The restless legs syndrome

The urge to move and breathe - the impact of obstructive sleep apnea syndrome treatment in patients with previously diagnosed, clinically significant restless legs syndrome

OBJECTIVE

The association between restless legs syndrome (RLS) and obstructive sleep apnea syndrome (OSAS) has seldom been reported. There is one study reporting improvement of RLS symptoms severity in patients naive of treatment after initiation of continuous positive airway pressure (CPAP) for OSAS. The aim of this study was to evaluate the impact of the OSAS treatment in patients with previously diagnosed, clinically significant RLS in a usual clinical setting.

METHODS

This was a retrospective study of RLS patients from a sleep clinic with a concomitant or subsequent diagnosis of OSAS. All patients who started treatment for OSAS and had a follow-up of ≥3 months were selected. Exclusion criteria included noncompliance, absence of sufficient information on clinical records, and RLS improvement following treatment of secondary causes. The primary outcome variable was clinical status of RLS symptoms following OSA treatment. Other variables included demographics, RLS treatment and outcome, OSA diagnosis, treatment, compliance, outcome, and PSG characteristics.

RESULTS

From a database of 97 RLS patients, 56 patients had both OSA and RLS. Of these patients, 28 met the criteria for the study. In all, 17 patients (60.9%) were female, with a mean age 60 years. A total of 16 patients (57.1%) were diagnosed with idiopathic RLS. OSAS was diagnosed, on average, 21 months after the RLS diagnosis. A total of 19 (70.4%) patients were overweight or obese, 26 (92.9%) reported snoring, and 10 (35.7%) witnessed apneas. A total of 16 patients (57.1%) had excessive daytime sleepiness and 23 (84.1%) had insomnia. The mean apnea-hypopnea index was 19. Patients were mostly treated with dopamine agonists (19 patients, 67.9%) for the RLS, and nine patients were treated with more than two drugs for RLS. A total of 20 patients (71.4%) had improvement of symptoms of RLS after therapy for OSAS, of whom nine stopped drug therapy and eight reduced the dose.

CONCLUSIONS

In patients with clinically significant RLS, treatment of concomitant OSAS significantly improved RLS symptoms, enabling drug therapy reduction in more than half of the patients. These data reinforce the need to actively diagnose OSAS in RLS patients.

Perceived sleep deficit is a strong predictor of RLS in multisite pain - A population based study in middle aged females

BACKGROUND

Chronic pain conditions as well as Restless Legs Syndrome (RLS) are known to be associated with subjectively and objectively disturbed sleep. RLS has been recently described as highly prevalent in multisite pain and the role of sleep as a modifying factor in this RLS phenotype is unknown. This study aimed to investigate if perceived sleep deficit and other sleep related parameters predict RLS in subjects with multisite pain.

CURRENT KNOWLEDGE/STUDY RATIONALE

We have recently demonstrated a strong association between Restless Legs Syndrome (RLS) and number of pain locations. In the current analysis we hypothesized that impaired sleep predicts RLS in subjects with multisite pain.

METHOD

Questionnaire-based data from 2727 randomly selected women aged 18-64 years were used to analyze RLS symptoms, self-reported sleep quality, and the degree of daytime sleepiness (Epworth Sleepiness Scale (ESS)) in relation to type, degree and localization of body pain. Potential confounders including anthropometrics, pain localization, co-morbidities, and medication were adjusted for in the Generalized Linear Models (GLM).

RESULTS

Perceived sleep deficit ≥90min (OR 2.4 (1.5-3.8), p<0.001) and frequent nocturnal awakenings (OR 2.3 (1.4-3.6), p<0.001) were the strongest sleep related predictors for RLS in subjects with multisite pain. Additional factors include prolonged sleep latency (≥30min, OR 1.8 (1.1-2.8), p=0.01) and daytime symptoms like elevated daytime sleepiness (ESS score ≥9, OR 1.8 (1.2-2.7), p=0.005). Accordingly, RLS diagnosis was associated with impaired sleep quality (TST (Total Sleep Time) -8.2min, sleep latency +8.0min, and number of awakenings from sleep +0.4, p<0.01). ESS score increased with RLS diagnosis (+0.74, p<0.01) and number of pain locations (0.5, 1.7, and 1.8 for 1, 3, and 5 pain areas, p<0.001). In addition, confounders like pain severity, the history of psychiatric disease, and current smoking were associated with impaired sleep quality in this group of females.

CONCLUSIONS

Perceived sleep deficit and sleep fragmentation are the strongest sleep related predictors of RLS in multisite pain. Potential implication of our results are that clinical management programmes of RLS in subjects with multisite pain need to consider both sleep quality and sleep quantity for individually tailored treatment regimes.

STUDY IMPACT

RLS, pain, and sleep disorders are highly interrelated. Our study strongly suggests that clinical management of RLS in patients with multisite pain needs to consider sleep quality as an independent risk factor.

Neurophysiological mechanisms of circadian cognitive control in RLS patients - an EEG source localization study

The circadian variation of sensory and motor symptoms with increasing severity in the evening and at night is a key diagnostic feature/symptom of the restless legs syndrome (RLS). Even though many neurological diseases have shown a strong nexus between motor and cognitive symptoms, it has remained unclear whether cognitive performance of RLS patients declines in the evening and which neurophysiological mechanisms are affected by the circadian variation. In the current study, we examined daytime effects (morning vs. evening) on cognitive performance in RLS patients (n = 33) compared to healthy controls (n = 29) by analyzing flanker interference effects in combination with EEG and source localization techniques. RLS patients showed larger flanker interference effects in the evening than in the morning (p = .023), while healthy controls did not display a comparable circadian variation. In line with this, the neurophysiological data showed smaller N1 amplitudes in RLS patients compared to controls in the interfering task condition in the evening (p = .042), but not in the morning. The results demonstrate diurnal cognitive changes in RLS patients with intensified impairments in the evening. It seems that not all dopamine-regulated cognitive processes are altered in RLS and thus show daytime-dependent impairments. Instead, the daytime-related cognitive impairment emerges from attentional selection processes within the extra-striate visual cortex, but not from later cognitive processes such as conflict monitoring and response selection.

