Excluding participants with common RLS comorbidities strengthened the association between RLS and total (adjusted HR 1.43, 95% CI 1.03-1.97) and CVD mortality (adjusted HR 2.27, 95% CI 1.21-4.28). However, we did not find a significant association between RLS and mortality due to cancer and other causes.

CONCLUSIONS

Women with RLS had a higher CVD mortality rate, which may not be fully explained by common co-occurring disorders of RLS.

Targeting hypersensitive corticostriatal terminals in restless legs syndrome

OBJECTIVE

The first aim was to demonstrate a previously hypothesized increased sensitivity of corticostriatal glutamatergic terminals in the rodent with brain iron deficiency (BID), a pathogenetic model of restless legs syndrome (RLS). The second aim was to determine whether these putative hypersensitive terminals could constitute a significant target for drugs effective in RLS, including dopamine agonists (pramipexole and ropinirole) and α₂ δ ligands (gabapentin).

METHODS

A recently introduced in vivo optogenetic-microdialysis approach was used, which allows the measurement of the extracellular concentration of glutamate upon local light-induced stimulation of corticostriatal glutamatergic terminals. The method also allows analysis of the effect of local perfusion of compounds within the same area being sampled for glutamate.

RESULTS

BID rats showed hypersensitivity of corticostriatal glutamatergic terminals (lower frequency of optogenetic stimulation to induce glutamate release). Both hypersensitive and control glutamatergic terminals were significant targets for locally perfused pramipexole, ropinirole, and gabapentin, which significantly counteracted optogenetically induced glutamate release. The use of selective antagonists demonstrated the involvement of dopamine D₄ and D₂ receptor subtypes in the effects of pramipexole.

INTERPRETATION

Hypersensitivity of corticostriatal glutamatergic terminals can constitute a main pathogenetic mechanism of RLS symptoms. Selective D₄ receptor agonists, by specifically targeting these terminals, should provide a new efficient treatment with fewer secondary effects. Ann Neurol 2017;82:951-960.

Sleep disorders in the elderly: Diagnosis and management

Compared with younger people, elderly people show age‐related sleep changes, including an advanced sleep phase and decreased slow‐wave sleep, which result in fragmented sleep and early awakening. Multiple etiologies contribute to insomnia in the elderly, consistent with the observation that elderly people are likely to have comorbid conditions and medications. When elderly individuals complain of insomnia, it is important to assess treatable medical conditions and medication use that may be responsible for the insomnia before the use of hypnotics is initiated. Also, screening for primary sleep disorders, such as sleep apnea syndrome, restless legs syndrome and rapid eye movement sleep behavior disorder, is essential. We review sleep disorders commonly observed in the elderly and describe their diagnosis and management.

Electrophysiological findings of Turkish patients with restless legs syndrome

We aimed to investigate changes in electrophysiological findings in Turkish patients with restless legs syndrome (RLS), including F-wave latency (FWL), peripheral silent period (PSP), and Hoffmann reflex. The study took place in a university hospital in Turkey and involved 30 newly diagnosed RLS patients and 30 healthy controls who were matched for age and gender. Participant's demographics (age, gender, weight, and height), laboratory findings, and electrophysiological test outcomes were gathered and analyzed. There was no significant difference in the FWL of the median and ulnar nerves, whereas the H-wave maximum amplitude and H/M ratio were significantly higher in the RLS patients than in the controls at rest. All of the PSP parameters were similar between patients and controls for the abductor pollicis brevis and gastrocnemius muscles. However, for the tibialis anterior muscle, all the PSP duration parameters were shorter in the RLS patients, whereas the PSP latency parameters were similar. The data suggest that there may be a reduction in spinal segmental inhibition at the L4-L5-S1 level, but the mechanisms of inhibition at the L4-L5 and S1 levels may be different; furthermore, there may be no pathology in the peripheral nerves. Further prospective studies with larger cohorts are now needed to evaluate the pathophysiology of RLS with different neurophysiological assessment tools.

Gabapentin treatment in clozapine-induced restless legs syndrome: two cases and a review of the literature

Restless legs syndrome (RLS) is a neuro-sensorimotor disorder affecting 2-4% of adults. It is characterized by intense urges to move the legs, associated with unpleasant sensory disturbances in the legs occurring at rest and manifests mostly in the evening and night, relieved by movement. Diagnosis is primarily based on clinical presentation and the consensus criteria for the diagnosis have been established. Antipsychotics, the dopamine antagonists, have been reported to induce RLS. Dopamine agonists, the effective first-line treatment of RLS, carry the risk of inducing or worsening psychosis. Many nondopaminergic agents including antiepileptic medications have also been used in the treatment of primary RLS. In this report we describe clozapine-induced RLS in two patients with schizophrenia and its successful treatment with gabapentin, a nondopaminergic agent. In addition, we have reviewed the available literature on clozapine-induced RLS and its management.

Epidemiology of sleep and sleep disorders in The Netherlands

OBJECTIVE

There is a surging public interest in The Netherlands concerning sleep, sleep disorders and associated health. For a proper perspective, it is necessary to have reliable information on the prevalence of sleep characteristics at the national level. This study set out to assess prevalence rates and key characteristics of sleep and sleep disorders in The Netherlands.

