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Chenini S, Barateau L, Dauvilliers Y. Restless legs syndrome: From clinic to personalized medicine. Rev Neurol (Paris) 2023; 179:703-714. [PMID: 37689536 DOI: 10.1016/j.neurol.2023.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2023]
Abstract
Restless legs syndrome (RLS) is a common neurological sensorimotor disorder that impairs sleep, mood and quality of life. RLS is defined by an urge to move the legs at rest that increases in the evening and at night, and is frequently associated with metabolic and cardiovascular diseases. Symptoms frequency, age at RLS onset, severity, familial history and consequences of RLS vary widely between patients. A genetic susceptibility, iron deficiency, dopamine deregulation, and possible hypo-adenosinergic state may play a role in the pathophysiology of RLS. Polysomnographic recordings found often periodic leg movements during sleep and wakefulness in patients with RLS. RLS can be classified as primary or comorbid with major diseases: iron deficiency, renal, neurological, rheumatological and lung diseases. First-line treatments are low-dose dopamine agonists, and alpha-2-delta ligands depending on the clinical context, and second/third line opiates for pharmacoresistant forms of RLS. Augmentation syndrome is a serious complication of dopamine agonists and should be prevented by using the recommended low dose. Despite an increase in knowledge, RLS is still underdiagnosed, poorly recognized, resulting in substantial individual health burden and socioeconomic coast, and education is urgently needed to increase awareness of this disabling disorder.
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Affiliation(s)
- S Chenini
- National Reference Centre for Orphan Diseases Narcolepsy and Rare Hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, University of Montpellier, Montpellier, France; Institute for Neurosciences of Montpellier (INM), University of Montpellier, INSERM, Montpellier, France.
| | - L Barateau
- National Reference Centre for Orphan Diseases Narcolepsy and Rare Hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, University of Montpellier, Montpellier, France; Institute for Neurosciences of Montpellier (INM), University of Montpellier, INSERM, Montpellier, France
| | - Y Dauvilliers
- National Reference Centre for Orphan Diseases Narcolepsy and Rare Hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, University of Montpellier, Montpellier, France; Institute for Neurosciences of Montpellier (INM), University of Montpellier, INSERM, Montpellier, France.
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Restless legs syndrome in multiple sclerosis is related to retinal thinning. Photodiagnosis Photodyn Ther 2022; 40:103169. [PMID: 36272508 DOI: 10.1016/j.pdpdt.2022.103169] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Restless legs syndrome (RLS) is one of the most frequent comorbidities accompanying multiple sclerosis. Patients with multiple sclerosis (MS) show thinning in the retinal layers throughout the disease. The thinning is related to acute attacks and progression and atrophy of the brain. Optical coherence tomography (OCT) provides relevant information on the pathophysiology of MS. We aimed to evaluate OCT parameters in patients with MS to investigate any changes related to the coexistence of RLS. METHODS We consecutively enrolled 75 adults with relapsing-remitting MS. Participants were assessed by using demographic and clinical parameters along with the excessive sleepiness in the daytime (ESS), fatigue severity scale (FSS), and RLS severity scale (IRLSSG). The thickness of the peripapillary retinal nerve fiber layer (pRNFL), macular thickness (MT), and macular ganglion cell - inner plexiform layer (MGCIPL) complex was measured with spectral-domain OCT. RESULTS Of the 75 participants, 20 were found to have RLS, and 55 did not. Scores of ESS, FSS, and MS disability (EDSS) were worse in patients with RLS. There was no significant difference in retinal nerve fiber layer thickness except for the inferior quadrant(p = 0.029). The mean inferior pRNFL thickness was 104.5 ± 22.6 μm in the RLS (+) group and 114.2 ± 21.6 μm in the RLS (-) group. CONCLUSION Patients with RLS had excessive daytime sleepiness, were more fatigued, had higher EDSS scores, and had a thinner retinal layer in the inferior quadrant. Overall, data from the study suggest a possible relationship between retinal volume changes in MS patients with RLS.
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Kim H, Jung HR, Kim JB, Kim DJ. Autonomic Dysfunction in Sleep Disorders: From Neurobiological Basis to Potential Therapeutic Approaches. J Clin Neurol 2022; 18:140-151. [PMID: 35274834 PMCID: PMC8926769 DOI: 10.3988/jcn.2022.18.2.140] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
Sleep disorder has been portrayed as merely a common dissatisfaction with sleep quality and quantity. However, sleep disorder is actually a medical condition characterized by inconsistent sleep patterns that interfere with emotional dynamics, cognitive functioning, and even physical performance. This is consistent with sleep abnormalities being more common in patients with autonomic dysfunction than in the general population. The autonomic nervous system coordinates various visceral functions ranging from respiration to neuroendocrine secretion in order to maintain homeostasis of the body. Because the cell population and efferent signals involved in autonomic regulation are spatially adjacent to those that regulate the sleep-wake system, sleep architecture and autonomic coordination exert effects on each other, suggesting the presence of a bidirectional relationship in addition to shared pathology. The primary goal of this review is to highlight the bidirectional and shared relationship between sleep and autonomic regulation. It also introduces the effects of autonomic dysfunction on insomnia, breathing disorders, central disorders of hypersomnolence, parasomnias, and movement disorders. This information will assist clinicians in determining how neuromodulation can have the greatest therapeutic effects in patients with sleep disorders.