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RLS patients have larger flanker interference effect in the evening.

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RLS patients have enhanced impairment of attentional selection in the evening.

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Nocturnal attentional impairment relies on the extra-striate visual cortex.

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Conflict monitoring and response selection are not affected by RLS.

Severity and frequency of restless legs syndrome in patients with familial Mediterranean fever

Objective:

Restless legs syndrome (RLS) is a common sensory motor disorder. RLS an urge to move the extremities that may be accompanied by dysesthesias, and significantly affects quality of life of affected patients. The frequency of RLS is higher in different systemic inflammatory diseases. Familial Mediterranean fever (FMF) is an inherited inflammatory disease characterized by attacks of polyserositis, arthritis, and fever. The prevalence of RLS in patients with FMF is unknown. This study aimed to evaluate the prevalence rate of RLS in a sample of patients with FMF and compare this prevalence with that of a matched normal population.

Method:

A total of 60 patients with FMF and 60 healthy controls were studied. All participants underwent a neurological examination. Diagnostic criteria as proposed by the International Restless Legs Syndrome Study Group (IRLSSG) were used to define RLS. The IRLSSG rating scale for the severity of RLS was applied to determine the severity of symptoms.

Results:

The prevalence of RLS was not significantly different between patients and controls. Although the mean International Restless Legs Syndrome Rating Scale (IRLSRS) scores tended to be higher in patients compared with controls, this difference was not significant. When each item of the severity scale was compared between the two groups, significantly higher scores were found in some items of the IRLSRS in patients with FMF compared with controls.

Conclusion:

According to this result, RLS symptoms in patients with FMF were more frequent and lasted longer than those in controls.

Restless Legs Syndrome: From Pathophysiology to Clinical Diagnosis and Management

Restless legs syndrome (RLS), a common neurological sensorimotor disorder in western countries, has gained more and more attention in Asian countries. The prevalence of RLS is higher in older people and females. RLS is most commonly related to iron deficiency, pregnancy and uremia. The RLS symptoms show a significant circadian rhythm and a close relationship to periodic limb movements (PLMs) in clinical observations, while the pathophysiological pathways are still unknown. The diagnostic criteria have been revised in 2012 to improve the validity of RLS diagnosis. Recent studies have suggested an important role of iron decrease of brain in RLS pathophysiology. Dopaminergic (DA) system dysfunction in A11 cell groups has been recognized long ago from clinical treatment and autopsy. Nowadays, it is believed that iron dysfunction can affect DA system from different pathways and opioids have a protective effect on DA system. Several susceptible single nucleotide polymorphisms such as BTBD9 and MEIS1, which are thought to be involved in embryonic neuronal development, have been reported to be associated with RLS. Several pharmacological and non-pharmacological treatment are discussed in this review. First-line treatments of RLS include DA agents and α2δ agonists. Augmentation is very common in long-term treatment of RLS which makes prevention and management of augmentation very important for RLS patients. A combination of different types of medication is effective in preventing and treating augmentation. The knowledge on RLS is still limited, the pathophysiology and better management of RLS remain to be discovered.

Benzodiazepines for restless legs syndrome

BACKGROUND

Restless legs syndrome (RLS) is a common disease affecting about 5% to 15% of the population. Symptoms of RLS can be severe in a minority of and can have a major impact on sleep, mostly sleep initiation, and quality of life. Benzodiazepines are drugs that can induce and maintain sleep and, hence, intuitively are thought to be beneficial to people with RLS. Altough benzodiazepines, particularly clonazepam, are used to treat RLS symptoms, a systematic review done by the American Academy of Sleep Medicine stated that benzodiazepines should not be used as a first-line treatment, although could be used as a coadjuvant therapy.

OBJECTIVES

To evaluate the efficacy and safety of benzodiazepine compared to placebo or other treatment for idiopathic RLS, including unconfounded trials comparing benzodiazepines versus open control.

SEARCH METHODS

In March 2016 we searched CENTRAL, MEDLINE, Embase and LILACS We checked the references of each study and contacted study authors to identify any additional studies. We considered studies published in any language.

SELECTION CRITERIA

Randomised clinical trials of benzodiazepine treatment in idiopathic RLS.

DATA COLLECTION AND ANALYSIS

We did not perform data collection and analysis, since we did not include any studies, MAIN RESULTS: We did not identify any studies that met the inclusion criteria of the review. Two cross-over studies are awaiting classification because the cross-over trials did not give data at the end of the first cross-over period.

AUTHORS' CONCLUSIONS

The effectiveness of benzodiazepines for RLS treatment is currently unknown.

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.

Evaluation of neurodegeneration through visual evoked potentials in restless legs syndrome

Restless legs syndrome (RLS) is a disease characterized by some type of dysesthesia, an indescribable abnormal sensation in the extremities. Our objective was to determine whether the visual evoked potentials (VEP) can be used as a quantitative monitoring method to evaluate demyelination-remyelination and neurodegeneration in the patients with RLS. The present study was carried out prospectively. It was planned to determine normal or pathological conditions in the form of increased latency or decreased amplitude of VEP and to evaluate possible pathologies in the visual and retinal pathways at early stages and at months 3 and 6 of follow-up in the patients with RLS (with or without iron deficiency anemia), in those without RLS (at the time of diagnosis prior to any medical therapy) without any visual symptoms. It was observed that latency of VEP improved but didn't return to normal limits following treatment with dopamin agonists, iron, or combination of both and that there was no significant difference between the post-treatment data and those of the control group. These results in combination with the fact that the latencies and amplitudes didn't return to normal levels despite the 6-month-treatment but showed a progressive course with partial regeneration suggests that there was incomplete remyelination. It should be kept in mind that this syndrome is likely to be a part of neurodegenerative process.