METHODS

In 2012, a nationally representative sample of 2089 individuals, aged 18-70 years, responded to a set of 48 questions, including the Holland Sleep Disorders Questionnaire, a validated questionnaire based on the International Classification of Sleep Disorders.

RESULTS

Prevalence rates were: 32.1% for a general sleep disturbance (GSD), 43.2% for insufficient sleep, 8.2 for insomnia, 5.3% for circadian rhythm sleep disorder, 6.1% for parasomnia, 5.9% for hypersomnolence, 12.5% for restless legs disorder and limb movements during sleep, 7.1% for sleep related breathing disorder, and 12.2% for the presence of comorbidity, ie, the presence of two or more concurrent sleep disorders. In addition, sleep onset time as well as sleep duration showed U-shaped relationships with GSD prevalence rates, with respectively the 22:00-24:00 period and seven to 8 h as optimal associates.

CONCLUSIONS

Sleep disorders and insufficient sleep have a high prevalence. As matter of concern, female adolescents reached the highest prevalence rates for most sleep disorders, insufficient sleep and daytime malfunctioning.

Adenosine receptors as markers of brain iron deficiency: Implications for Restless Legs Syndrome

Deficits of sensorimotor integration with periodic limb movements during sleep (PLMS) and hyperarousal and sleep disturbances in Restless Legs Syndrome (RLS) constitute two pathophysiologically distinct but interrelated clinical phenomena, which seem to depend mostly on alterations in dopaminergic and glutamatergic neurotransmission, respectively. Brain iron deficiency is considered as a main pathogenetic mechanism in RLS. Rodents with brain iron deficiency represent a valuable pathophysiological model of RLS, although they do not display motor disturbances. Nevertheless, they develop the main neurochemical dopaminergic changes found in RLS, such as decrease in striatal dopamine D₂ receptor density. On the other hand, brain iron deficient mice exhibit the characteristic pattern of hyperarousal in RLS, providing a tool to find the link between brain iron deficiency and sleep disturbances in RLS. The present study provides evidence for a role of the endogenous sleep-promoting factor adenosine. Three different experimental preparations, long-term (22 weeks) severe or moderate iron-deficient (ID) diets (3- or 7-ppm iron diet) in mice and short-term (3 weeks) severe ID diet (3-ppm iron diet) in rats, demonstrated a significant downregulation (Western blotting in mouse and radioligand binding saturation experiments in rat brain tissue) of adenosine A₁ receptors (A1R) in the cortex and striatum, concomitant to striatal D2R downregulation. On the other hand, the previously reported upregulation of adenosine A_2A receptors (A2AR) was only observed with severe ID in both mice and rats. The results suggest a key role for A1R downregulation in the PLMS and hyperarousal in RLS.

Restless legs syndrome is associated with poor sleep quality and quality of life in patients with ankylosing spondylitis: a questionnaire-based study

We aimed to investigate the frequency of restless legs syndrome (RLS) and the associations between RLS and quality of sleep and life in patients with ankylosing spondylitis (AS). One hundred and eight AS patients and 64 controls were included in this study. Demographics, clinical, and laboratory data were recorded. The presence of RLS was determined with face-to-face interview by an experienced neurologist based on the International RLS Study Group criteria. RLS severity was evaluated using International RLS Study Group rating scale. Sleep quality and insomnia severity were assessed by Pittsburgh sleep quality index (PSQI) and insomnia severity index (ISI), respectively. Disease-related quality of life was evaluated by AS quality of life questionnaire (ASQoL). The frequency of RLS was significantly higher in AS patients than in controls (36.4 vs. 14.0 %, p = 0.004). RLS severity score for AS patients was significantly higher than that for controls (p = 0.03). The AS patients had higher scores in the subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication domains of PSQI, and also total PSQI and ISI than controls (p < 0.05, for all). ASQoL scores were higher in AS patients with RLS compared to those without RLS (p < 0.001). RLS severity was observed to be independently associated with total PSQI, ISI and ASQoL (p < 0.05, for all). As RLS may adversely affect the sleep and quality of life in AS patients, clinicians should be aware of RLS for early diagnosis and management in AS patients.

Prevalence of Restless Legs Syndrome in Adult ADHD and Its Subtypes

In this observational cross-sectional study, 49 subjects were assessed for sleep disorders and for ADHD symptoms. Thirty-six received an ADHD diagnosis (29: combined type (ADHD-C); 7: inattentive type). An RLS and RLS symptoms prevalence of 34.5% was found, with a higher prevalence rate in the ADHD-C subgroup, although not significantly (p = 0.066). RLS symptoms were correlated with particularly hyperactivity-impulsivity (ρ = 0.742; p: 0.000). ADHD patients with positive RLS scores reported higher scores on the ADHD-Rating scale compared with patients with negative RLS scores (Z: -2.968, p = 0.003), mainly due to higher hyperactivity-impulsivity scores (Z: -3.145; p = 0.002). Our findings show that clinicians need to be aware of RLS among adult ADHD patients, particularly those with severe hyperactivity-impulsivity symptoms.