Prevalence of restless legs syndrome in migraine patients with and without aura: a cross-sectional, case-controlled study

BACKGROUND

Although the comorbidity of migraine and restless legs syndrome (RLS) has been well-documented, the association between RLS and migraine frequency has yet to be elucidated. The present study aims to evaluate the prevalence of RLS among individuals who experience low-frequency, high-frequency, or chronic migraine presenting with and without aura.

METHODS

We conducted a cross-sectional, case-controlled study involving 505 participants receiving outpatient headache treatment. Standardized questionnaires were administered to collect information on experiences of migraine, RLS, sleep quality, anxiety, depression, and demographics. Participants were categorized into low-frequency (1-8/month), high-frequency (9-14/month), and chronic (≥15/month) headache groups. RLS was diagnosed according to the criteria outlined by the International RLS Study Group (IRLSSG). The Pittsburgh Sleep Quality Index (PSQI) and Hospital Anxiety and Depression Scale (HADS) were used to assess sleep quality and identify symptoms of anxiety and depression. Associations between migraine frequency and RLS prevalence were investigated using multivariate linear and logistic regression.

RESULTS

Univariate analysis revealed an effect of migraine frequency on RLS prevalence (p = 0.026), though this effect did not persist following adjustment for baseline characteristics (p = 0.256). The trend was robust in patients whose migraines presented with auras (p _univariate = 0.002; p _multivariate = 0.043) but not in those without auras (p _univariate and p _multivariate > 0.05). Higher anxiety [odds ratio (OR) = 1.18, p = 0.019] and sleep disturbance (OR = 1.17, p = 0.023) scores were associated with higher RLS prevalence.

CONCLUSIONS

Higher migraine frequency correlates with a higher prevalence of RLS, particularly among patients with auras.

Circadian Change in Blink Reflex Recovery in Restless Legs Syndrome

INTRODUCTION

Restless legs syndrome (RLS) is associated with dysfunction of the dopaminergic systems in the pathways that specifically link the sensory input and motor output. Keeping in mind that clinical symptomatology in RLS and cerebrospinal fluid dopamine concentrations in healthy individuals show changes throughout the day, we hypothesized that excitability of the related pathways increases during the night in RLS, and in the present study, we aimed to analyze our hypothesis by the assessment of blink reflex (BR) recovery.

METHODS

Eleven patients with primary RLS and eight age- and gender-matched healthy subjects were included in the study. All participants underwent detailed interviews and neurological examinations. BR responses were recorded after single and paired supraorbital stimulation during the early afternoon and late at night. For double stimulation, interstimulus intervals (ISI) of 100, 300, and 500 ms were used. Daytime and nighttime investigations were separately compared between the patient and control groups (between-group analyses). In-group analyses were conducted between daytime and nighttime investigations of the patient and control groups.

RESULTS

BR responses to single stimuli were normal in all participants at all sessions. R2 recovery was the highest in the patient group during nighttime investigations. In-group analysis showed a reduction of R2 recovery during the night in healthy subjects. R2 recoveries at ISIs of 300 and 500 ms at nighttime were higher in RLS patients but did not reach statistical significance.

CONCLUSION

The BR circuit is less excitable during the night in healthy individuals, whereas the reduction of excitability is lost in RLS. Despite the limited number of included subjects, we suggest that the normal circadian modulation of the BR circuit is lost in RLS.

Opioids for restless legs syndrome

BACKGROUND

Restless legs syndrome (RLS) is a distressing and common neurological disorder that may have a huge impact in the quality of life of those with frequent and intense symptoms. Patients complain of unpleasant sensations in the legs, at or before bedtime, and feel an urge to move the legs, which improves with movement, such as walking. Symptoms start with the patient at rest (e.g. sitting or lying down), and follow a circadian pattern, increasing during the evening or at night. Many pharmacological intervention are available for RLS, including drugs used to treat Parkinson's disease (L-Dopa and dopaminergic agonists), epilepsy (anticonvulsants), anxiety (benzodiazepines), and pain (opioids). Dopaminergic drugs are those most frequently used for treatment of RLS, but some patients do not respond effectively and require other medication. Opioids, a class of medications used to treat severe pain, seem to be effective in treating RLS symptoms, and are recommended for patients with severe symptoms, because RLS and pain appear to share the same mechanism in the central nervous system. All available drugs are associated to some degree with side effects, which can impede treatment. Opioids are associated with adverse events such as constipation, tolerance, and dependence. This justifies the conduct of a systematic review to ascertain whether opioids are safe and effective for treatment of RLS.

OBJECTIVES

To asses the effects of opioids compared to placebo treatment for restless legs syndrome in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled trials, CENTRAL 2016, issue 4 and MEDLINE, EMBASE, and LILACS up to April 2016, using a search strategy adapted by Cochraneto identify randomised clinical trials. We checked the references of each study and established personal communication with other authors to identify any additional studies. We considered publications in all languages.

SELECTION CRITERIA

Randomised controlled clinical trials of opioid treatment in adults with idiopathic RLS.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened articles, independently extracted data into a standard form, and assessed for risk of bias. If necessary, they discussed discrepancies with a third researcher to resolve any doubts.

MAIN RESULTS

We included one randomised clinical trial (N = 304 randomised; 204 completed; 276 analysed) that evaluated opioids (prolonged release oxycodone/naloxone) versus placebo. After 12 weeks, RSL symptoms had improved more in the drug group than in the placebo group (using the IRLSSS: MD -7.0; 95% CI -9.69 to -4.31 and the CGI: MD -1.11; 95% CI -1.49 to -0.73). More patients in the drug group than in the placebo group were drug responders (using the IRLSSS: RR 1.82; 95% CI 1.37 to 2.42 and the CGI: RR1.92; 95% ICI 1.49 to 2.48). The proportion of remitters was greater in the drug group than in the placebo group (using the IRLSSS: RR 2.14; 95% CI 1.45 to 3.16). Quality of life scores also improved more in the drug group than in the placebo group (MD -0.73; 95% CI -1.1 to -0.36). Quality of sleep was improved more in the drug group measured by sleep adequacy (MD -0.74; 95% CI -1.15 to -0.33), and sleep quantity (MD 0.89; 95% CI 0.52 to 1.26).There was no difference between groups for daytime somnolence, trouble staying awake during the day, or naps during the day. More adverse events were reported in the drug group (RR 1.22; 95% CI 1.07 to 1.39). The major adverse events were gastrointestinal problems, fatigue, and headache.

AUTHORS' CONCLUSIONS

Opioids seem to be effective for treating RLS symptoms, but there are no definitive data regarding the important problem of safety. This conclusion is based on only one study with a high dropout rate (moderate quality evidence).

Is it only a sleeping disorder or more? Restless legs syndrome and erectile function

OBJECTIVE

Sexual dysfunction and restless legs syndrome (RLS) have similar pathophysiological properties. This study evaluated the presence of erectile dysfunction (ED) and premature ejaculation (PE) in patients with RLS.

MATERIALS AND METHODS

Fifty patients in the RLS group and 50 in the control group were included in the study. The International Restless Legs Syndrome Study Group rating scale, the five-item International Index of Erectile Function and the Premature Ejaculation Diagnostic Tool were used to define the RLS and erectile function of both the study and control groups. A stopwatch technique was used to evaluate the intravaginal ejaculatory latency time of patients in the study.

RESULTS

The mean age of patients in the RLS and control groups was 53.5 ± 9.9 and 53.2 ± 8.8 years, respectively (p = 0.527). None of the patients in either group had diabetes mellitus. There was no difference between the groups in terms of history of hypertension, body mass index and total testosterone level. There were 27 patients (54%) in the RLS group and 17 patients (34%) in the control group with PE (p = 0.008). There were 26 patients (52%) with ED in the RLS group and 17 (34%) in the control group (p = 0.069). The prevalence of moderate and severe ED was significantly higher in the RLS group (p = 0.045).

CONCLUSIONS

PE was more prevalent in RLS than in control patients. On the other hand, the rate of ED did not differ between the groups. In addition to receiving a neurological evaluation, RLS patients must be evaluated for sexual function.

Patterns of increased intrinsic functional connectivity in patients with restless legs syndrome are associated with attentional control of sensory inputs

INTRODUCTION

Potential alterations of intrinsic functional connectivity in idiopathic restless legs syndrome (RLS) are to be assumed since RLS is considered a network disorder. Whole-brain-based investigation of intrinsic functional connectivity networks including the sensorimotor systems in patients with RLS was compared with matched healthy controls.

METHODS

'Resting-state' functional MRI (1.5 T) from 26 patients with RLS and 26 matched controls were analyzed using standardized seed-based analysis procedures. The motor/sensorimotor, sensory thalamic, ventral and dorsal attention, basal ganglia-thalamic, cingulate, and brainstem networks were used for voxel-based group comparisons between RLS patients and controls.

RESULTS

Significantly increased connectivities were observed in the sensory thalamic, ventral and dorsal attention, basal ganglia-thalamic, and cingulate networks in RLS patients, whereas no differences could be demonstrated for the motor/sensorimotor and the brainstem system. The pattern of functional connectivity alterations was positively correlated with increasing symptom severity.

CONCLUSIONS

Abnormally increased regional BOLD synchronization appears to be a key feature of intrinsic brain architecture in RLS. Alterations in cortical and sub-cortical functional networks support the notion that the underlying pathophysiology of RLS is beyond the sensorimotor and the brainstem system and may be also associated with altered attentional control of sensory inputs.

Microstructure of the Midbrain and Cervical Spinal Cord in Idiopathic Restless Legs Syndrome: A Diffusion Tensor Imaging Study

STUDY OBJECTIVES

Diffusion tensor imaging (DTI) allows the study of white matter microstructure in the central nervous system. The aim of this study was to examine the DTI metrics of the cervical spinal cord and the brainstem up to the midbrain in patients with idiopathic restless legs (RLS) compared to matched healthy controls.

METHODS

DTI analysis of the cervical spinal cord and the brainstem up into the midbrain was performed in 25 patients with idiopathic RLS and 25 matched healthy controls. Data analysis in the brain was performed by voxelwise comparison of fractional anisotropy (FA) maps at group level. Cervical spinal cord data analysis was performed by slicewise analysis of averaged FA values in axial slices along the spinal cord.

RESULTS

Voxelwise comparison of FA maps in the brainstem showed significant microstructural alterations in two clusters in the midbrain bilaterally. Slicewise comparison of the FA maps in the cervical spinal cord showed a trend for lower FA values at the level of the second and third vertebra area in the patient sample.

CONCLUSIONS

The imaging data suggest that significant alterations in the midbrain in RLS can be visualized by DTI and might correlate to a macroscopically subtle process with changes of the tissue microstructure in the corresponding tracts. An additional area of interest is regionally clustered in the upper cervical spinal cord with a tendency toward altered diffusion metrics. These results might be addressed by further studies, e.g., at higher magnetic field strengths.