Restless Legs Syndrome: Current Concepts about Disease Pathophysiology

Background

In the past few decades, much has been learned about the pathophysiology of restless legs syndrome (RLS). Investigators have studied neuropathology, imaging, electrophysiology, and genetics of RLS, identifying brain regions and biological systems affected in RLS. This manuscript will review RLS pathophysiology literature, examining the RLS state through consideration of the neuroanatomy, then the biological, organ, and genetic systems.

Methods

Pubmed (1966 to April 2016) was searched for the term “restless legs syndrome” cross-referenced with “pathophysiology,” “pathogenesis,” “pathology,” or “imaging.” English language papers were reviewed. Studies that focused on RLS in relation to another disease were not reviewed.

Results

Although there are no gross structural brain abnormalities in RLS, widespread brain areas are activated, including the pre- and post-central gyri, cingulate cortex, thalamus, and cerebellum. Pathologically, the most consistent finding is striatal iron deficiency in RLS patients. A host of other biological systems are also altered in RLS, including the dopaminergic, oxygen-sensing, opioid, glutamatergic, and serotonergic systems. Polymorphisms in genes including BTBD9 and MEIS1 are associated with RLS.

Discussion

RLS is a neurologic sensorimotor disorder that involves pathology, most notably iron deficiency, in motor and sensory brain areas. Brain areas not subserving movement or sensation such as the cingulate cortex and cerebellum are also involved. Other biological systems including the dopaminergic, oxygen-sensing, opioid, glutamatergic, and serotonergic systems are involved. Further research is needed to determine which of these anatomic locations or biological systems are affected primarily, and which are affected in a secondary response.

Co-Morbidity, Mortality, Quality of Life and the Healthcare/Welfare/Social Costs of Disordered Sleep: A Rapid Review

Sleep disorders are frequent (18%-23%) and constitute a major risk factor for psychiatric, cardiovascular, metabolic or hormonal co-morbidity and mortality. Low social status or income, unemployment, life events such as divorce, negative lifestyle habits, and professional requirements (e.g., shift work) are often associated with sleep problems. Sleep disorders affect the quality of life and impair both professional and non-professional activities. Excessive daytime drowsiness resulting from sleep disorders impairs efficiency and safety at work or on the road, and increases the risk of accidents. Poor sleep (either professional or voluntary) has detrimental effects comparable to those of major sleep disorders, but is often neglected. The high incidence and direct/indirect healthcare and welfare costs of sleep disorders and poor sleep currently constitute a major medical problem. Investigation, monitoring and strategies are needed in order to prevent/reduce the effects of these disorders.

Restless Legs Syndrome in a Nigerian Elderly Population

STUDY OBJECTIVES

The prevalence of restless legs syndrome (RLS) is highest in the elderly in Caucasian populations; the prevalence of RLS in elderly Africans is not known. This study aimed at determining the frequency and associations of RLS in a Nigerian elderly population.

METHODS

The study population comprised of 633 consecutive elderly individuals aged 65-105 years attending the general outpatient clinic of the State Hospital, Ilesa, for minor complaints and routine check-up. The diagnosis of RLS was made using the 2003 minimal criteria of the International Restless Legs Syndrome Study Group. Relevant sociodemographic and clinical data, including sleep duration, were also obtained.

RESULTS

Restless legs syndrome was found in 3.5% of the study population with a male-female ratio of 2:1. There was no significant age (p = 0.427) or gender (p = 0.178) influence on the prevalence of RLS except in the 75- to 84-year age group where there was significant male preponderance (p = 0.044). A strong independent association between RLS and sleep duration (OR, 3.229; 95% CI, 1.283-8.486; p = 0.013) and past history of head injury (OR, 4.691; 95% CI, 1.750-12.577; p = 0.002) was found.

CONCLUSIONS

Our finding support previous reports of a possible lower prevalence of RLS in Africans. Restless legs syndrome independently increases the odds of habitual sleep curtailment in elderly individuals. Head injury may be a risk factor for future RLS; this requires further investigation as indirect evidence for a possible link between RLS and traumatic brain injury exists.

Achievements, challenges, and future perspectives of epidemiologic research in restless legs syndrome (RLS)

In the 20 years since the initial consensus on a common definition for restless legs syndrome (RLS), over 600 scientific reports on epidemiological aspects of RLS have been published. Most are descriptive and address important issues such as prevalence, familial patterns, comorbidities, and quality of life. While the establishment of prospective cohort studies and the use of secondary data sources are rather new to RLS research, both options significantly broaden the possibilities for analysis of disease risk factors. These two options, as well as the inclusion of a broader phenotyping of individual patients, have great potential to elucidate etiologic factors for RLS and expand knowledge about this common disorder. This article summarizes achievements in the area of RLS epidemiology, describes current challenges, and highlights future perspectives in the field.

The Effect of Gabapentin Enacarbil on Pain Associated with Moderate-to-Severe Primary Restless Legs Syndrome in Adults: Pooled Analyses from Three Randomized Controlled Trials

BACKGROUND

Adults with moderate-to-severe primary restless legs syndrome (RLS) often experience painful dysesthesias, which may lead to impaired quality of life.

OBJECTIVES

The aim of this study was to assess the effects of gabapentin enacarbil (GEn) on pain associated with moderate-to-severe primary RLS in adults.