Intractable restless legs syndrome: role of prolonged-release oxycodone-naloxone

Restless legs syndrome (RLS) is a common neurological disorder characterized by an irresistible urge to move the legs accompanied by uncomfortable sensations that occur at night or at time of rest. Pharmacological therapy should be limited to patients who suffer from clinically relevant symptoms. Chronic RLS is usually treated with either a dopamine agonist (pramipexole, ropinirole, rotigotine) or an α2δ calcium-channel ligand (gabapentin, gabapentin enacarbil, pregabalin). Augmentation is the main complication of long-term dopaminergic treatment, and frequently requires a reduction of current dopaminergic dose or a switch to non-dopaminergic medications. Opioids as monotherapy or add-on treatment should be considered when alternative satisfactory regimens are unavailable and the severity of symptoms warrants it. In a recent Phase III trial, oxycodone-naloxone prolonged release (PR) demonstrated a significant and sustained effect on patients with severe RLS inadequately controlled by previous treatments. The adverse-event profile was consistent with the safety profile of opioids. The most frequent adverse events were fatigue, constipation, nausea, headache, hyperhidrosis, somnolence, dry mouth, and pruritus. Adverse events were usually mild or moderate in intensity. No cases of augmentation were reported. Oxycodone-naloxone PR is approved for the second-line symptomatic treatment of adults with severe to very severe idiopathic RLS after failure of dopaminergic treatment. Further studies are needed to evaluate if oxycodone-naloxone PR is equally efficacious as a first-line treatment. Moreover, long-term comparative studies between opioids, dopaminergic drugs and α2δ ligands are needed.

The clinical challenges of akathisia

Akathisia is one of the most vexing problems in neuropsychiatry. Although it is one of the most common side effects of antipsychotic medications, it is often difficult to describe by patients, and is difficult to diagnose and treat by practitioners. Akathisia is usually grouped with extrapyramidal movement disorders (ie, movement disorders that originate outside the pyramidal or corticospinal tracts and generally involve the basal ganglia). Yet, it can present as a purely subjective clinical complaint, without overt movement abnormalities. It has been subtyped into acute, subacute, chronic, tardive, withdrawal-related, and "pseudo" forms, although the distinction between many of these is unclear. It is therefore not surprising that akathisia is generally either underdiagnosed or misdiagnosed, which is a serious problem because it can lead to such adverse outcomes as poor adherence to medications, exacerbation of psychiatric symptoms, and, in some cases, aggression, violence, and suicide. In this article, we will attempt to address some of the confusion surrounding the condition, its relationship to other disorders, and differential diagnosis, as well as treatment alternatives.

Restless-legs syndrome and insomnia in hemodialysis patients

AIM/BACKGROUND

Restless legs syndrome (RLS) is a common neurological movement disorder which is commonly seen in hemodialysis (HD) patients. Insomnia, depression, and anxiety disorders frequently show concurrence. In this study, we aimed to investigate RLS and insomnia prevalence and related factors in HD patients.

SUBJECTS AND METHODS

Patients who were under HD treatment and healthy controls with similar mean age, sex ratio, and hypertension and diabetes mellitus frequency were included in this study. Depression, insomnia, and daytime sleepiness assessments were performed by using Beck Depression Inventory, Insomnia Severity Index, and Epworth Sleepiness Scale. The diagnosis of RLS was made using the International RLS Study Group consensus criteria.

RESULTS

About 156 HD patients and 35 controls were enrolled. The mean age was 50.6 in the HD group and 49.7 in the control group. Female sex was 43.9% in the HD group and 57.1% in the control group. RLS was significantly more frequent in HD patients compared with controls. The rate of sub-threshold insomnia and insomnia with moderate severity was higher in HD patients. While insomnia severity score and diabetes mellitus were significantly associated with the presence of RLS, depression, RLS, older age, and being under HD treatment were independently associated with insomnia severity.

CONCLUSIONS

HD patients commonly have RLS and insomnia. Insomnia and diabetes mellitus seem to be major factors underlying RLS in HD patients. Furthermore, depression and RLS seem to be closely related to insomnia in these patients. Treatment of depression, insomnia, and RLS may be beneficial to improve quality of life in HD patients.

Restless Legs Syndrome and Leg Motor Restlessness in Parkinson's Disease

Sleep disturbances are important nonmotor symptoms in Parkinson's disease (PD) that are associated with a negative impact on quality of life. Restless legs syndrome (RLS), which is characterized by an urge to move the legs accompanied by abnormal leg sensations, can coexist with PD, although the pathophysiology of these disorders appears to be different. RLS and PD both respond favorably to dopaminergic treatment, and several investigators have reported a significant relationship between RLS and PD. Sensory symptoms, pain, motor restlessness, akathisia, and the wearing-off phenomenon observed in PD should be differentiated from RLS. RLS in PD may be confounded by chronic dopaminergic treatment; thus, more studies are needed to investigate RLS in drug-naïve patients with PD. Recently, leg motor restlessness (LMR), which is characterized by an urge to move the legs that does not fulfill the diagnostic criteria for RLS, has been reported to be observed more frequently in de novo patients with PD than in age-matched healthy controls, suggesting that LMR may be a part of sensorimotor symptoms intrinsic to PD. In this paper, we provide an overview of RLS, LMR, and PD and of the relationships among these disorders.

Restless legs syndrome-current therapies and management of augmentation

Idiopathic restless legs syndrome (RLS) can severely affect quality of life and disturb sleep, so that pharmacological treatment is necessary, especially for elderly patients. Treatment guidelines recommend initiation of therapy with dopamine agonists (pramipexole, ropinirole or the rotigotine transdermal patch, all approved in most countries) or α-2-δ ligands (gabapentin enacarbil, approved in the USA and Japan), depending on the country and availability. Where approved, opioids (prolonged release oxycodone-naloxone, approved in Europe) are also recommended as a second-line therapy for severe RLS. Several iron formulations can be effective but are not yet approved for RLS therapy, whereas benzodiazepines and other anticonvulsants are not recommended or approved. Less is known about effective management of RLS that is associated with other conditions, such as uraemia or pregnancy. Furthermore, very little data are available on the management of RLS when first-line treatment fails or patients experience augmentation. In this Review, we summarize state-of-the-art therapies for RLS in the context of the diagnostic criteria and available guidelines, based on knowledge ranging from Class I evidence for the treatment of idiopathic RLS to Class IV evidence for the treatment of complications such as augmentation. We consider therapies, including combination therapies, that are used in clinical practice for long-term management of RLS, despite a lack of trials and approval, and highlight the need for practical long-term evaluation of current trials.

Rotigotine in the treatment of primary restless legs syndrome: A meta-analysis of randomized placebo-controlled trials

The aim of this study was to summarize the efficacy and tolerability of rotigotine in the treatment of primary restless legs syndrome (RLS). PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for English-language randomized controlled trials (RCTs) that assessed the effectiveness of rotigotine for RLS. The pooled mean change from baseline in International RLS (IRLS) Study Group Rating Scalescore and relative risk (RR) of response based on the Clinical Global Impression-Improvement (CGI-I) scale score were applied to evaluate the outcomes. The pooled proportions of adverse events (AEs) were also estimated. Six RCTs were included. The meta-analysis showed a favorable effectiveness of rotigotine versus placebo on RLS [mean change on IRLS score: mean difference (MD)=-4.80; 95% confidence interval (CI): -5.90 to -3.70; P<0.00001 and RR of response on CGI-I was 2.19; 95% CI: 1.86 to 2.58, P<0.00001]. The most common AEs were application site reactions, nausea, headache and fatigue. In general, rotigotine was well-tolerated in patients with primary RLS. Based on the findings from the meta-analysis, rotigotine was more significantly efficacious in the treatment of RLS than placebo. Nevertheless, long-term studies and more evidence of comparisons of rotigotine with other dopamine agonists are needed.

The relationship between dipping-non-dipping arterial blood pressure pattern and frequency of restless leg syndrome with related factors

Objective:

The lack of nocturnal decline in blood pressure (BP) is associated with an increase in cardiovascular events. Restless leg syndrome (RLS) is an uncomfortable feeling in which the patient wants to budge the legs with ache in the legs. RLS also increases the hypertension and cardiovascular risk. In this study, we aimed to evaluate the relationship between dipping and non-dipping blood pressure patterns with RLS and its severity.

Methods:

Two hundred patients who had 24-hour ambulatory blood pressure monitoring (ABPM) were enrolled into this cross-sectional study. They were classified by blood pressure pattern as dipping and non-dipping. Then, 100 patients with the dipper pattern and 100 patients with the non-dipper pattern were chosen. A questionnaire for RLS diagnosis that was prepared by the International RLS Study Group was given performed to the patients.

Results:

RLS symptom score was higher in patients with non-dipping blood pressure patterns (NDBPP), and patients with NDBPP had more severe RLS. Beside this, there were no differences in terms of RLS frequency in dipping and non-dipping blood pressure patterns.

Conclusion:

As a conclusion, dipping and non-dipping blood pressure patterns do not increase RLS risk. But, if patients with NDBPP have RLS, they have more severe RLS. So, we suggest that evaluating a patient with a non-dipping blood pressure pattern, considering RLS, would be helpful to ameliorate the quality of life of the patient

Growing pains and periodic limb movements of sleep in children

AIM

To investigate whether there was any association between growing pains (GP) and periodic limb movements of sleep (PLMS) in children referred for polysomnography (PSG), in light of the possible shared genetic determinants between GP and restless legs syndrome.

METHODS

Records of all 903 children who underwent PSG at a paediatric hospital between January 2009 and May 2010 were retrospectively reviewed. Children aged 3-16 years, without neuromuscular or neurological/developmental disorders who were seen by a single sleep physician were included in the analysis. Data extracted included: current GP, PLMS index, mixed obstructive apnoea/hypopnoea index and patient demographics. GP was diagnosed in the pre-PSG consultation.

RESULTS

GP was recorded in 43 of the eligible 230 children referred for PSG of whom 25.6% had a PLMS index ≥ 5/h, significantly higher than in the children without GP (10.2%) (odds ratio 3.04, χ(2) = 6.0, P = 0.014). The adjusted odds ratio for the association between GP and PLMS remained significant at 2.53 (95% CI 1.1-6.1, P < 0.05). A PLMS index ≥ 5/h was recorded in 30 of the 230 participants. GP and PLMS were also significantly multivariately associated with restlessness as the indication for PSG.

CONCLUSIONS

Children with GP were three times more likely to have a PLMS index ≥ 5/h than children without GP on PSG. These results suggest that GP may be associated with PLMS, giving greater support for the hypothesis that GP might lie on the phenotypic spectrum of restless legs syndrome.

Restless legs syndrome and pregnancy: a review

Restless legs syndrome (RLS) is a common sensorimotor neurological disorder that is diagnosed according to the revised criteria of the International RLS Study Group (IRLSSG). The pathophysiology of RLS is still unknown and its prevalence is influenced by ethnicity, age, and gender. RLS is divided into two types by etiology: primary or idiopathic and secondary. Primary RLS is strongly influenced by a genetic component while secondary RLS is caused by other associated conditions such as end-stage renal disease or peripheral neuropathy. Another common condition associated with RLS is pregnancy. The prevalence of RLS during pregnancy is two to three times higher than in the normal population and is influenced by the trimester and the number of parity. The main mechanisms that may contribute to the pathophysiology of RLS during pregnancy are hormonal changes and iron and folate status. Standard medications for treating RLS during pregnancy are not established. Most medications have been used according to the evidence from non-pregnant patients. Therefore, consideration of the medical treatment for treating RLS during pregnancy should be balanced between the benefit of relieving the symptoms and maternal and fetal risk. In general, the prognosis of RLS during pregnancy is good and symptoms are usually relieved after delivery.

High prevalence of restless legs syndrome among women with multi-site pain: a population-based study in Dalarna, Sweden

BACKGROUND

The chronic pain (CP) and chronic multi-site pain (CMP) condition is a highly prevalent health problem. Several studies have reported a high (31-64%) prevalence of co-morbid restless legs syndrome (RLS) in patients with fibromyalgia, one specifically defined form of chronic widespread pain. The current study explored the association between CMP and RLS.