METHODS

Data were pooled from three double-blind, randomized, placebo-controlled, 12-week trials (NCT00298623, NCT00365352, NCT01332305) for adults receiving GEn or placebo once daily. Change in average daily RLS pain score and a combined International Restless Legs Scale (IRLS)-pain response were examined.

RESULTS

The modified intention-to-treat population included 671 adults (placebo, n = 244; GEn 600 mg, n = 161; GEn 1200 mg, n = 266). Both GEn doses significantly improved average daily RLS pain score at week 12 (p < 0.001 for GEn 600 mg vs. placebo and GEn 1200 mg vs. placebo). The combined IRLS-pain response subanalysis included 366 patients with a baseline IRLS total score ≥15 and pain score ≥4 (placebo, n = 133; GEn 600 mg, n = 86; GEn 1200 mg, n = 147). Most patients were both IRLS and pain responders (placebo, 40 %; GEn 600 mg, 70 %; GEn 1200 mg, 67 %). Spearman rank correlations between IRLS total and pain score (change from baseline to week 12) were moderate or strong. The most frequent treatment-emergent adverse events were somnolence (placebo, 5 %; GEn 600 mg, 20 %; GEn 1200 mg, 23 %) and dizziness (placebo, 4 %; GEn 600 mg, 13 %; GEn 1200 mg, 22 %).

CONCLUSIONS

This post hoc pooled analysis suggests that GEn (600 and 1200 mg) once daily significantly improved pain associated with moderate-to-severe primary RLS in adults; however, the analysis was not powered to detect statistical differences between the two GEn doses. Numerically, more GEn-treated patients had a combined IRLS-pain response than placebo-treated patients.

Pregabalin for the Treatment of Restless Legs Syndrome

OBJECTIVE

To evaluate the efficacy and safety of pregabalin for the treatment of restless legs syndrome (RLS).

DATA SOURCES

A search of the MEDLINE database (1956-February 2016) and EMBASE (1957-February 2016) was conducted, using the terms pregabalin and restless legs syndrome In addition, a manual review of the references cited in each publication identified from the database search was conducted to identify relevant articles.

STUDY SELECTION AND DATA EXTRACTION

All English-language, peer-reviewed publications were evaluated for relevance. From an initial review of 285 articles, 5 clinical trials were included in the final analysis.

DATA SYNTHESIS

Pregabalin is an analog of γ-aminobutyric acid that exhibits antinociceptive and anticonvulsant activity by binding to voltage-gated calcium channels in the central nervous system. Studies of pregabalin have demonstrated efficacy through significant reductions in mean International RLS Scale scores and wake after sleep onset scores, and it had a lower rate of augmentation than pramipexole treatment. Study durations ranged from 6 to 52 weeks, with doses ranging from 150 to 600 mg daily. The most common adverse effects associated with pregabalin use in all studies included dizziness and somnolence.

CONCLUSIONS

Clinical evidence suggests that pregabalin may improve symptoms of RLS and reduce disturbances in sleep, resulting in improvements in quality of life for patients affected by the disease. Pregabalin is considered to be relatively safe and poses a minimal risk of augmentation unlike current recommended first-line treatments for RLS. Thus, evidence suggests that pregabalin is a reasonable therapeutic option for the treatment of RLS.

The Relationship of Restless Legs Syndrome to History of Pregnancy-Induced Hypertension

BACKGROUND

Restless legs syndrome (RLS), a burdensome sleep disorder, has been associated with cardiovascular disease (CVD), hypertension, diabetes, and related disorders. However, the relationship of RLS to history of pregnancy-induced hypertension (PIH), a predictor of subsequent CVD, diabetes, and associated conditions, remains little explored. In this study, we investigated the relationship of RLS to history of PIH in a sample of primary care patients.

METHODS

Participants were women aged ≥40 years drawn from an anonymous survey study of West Virginia primary care patients. Data collected included detailed information on demographics, lifestyle factors, sleep patterns, and reproductive/medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or unsure about their pregnancy status were excluded from the analyses.

RESULTS

Of the 498 participants in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms ≥once/week, 11.9% with symptoms ≥3 times/week); 73 (16.5% of parous women) reported a history of PIH, defined as physician-diagnosed preeclampsia or gestational hypertension. After adjustment for demographics, lifestyle characteristics, obesity, reproductive history, health conditions, and other factors, those reporting a history of PIH were approximately twice as likely to meet criteria for RLS (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.1, 3.6). These associations increased in magnitude with increasing symptom frequency (adjusted OR for RLS with symptoms ≥3 times/week = 3.8; CI 1.9, 7.6; p for trend = 0.003).

CONCLUSIONS

History of PIH was strongly and positively related to current RLS in this study of primary care patients; these findings further support a possible role for metabolic dysregulation in RLS etiology.

Restless leg syndrome in hospitalized psychiatric patients in Lebanon: a pilot study

OBJECTIVES

To characterize and describe the prevalence of restless leg syndrome (RLS) in hospitalized psychiatric patients and to investigate the correlations between patient profile and RLS.

METHODS

Demographic information, psychiatric diagnoses, psychotropic medication use, and history of substance use were collected from hospitalized psychiatric patients at the American University of Beirut Medical Center; Beirut, Lebanon. A validated questionnaire to evaluate RLS symptomatology was also administered to 126 participants who agreed to participate, as well as questionnaires for insomnia, depression, and anxiety symptoms. Statistical analysis was conducted to detect the prevalence of RLS among the participants and to examine correlations with RLS in a hospitalized psychiatric population.

RESULTS

Out of the 126 participants who completed the survey, RLS was detected in 18% of the participants. Of interest, RLS was also found to be associated with higher depressive symptomatology, suicidal ideation, and working night shifts.

Sleep and Quality of Life Under Prolonged Release Oxycodone/Naloxone for Severe Restless Legs Syndrome: An Analysis of Secondary Efficacy Variables of a Double-Blind, Randomized, Placebo-Controlled Study with an Open-Label Extension

OBJECTIVE

The aim was to assess the effects of prolonged release oxycodone/naloxone (OXN PR) on sleep and quality of life (QoL) in patients with severe restless legs syndrome (RLS) refractory to first-line dopaminergic RLS treatment.

METHODS

Sleep and QoL data from a 12-week, randomized, double-blind, placebo-controlled study with subsequent 40-week, open-label extension were analyzed. Instruments included the Medical Outcomes Study (MOS) sleep scale, RLS-6 rating scale, and RLS-QoL questionnaire.

RESULTS

The full analysis population included 132 OXN PR and 144 placebo patients. After 12 treatment weeks, improvements in the MOS domains 'sleep disturbance' [-18.6; 95 % confidence interval (CI) -24.4 to -12.9; p < 0.0001], 'sleep adequacy' (14.9; 95 % CI 7.9-21.9; p < 0.0001), and 'sleep quantity' (0.77 h; 95 % CI 0.43-1.11; p < 0.0001) were significantly greater under OXN PR than under placebo. OXN PR also reduced symptom severity (when falling asleep and during the night) and daytime tiredness, and increased sleep satisfaction to a significantly greater extent than placebo (all p < 0.001; RLS-6). QoL improved in both treatment arms, with a significant difference of -9.02 (95 % CI -12.85 to -5.19; p < 0.001) in the mean sum score in favor of OXN PR. All sleep and QoL aspects also improved under 40 weeks of open-label OXN PR treatment.

CONCLUSIONS

OXN PR improved RLS symptom severity and sleep quantity and adequacy, resulting in greater sleep satisfaction, less daytime tiredness, and improved QoL. In appropriate patients, OXN PR should be considered as an alternative treatment option for severe RLS that cannot be controlled by first-line dopaminergic medications.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01112644) and EudraCT (2009-011107-23).

Relationship between quality of life and restless legs syndrome among a community-dwelling population in Japan

OBJECTIVES

Restless legs syndrome (RLS) is a sensorimotor disturbance that causes the production of impulses and dysesthesia and makes the patients feel as though they must move their lower extremities. Because the symptoms of RLS in the lower limbs tend to develop at night, RLS could cause sleep disorders. We investigated an association between the symptoms of RLS and the health-related quality of life among community-dwelling individuals in Japan.

METHODS

In this cross-sectional survey, we enrolled 985 volunteers who participated in the Iwaki Health Promotion Project in 2013. The symptoms of RLS were evaluated by the criteria of the International Restless Legs Syndrome Study Group. The assessments included an interview to obtain sociodemographic data, the second version of the Short Form Health Survey, the Center for Epidemiological Studies Depression scale, and the Pittsburgh Sleep Quality Index. A multiple regression analysis was used to assess the relationship between the symptoms of RLS and subscores of the Short Form Health Survey, Version 2.

RESULTS

The overall prevalence of RLS in our participants was 1.0%. We found a significant and negative association between symptoms of RLS and physical functioning, role - physical functioning, bodily pain, social functioning, and the physical composite summary score.

CONCLUSION

After adjusting for confounders such as age, sex, and comorbidity, the burden of RLS appears to be mainly a physical problem. Impaired health-related quality of life among community individuals with RLS emphasizes the importance of screening for these symptoms and evaluating the need for treatment.

Comparison of impact of insomnia on depression and quality of life in restless legs syndrome/Willis-Ekbom disease and primary insomnia patients

BACKGROUND

Although insomnia is common among people with restless legs syndrome (RLS), its impact on the daily suffering of those with RLS remains unclear. This study aimed to compare the differential impact of clinical insomnia on depression and quality of life (QoL) among people with RLS, primary insomnia, and healthy controls.

METHODS

A total of 148 people with RLS, 115 with primary insomnia, and 117 healthy controls were enrolled into this cross-sectional study. Participants completed sleep, depression, and QoL questionnaires. Clinical insomnia was defined as Korean version of the Insomnia Severity Index (K-ISI) ≥ 15. Correlation coefficients between sleep measures and both depression and QoL were calculated. Multivariate regression was used to identify the clinical factors that were most closely associated with depression and QoL among people with RLS and primary insomnia.