METHOD

The study included 4040 respondents to a postal questionnaire sent to 10,000 women in the age range of 18-64 years and randomly selected from the general population. Complete questionnaire data on type (acute/chronic), degree (mild to severe) and spreading (0-5 body zones) of pain, as well as RLS symptoms (validated questionnaire), were obtained from 3060 subjects. Information on lifestyle, anthropometrics, co-morbidities and medication was collected.

RESULTS

RLS prevalence increased from 9.6% in subjects with no report of pain to 23,9%, 26.4%, 39.2%, 44.9% and 54.8% in those reporting one, two, three, four and five pain areas, respectively (p < 0.001). Further, RLS prevalence increased from 9.6% (no pain) to 27.9%, 37.9% and 42.4% in subjects with mild, moderate and severe chronic pain (p < 0.001). Multi-site pain, pain localized in the leg, extended pain duration and co-morbid psychiatric disorder were all independently associated with a RLS diagnosis in a multiple regression analysis.

CONCLUSION

The prevalence of RLS increased progressively with pain severity and even more sharply with the degree of pain spreading in women recruited from the general population. Both acute and chronic pain was associated with RLS-related symptoms.

May diabetes patients have trouble sleeping despite not having obesity?

Obstructive sleep apnea (OSA) and periodic limb movements during sleep (PLMs) are sleep-related disorders with a high prevalence in type 2 diabetes. Commonly OSA is considered as a consequence of obesity, but several previous studies have shown the presence of OSA in non-obese diabetic patients. A previous study showed higher PLMs prevalence in patients with type 2 diabetes, compared to age-matched controls. We speculated that both OSA and PLMs may reflect the presence of diabetic autonomic neuropathy. To test this hypothesis, we compared a group of 112 non-obese patients with type 2 diabetes with 66 age-, sex-, and body mass index- matched nondiabetic patients. Both groups have been investigated through a set of tests including the Epworth Sleepiness Scale, polysomnography, and the Orthostatic Grading Scale (OGS), a questionnaire to assess the degree of autonomic dysfunction. Diabetic patients with OSA and PLMs scored higher on the OGS than controls. Our results confirm that both OSA and PLMs are related to dysautonomy and may be unrelated to obesity in type 2 diabetes patients.

Altered white matter integrity in primary restless legs syndrome patients: diffusion tensor imaging study

OBJECTIVES

A prior diffusion tensor imaging (DTI) of restless legs syndrome (RLS) subjects found alterations in brain white matter (WM). The aim of this study was to explore the possible mechanism of altered integrity of brain WM in RLS patients.

METHODS

The DTI measurement was performed in 22 subjects with RLS and 22 age-matched control subjects. Using a voxel-based analysis, fractional anisotropy (FA) and axial and radial diffusivities (AD and RD) were compared between RLS and control subjects with a two-sample t-test, and correlation analysis was performed in RLS subjects.

RESULTS

RLS subjects demonstrated decreased FA in the genu of the corpus callosum and frontal WM adjacent to the inferior frontal gyrus compared with the control subjects. For areas of decreased FA, both the AD and RD were higher than that in the control subjects.

DISCUSSION

Our findings suggest that loss of axonal density and myelin may account for WM changes seen in a prior study of RLS subjects.

Treatment of restless legs syndrome

Restless legs syndrome (RLS) is a common disorder diagnosed by the clinical characteristics of restlessness in the legs associated often with abnormal sensations that start at rest and are improved by activity, occurring with a diurnal pattern of worsened symptoms at night and improvement in the morning. RLS is the cause of impaired quality of life in those more severely afflicted. Treatment of RLS has undergone considerable change over the last few years. Several classes of medications have demonstrated efficacy, including the dopaminergic agents and the alpha-2-delta ligands. Levodopa was the first dopaminergic agent found to be successful. However, chronic use of levodopa is frequently associated with augmentation that is defined as an earlier occurrence of symptoms frequently associated with worsening severity and sometimes spread to other body areas. The direct dopamine agonists, including ropinirole, pramipexole, and rotigotine patch, are also effective, although side effects, including daytime sleepiness, impulse control disorders, and augmentation, may limit usefulness. The alpha-2-delta ligands, including gabapentin, gabapentin enacarbil, and pregabalin, are effective for RLS without known occurrence of augmentation or impulse control disorders, although sedation and dizziness can occur. Other agents, including the opioids and clonazepam do not have sufficient evidence to recommend them as treatment for RLS, although in an individual patient, they may provide benefit.

Sleep quality, arousal and pain thresholds in tension-type headache: a blinded controlled polysomnographic study

INTRODUCTION

We aimed to compare subjective and objective sleep quality in tension-type headache (TTH) patients and to evaluate the relationship between sleep quality and pain thresholds (PT) in controls and TTH patients.

METHODS

A blinded cross-sectional study where polysomnography (PSG) and PT (to pressure, heat and cold) measurements were done in 20 patients with TTH (eight episodic (ETTH) and twelve chronic (CTTH) TTH) and 29 healthy controls. Sleep diaries and questionnaires were applied.

RESULTS

TTH patients had more anxiety ( P = 0.001), insomnia ( P < 0.0005), daytime tiredness ( P < 0.0005) and reduced subjective sleep quality ( P < 0.0005) compared to healthy controls. Sleep diaries revealed more long awakenings in TTH ( P = 0.01) but no total sleep-time differences. TTH patients had more slow-wave sleep ( P = 0.002) and less fast arousals ( P = 0.004) in their PSGs. CTTH subjects had lower pressure PT ( P = 0.048) and more daytime sleepiness than the controls ( P = 0.039). Among TTH lower cold PT (CPT) correlated inversely with light sleep (N1) ( R  = -0.49, P = 0.003) while slow arousals correlated inversely with headache-frequency ( R  = -0.64, P = 0.003).