RESULTS

Participants with RLS had insomnia and sleep quality at intermediate levels between the healthy controls and primary insomnia subjects, but those with clinical insomnia had equivalent depression and QoL scores regardless of RLS diagnosis. Insomnia severity correlated with depression and QoL in RLS and primary insomnia. Multivariate regression, however, revealed that RLS severity was the most overall predictive factor for depression and QoL among those with RLS. Insomnia severity was the strongest predictor in primary insomnia.

CONCLUSION

Insomnia was more closely associated with depression and QoL among people with primary insomnia than those with RLS, but clinical insomnia may have a significant impact in RLS as well. Future RLS studies should account for sleep quality in addition to RLS symptom severity when investigating mood and QoL.

The Association of Restless Legs Syndrome to History of Gestational Diabetes in an Appalachian Primary Care Population

OBJECTIVES

Restless legs syndrome (RLS) is a burdensome sensorimotor disorder that has been linked to diabetes and obesity. However, the relationship of RLS to gestational diabetes mellitus (GDM), a common pregnancy complication strongly associated with obesity and a harbinger of diabetes, remains unknown. In this study, we examined the association of RLS to history of GDM in a sample of older female primary care patients.

METHODS

Participants were community-dwelling women aged ≥ 40 years drawn from an anonymous survey study of West Virginia adult primary care patients. Data gathered included detailed information on demographics, lifestyle factors, reproductive history, sleep patterns, and medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or had missing data on key variables were excluded from the analyses.

RESULTS

Of the 498 participants included in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms at least once/week). After adjustment for demographics, lifestyle characteristics, body mass index, diabetes and other comorbid conditions, parity, and other factors, those reporting history of GDM were almost three times as likely to meet criteria for RLS (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.3, 5.3). This association increased in magnitude with increasing symptom frequency (adjusted OR for RLS symptoms ≥ 3×/week = 4.8, CI 2.1, 11.2, p for trend = 0.004).

CONCLUSIONS

History of GDM was strongly and positively related to RLS in this study of older female primary care patients, offering further support for a possible role of metabolic dysregulation in RLS development.

Musculoskeletal pain is associated with restless legs syndrome in young adults

BACKGROUND

In recent years, there is considerable evidence of a relationship between the sensorimotor disorder restless legs syndrome (RLS) and pain disorders, including migraine and fibromyalgia. An association between multi-site pain and RLS has been reported in adult women. In the current study, we explored the association between musculoskeletal (MSK) pain and RLS in a large cohort of young adults.

METHODS

Twenty two year olds (n = 1072), followed since birth of part of the Western Australian Pregnancy Cohort (Raine) Study, provided data on MSK pain (duration, severity, frequency, number of pain sites). RLS was considered present when 4 diagnostic criteria recommended by the International Restless Legs Syndrome Study Group were met (urge to move, dysaesthesia, relief by movement, worsening symptoms during the evening/night) and participants had these symptoms at least 5 times per month. Associations between MSK pain and RLS were analyzed by multivariable logistic regression with bias-corrected bootstrapped confidence intervals, with final models adjusted for sex, psychological distress and sleep quality.

RESULTS

The prevalence of RLS was 3.0 % and MSK pain was reported by 37.4 % of the participants. In multivariable logistic regression models, strong associations were found between RLS-diagnosis and long duration (three months or more) of MSK pain (odds ratio 3.6, 95 % confidence interval 1.4-9.2) and reporting three or more pain sites (4.9, 1.6-14.6).

CONCLUSIONS

Different dimensions of MSK pain were associated with RLS in young adults, suggestive of shared pathophysiological mechanisms. Overlap between these conditions requires more clinical and research attention.

Hindi translation and validation of Cambridge-Hopkins Diagnostic Questionnaire for RLS (CHRLSq)

Background:

Restless legs syndrome also known as Willis-Ekbom's Disease (RLS/WED) is a common illness. Cambridge-Hopkins diagnostic questionnaire for RLS (CHRLSq) is a good diagnostic tool and can be used in the epidemiological studies. However, its Hindi version is not available. Thus, this study was conducted to translate and validate it in the Hindi speaking population.

Materials and Methods:

After obtaining the permission from the author of the CHRLSq, it was translated into Hindi language by two independent translators. After a series of forward and back translations, the finalized Hindi version was administered to two groups by one of the authors, who were blinded to the clinical diagnosis. First group consisted of RLS/WED patients, where diagnosis was made upon face to face interview and the other group — the control group included subjects with somatic symptoms disorders or exertional myalgia or chronic insomnia. Each group had 30 subjects. Diagnosis made on CHRLSq was compared with the clinical diagnosis.

Statistical Analysis:

Analysis was done using Statistical Package for Social Sciences (SPSS) v 21.0. Descriptive statistics was calculated. Proportions were compared using chi-square test; whereas, categorical variables were compared using independent sample t-test. Sensitivity, specificity, and positive predictive value of the translated version of questionnaire were calculated.

Results:

Average age was comparable between the cases and control group (RLS/WED = 39.1 ± 10.1 years vs 36.2 ± 11.4 years in controls; P = 0.29). Women outnumbered men in the RLS/WED group (87% in RLS/WED group vs 57% among controls; χ² = 6.64; P = 0.01). Both the sensitivity and specificity of the translated version was 83.3%. It had the positive predictive value of 86.6%.