CONCLUSIONS

We hypothesize that TTH patients need more sleep than healthy controls and might be relatively sleep deprived. Inadequate sleep may also contribute to increased pain sensitivity and headache frequency in TTH.

Aerobic exercise improves signs of restless leg syndrome in end stage renal disease patients suffering chronic hemodialysis

Background. Restless leg syndrome (RLS) is one of the prevalent complaints of patients with end stage renal diseases suffering chronic hemodialysis. Although there are some known pharmacological managements for this syndrome, the adverse effect of drugs causes a limitation for using them. In this randomized clinical trial we aimed to find a nonpharmacological way to improve signs of restless leg syndrome and patients' quality of life. Material and Methods. Twenty-six patients were included in the study and divided into 2 groups of control and exercise. The exercise group used aerobic exercise during their hemodialysis for 16 weeks. The quality of life and severity of restless leg syndrome were assessed at the first week of study and final week. Data were analyzed using SPSS software. Results. The difference of means of RLS signs at the first week of study and final week was −5.5 ± 4.96 in exercise group and −0.53 ± 2.3 in control group. There was not any statistical difference between control group and exercise group in quality of life at the first week of study and final week. Conclusions. We suggest using aerobic exercise for improving signs of restless leg syndrome, but no evidence was found for its efficacy on patient's quality of life.

Restless legs syndrome in hemodialysis patients: an epidemiologic survey in Greece

BACKGROUND

Restless legs syndrome (RLS) is a sensorimotor disorder characterized by an uncontrolled need to move extremities accompanied by unpleasant sensations, which frequently leads to sleep disturbances. In hemodialysis (HD) patients, the previously reported RLS prevalence varied enormously, between 6% and 60%. In our study, we investigated the RLS prevalence in HD patients for the first time in Greece.

METHODS

A continuous sample of HD patients was studied between January and September of 2010 in six dialysis units in Greece. RLS diagnosis was based on the essential clinical criteria of the International RLS Study Group (IRLSSG). The standardized incidence ratio (SIR) for RLS in HD patients was calculated in comparison to data from a recent survey of the general population in Greece.

RESULTS

In our study of 579 HD patients in Greece (236 women; mean age, 65±13years), the prevalence of RLS was elevated in comparison to the general population (26.6% vs 3.9%), with an SIR of 5.4 (95% confidence interval [CI], 4.6-6.3). In the fully adjusted model, the risk for RLS in HD patients was reduced in older age (odds ratio [OR], 0.98 [95% CI, 0.96-0.99]) and increased in women (OR, 1.60 [95% CI, 1.05-2.43]) in cases with elevated levels of β2 microglobulin (OR, 1.15 [95% CI, 1.01-1.32]) and intact parathormone (iPTH) (OR, 1.30 [95% CI, 1.08-1.56]).

CONCLUSION

A high RLS prevalence was recorded in a large HD population in Greece, clearly suggesting the need for enhanced awareness of RLS in nephrology. The RLS risk was increased in women and in younger HD patients as well as in those with elevated β2 microglobulin and iPTH levels.

Restless legs syndrome associated with exercise intolerance: Data from a retrospective observational clinical neuromuscular center study

INTRODUCTION

Exercise intolerance (EI) is a frequent motive for seeking neuromuscular consultation and may be a sign of metabolic disease or, rarely, muscular dystrophy. The diagnosis is not established in many patients with a typical clinical presentation. Nevertheless, some of them complain of sleep disorders and more especially of restless legs syndrome (RLS).

OBJECTIVE

The objective of our study was to estimate the frequency of RLS in patients presenting with EI.

METHODS

Our retrospective observational study included all patients seen in the center from 2005 to 2011, who were subsequently investigated for EI in the neuromuscular department of the Caen University hospital. Data were collected on clinical RLS and muscular investigations (creatine kinase [CK], EMG, maximal exercise tests magnetic resonance imaging [MRI] and muscle biopsy obtained along with muscle exploration).

RESULTS

Of the 318 patient records analyzed, 84 showed patients accurately complaining of EI. RLS was diagnosed in 25 of these patients (29.7%). This percentage was significantly higher (P<0.001) than found in the general population. Improvement was seen in 91.3% of the patients receiving specific treatment.

CONCLUSION

RLS can sometimes present with pain, potentially worsening with exercise, inappropriately leading to a hypothesis of EI. Clinicians should thus explore the possible diagnosis of RLS when a muscular disease is not found in patients presenting with such symptoms.

Prevalence of restless legs syndrome in Ankara, Turkey: an analysis of diagnostic criteria and awareness

The aim of this study was threefold: (1) to investigate the prevalence of restless legs syndrome (RLS), in Ankara, Turkey; (2) to determine the predictive values of diagnostic criteria; and (3) to determine the frequency of physician referrals and the frequency of getting the correct diagnosis. A total of 815 individuals, from randomly selected addresses, above the age of 15, were reached using the questionnaire composed of the four diagnostic criteria. Individuals who responded by answering 'yes' for at least one question were interviewed by neurologists for the diagnosis of RLS. Frequency of physician referrals and frequency of getting the correct diagnosis of RLS were also determined for patients getting the final diagnoses of RLS. Prevalence of RLS in Ankara was 5.52 %; 41.0 % of the individuals diagnosed with RLS had replied 'yes' to either one, two or three questions asked by interviewers. However, only 21.3 % of individuals who replied 'yes' to all four questions received the diagnosis of RLS. Among the patients who had the final diagnosis of RLS, 25.7 % had referred to a physician for the symptoms and 22.2 % got the correct diagnosis. The RLS prevalence in Ankara was somewhere between Western and Far East countries compatible with the geographical location. Diagnostic criteria may not be fully predictive when applied by non-physician pollsters. Physician's probability of correctly diagnosing RLS is still low.