Conclusion:

Hindi version of CHRLSq has positive predictive value of 87% and it can be used to diagnose RLS in Hindi speaking population.

Restless Legs Syndrome/Willis-Ekbom Disease Morbidity: Burden, Quality of Life, Cardiovascular Aspects, and Sleep

Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) has a significant negative effect on quality of life. The decreased quality of life is similar to that of other chronic diseases, such as diabetes type 2, depression, and osteoarthritis. RLS/WED disrupts sleep length, sleep quality, and daytime alertness. Sleep disruption can contribute to depression. RLS/WED has been associated with cardiovascular disease and high blood pressure, possibly because of increased sympathetic tone caused by periodic limb movements of sleep. RLS/WED is underdiagnosed, leading to chronic sleep disruption and daytime consequences. Patients with RLS/WED have decreased productivity at work, which potentially has far-reaching economic consequences.

Management of Restless Legs Syndrome/Willis-Ekbom Disease in Hospitalized and Perioperative Patients

Restless legs syndrome (RLS) is a sensorimotor disorder that can cause significant discomfort, impaired quality of life, poor mood, and disturbed sleep. Because the disorder is chronic and associated with multiple comorbidities, RLS can be seen in an inpatient or perioperative setting. Certain characteristics of the hospitalized or surgical context can exacerbate or unmask RLS. Importantly, RLS and the associated discomfort and insomnia can prolong hospital stay and negatively impact outcomes. RLS medications should be continued during the hospital admission when possible. Avoidance of excessive phlebotomy and medications known to trigger RLS is helpful. Patients should increase activity when acceptable.

Treatment response to sleep, pain, and mood disturbance and their correlation with sleep disturbance in adult patients with moderate-to-severe primary restless legs syndrome: Pooled analyses from 3 trials of gabapentin enacarbil

INTRODUCTION

This pooled analysis investigated the effects of gabapentin enacarbil (GEn) on clinical correlates of sleep disturbance in adults with moderate-to-severe primary restless legs syndrome (RLS) and no-to-moderate or severe-to-very severe baseline sleep disturbance.

METHODS

Co-primary end-points were mean change from baseline to week 12 in International Restless Legs Scale (IRLS) total score and proportion of responders ('much'/'very much' improved) on the investigator-rated Clinical Global Impression-Improvement (CGI-I) scale (week 12). Pain, mood, individual IRLS items, and safety were assessed.

RESULTS

The modified intent-to-treat population was 671 adults randomized to GEn 600 mg (n = 161), GEn 1200 mg (n = 266), or placebo (n = 244). GEn significantly improved least squares mean change in IRLS total score from baseline versus placebo for no-to-moderate (GEn 600 mg,- 12.3; 1200 mg, - 11.3; placebo, - 7.7) and severe-to-very severe (- 16.6; - 17.0; - 12.7) groups (all P < 0.01). Significantly more GEn-treated patients (both doses) were CGI-I responders (week 12) versus placebo in both sleep subgroups (all P < 0.01). GEn substantially improved mood and pain scores for both sleep subgroups versus placebo. The most frequent treatment-emergent adverse events were somnolence and dizziness.

CONCLUSION

GEn (600 mg and 1200 mg) was effective and well tolerated in adults with moderate-to-severe primary RLS regardless of baseline sleep disturbance level.

Restless legs syndrome

Restless legs syndrome is a common sensorimotor disorder characterized by an urge to move, and associated with uncomfortable sensations in the legs (limbs). Restless legs syndrome can lead to sleep-onset or sleep-maintenance insomnia, and occasionally excessive daytime sleepiness, all leading to significant morbidity. Brain iron deficiency and dopaminergic neurotransmission abnormalities play a central role in the pathogenesis of this disorder, along with other nondopaminergic systems, although the exact mechanisms are still. Intensive care unit patients are especially vulnerable to have unmasking or exacerbation of restless legs syndrome because of sleep deprivation, circadian rhythm disturbance, immobilization, iron deficiency, and use of multiple medications that can antagonize dopamine.

Sleep disorders in chronic obstructive pulmonary disease: etiology, impact, and management

ABSTRACT

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality and may frequently be complicated by sleep disorders. Insomnia and obstructive sleep apnea are commonly encountered in patients with COPD. Nocturnal hypoxemia is also prevalent in COPD may occur despite adequate awake oxygenation and can be especially severe in rapid eye movement sleep. Additionally, several factors--some of them unique to COPD--can contribute to sleep-related hypoventilation. Recognition of hypoventilation can be vital as supplemental oxygen therapy itself can acutely worsen hypoventilation and lead to disastrous consequences. Finally, accruing data establish an association between restless leg syndrome and COPD--an association that may be driven by hypoxemia and/or hypercapnia. Comorbid sleep disorders portend worse sleep quality, diminished quality of life, and multifarious other adverse consequences. The awareness and knowledge regarding sleep comorbidities in COPD has continued to evolve over past many years. There are still several lacunae, however, in our understanding of the etiologies, impact, and therapies of sleep disorders, specifically in patients with COPD. This review summarizes the latest concepts in prevalence, pathogenesis, diagnosis, and management of diverse sleep disorders in COPD.

An update on restless legs syndrome (Willis-Ekbom disease): clinical features, pathogenesis and treatment

PURPOSE OF REVIEW

In recent years, there have been a number of advances in the field of restless legs syndrome (RLS) or Willis-Ekbom disease (WED). Here, we review recent studies pertaining to the diagnosis and clinical features, pathogenesis, and treatment of RLS/WED.

RECENT FINDINGS

Recent studies have added a temporal dimension to RLS/WED epidemiology by examining both the incidence and persistence rates in different populations. Diagnostic criteria have been modified to increase sensitivity, and new guidelines take into account recently published studies of different drug classes.

SUMMARY

Recent epidemiological findings have shown that RLS/WED is a common neurological disorder that affects up to 5% of the adult population in Western countries. In moderate and severe cases, RLS/WED has a strong impact on sleep and quality of life and can involve an increased cardiovascular risk. Diagnosis is made clinically by confirming the presence of the five essential criteria. However, in difficult cases objective tests such as the multiple suggested immobilization test (m-SIT) can be used. The pathophysiology is partially known, with several risk polymorphisms (BTBD-9 (BTB (POZ) domain containing 9), MEIS-1 (Meis homeobox 1), protein tyrosine phosphatase, receptor type, D, and others) playing an important role, along with dopaminergic and iron dysfunctions. The disorder frequently requires long-term treatment with low-dose dopamine agonists or α2δ ligands. Dopamine agonists are usually effective but the main complication, RLS/WED augmentation, can arise.

Restless legs syndrome in non-dialysis renal patients: is it really that common?

BACKGROUND

Sleep disorders are frequent in chronic kidney disease (CKD). Among them, restless legs syndrome (RLS) may affect up to 60% of patients on dialysis, and it has been related to a poor quality of life and higher cardiovascular risk. Despite its high prevalence in advanced stages of renal disease, RLS frequency in non-dialysis CKD has not been clearly established. The aim of this study was to assess the frequency of RLS in non-dialysis CKD patients (stages 2 to 4) followed in a reference nephrology outpatient clinic.

METHODS

A standardized questionnaire following the international RLS study group diagnostic criteria was self-administered by 110 patients regularly followed in the nephrology clinic. The series comprised 69 men and 41 women, aged 68 ± 13.2 years, with mean serum creatinine of 1.7 ± 0.8 mg/dL. Subsequently, patients classified as probable RLS according to the questionnaire underwent a systematic neurological examination. The presence of peripheral artery disease was evaluated by the ankle-brachial index (ABI).

RESULTS

The frequency of probable RLS according to the questionnaire results was 21% (17% for men and 27% for women). However, after thorough neurological examination, the diagnosis of RLS was confirmed in only 5 patients. Therefore, the overall definitive RLS frequency was 4.5% (within the prevalence reported for the general population) and was higher among women (9.7% vs 0.2%). In the remaining cases symptoms were due to leg discomfort related with other disorders. Patients with probable and improbable RLS were not significantly different in age, ABI, diabetes, and other comorbid circumstances, except for tricyclic antidepressant prescription, which was more frequent in the probable RLS group (17% vs 2%). Renal function was better in definitive RLS patients than cases classified as probable RLS by the questionnaire but not confirmed after neurological exam.

CONCLUSIONS

Although RLS can represent an early manifestation of CKD, its prevalence seems very close to that reported for the general population. Diagnostic confirmation of RLS dramatically falls after expert examination, raising the question whether, in the study of RLS cohorts, CKD has a potentially causal relationship or is a confounding factor associated with other causes of leg discomfort.

Diagnosis, comorbidities, and management of restless legs syndrome

OBJECTIVE

This narrative review describes the differential diagnosis of restless legs syndrome, and provides an overview of the evidence for the associations between RLS and potential comorbidities. Secondary causes of RLS and the characteristics of pediatric RLS are also discussed. Finally, management strategies for RLS are summarized.

METHODS

The review began with a comprehensive PubMed search for 'restless legs syndrome/Willis-Ekbom disease' in combination with the following: anxiety, arthritis, attention-deficit hyperactivity disorder, cardiac, cardiovascular disease, comorbidities, depression, end-stage renal disease, erectile dysfunction, fibromyalgia, insomnia, kidney disease, liver disease, migraine, mood disorder, multiple sclerosis, narcolepsy, neuropathy, obesity, pain, Parkinson's disease, polyneuropathy, pregnancy, psychiatric disorder, sleep disorder, somatoform pain disorder, and uremia. Additional papers were identified by reviewing the reference lists of retrieved publications.

RESULTS AND CONCLUSIONS

Although clinical diagnosis of RLS can be straightforward, diagnostic challenges may arise when patients present with comorbid conditions. Comorbidities of RLS include insomnia, depressive and anxiety disorders, and pain disorders. Differential diagnosis is particularly important, as some of the medications used to treat insomnia and depression may exacerbate RLS symptoms. Appropriate diagnosis and management of RLS symptoms may benefit patient well-being and, in some cases, may lessen comorbid disease burden. Therefore, it is important that physicians are aware of the presence of RLS when treating patients with conditions that commonly co-occur with the disorder.