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Affiliation(s)
- Hakseung Kim
- Department of Brain and Cognitive Engineering, Korea University, Seoul, Korea
| | - Hee Ra Jung
- Department of Psychological and Brain Sciences, Washington University in St. Louis, St. Louis, MO, USA
| | - Jung Bin Kim
- Department of Neurology, Korea University College of Medicine, Seoul, Korea
| | - Dong-Joo Kim
- Department of Brain and Cognitive Engineering, Korea University, Seoul, Korea
- Department of Neurology, Korea University College of Medicine, Seoul, Korea
- Department of Artificial Intelligence, Korea University, Seoul, Korea
- NeuroTx, Co., Ltd., Seoul, Korea
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Leclair-Visonneau L, Vecchierini MF, Schröder C, Charley Monaca C. French Consensus: How to diagnose restless legs syndrome. Rev Neurol (Paris) 2018; 174:508-514. [PMID: 30049562 DOI: 10.1016/j.neurol.2018.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/16/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Abstract
Correct diagnosis of restless legs syndrome (RLS) is essential to patient care and treatment. Diagnosis is most often clinical and based on diagnostic criteria: the need to move the legs accompanied to varying degrees by unpleasant sensations, predominantly during the evening and improved by movement. In rare cases, clinical examination is insufficient and a polysomnography is necessary. Once a positive diagnosis has been made, a neurological examination and an assessment of iron status are required. The severity of the RLS must be evaluated to determine whether a specific treatment is necessary. Before treatment, it is essential to ensure that a definite diagnosis of RLS has been made and the phenotype characterised. This enables a personal treatment plan and limits the risk of augmentation syndrome.
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Affiliation(s)
- L Leclair-Visonneau
- Inserm CIC-04, Inserm U1235, université de Nantes, laboratoire d'explorations fonctionnelles, CHU de Nantes, CHU-Hotel Dieu, 1, place Alexis-Ricordeau, 44093 Nantes, France
| | - M-F Vecchierini
- Sleep Center Hôtel-Dieu, place Jean-Paul II, 1, parvis Notre-Dame, 75004 Paris, France
| | - C Schröder
- Child, Adolescent Psychiatry Service, Psychiatry Pole, Mental Health, Addiction, Strasbourg Teaching Hospitals, Strasbourg University, 1, place de l'Hôpital, 67091 Strasbourg cedex, France; CNRS UPR 3212, Team 9, Institute of Cellular, Integrative Neurosciences (INCI), 5, rue Blaise-Pascal, 67084 Strasbourg cedex, France
| | - C Charley Monaca
- Inserm UMR 1171, Clinical Neurophysiology, Teaching Hospital, Lille University, 1, place de Verdun, 59045 Lille cedex, France.
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Tak AZA, Çelİk M, Kalenderoğlu A, Sağlam S, Altun Y, Gedİk E. Evaluation of Optical Coherence Tomography Results and Cognitive Functions in Patients with Restless Legs Syndrome. ACTA ACUST UNITED AC 2018; 56:243-247. [PMID: 31903030 DOI: 10.5152/npa.2017.21598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/30/2017] [Indexed: 11/22/2022]
Abstract
Introduction The aim of this study was to evaluate whether retinal neural network was impaired and cognitive functions were disturbed in restless legs syndrome (RLS) considering the hypothesis that there may be a dysfunction in dopaminergic pathways in RLS like in Parkinson's disease. Therefore, we evaluated retinal neural network with optical coherence tomography (OCT) and presence of cognitive impairment with Montreal Cognitive Assessment (MOCA). Methods OCT evaluations were performed for 30 RLS patients and 30 healthy controls. Ganglion cell complex was segmented to retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), and inner plexiform layer (IPL) automatically by the device, and recorded. Additionally, all the patients and the controls were evaluated using MOCA. Results No statistically significant difference was detected between RLS and controls in RNFL, GCL, IPL, and choroidal thicknesses. However, total MOCA score and all of its subscale scores were significantly lower in the RLS patients compared with the controls. No significant correlation was detected between OCT and MOCA parameters. Conclusion No degeneration was detected in retinal neurons (RNFL, GCL, and IPL) of RLS patients. However, impairments were seen in MOCA total and subscale scores of these patients. On the other hand, no significant correlation was detected between MOCA scores and RNFL, GCL, or IPL thicknesses. These findings suggest decrease in cognitive functions of RLS patients probably due to dopaminergic dysfunction regardless of anatomical neural degeneration. Longitudinal follow-up studies are warranted to evaluate whether neuronal degeneration will develop.
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Affiliation(s)
| | - Mustafa Çelİk
- Adiyaman University School of Medicine, Department of Psychiatry, Adiyaman, Turkey
| | - Aysun Kalenderoğlu
- Adiyaman University School of Medicine, Department of Psychiatry, Adiyaman, Turkey
| | | | - Yaşar Altun
- Adiyaman University Training and Research Hospital, Department of Neurology, Adiyaman, Turkey
| | - Emre Gedİk
- Adiyaman University School of Medicine, Department of Neurology, Adiyaman, Turkey
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Szatmari S, Bereczki D, Fornadi K, Kalantar-Zadeh K, Kovesdy CP, Molnar MZ. Association of Restless Legs Syndrome With Incident Parkinson's Disease. Sleep 2017; 40:2667757. [PMID: 28364505 DOI: 10.1093/sleep/zsw065] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Study Objectives The association between restless legs syndrome (RLS) and Parkinson's disease (PD) has been extensively studied with inconclusive results; therefore, we prospectively examined the associations of the presence of RLS with development of incident PD. Methods From a nationally representative prospective cohort of almost 3.5 million US veterans (age: 60 ± 14 years, 93% male, median follow-up time of 7.8 years [interquartile range: 6.4-8.4 years]), we created a propensity-matched cohort of 100882 PD-free patients and examined the association between prevalent RLS and incident PD. This association was also assessed in the entire cohort. Associations were examined using Cox models. Results There were 68 incident PD events (0.13%, incidence rate 1.87 [1.48-2.37]/10000 patient-years) in the RLS-negative group, and 185 incident PD events (0.37%, incidence rate 4.72 [4.09-5.45]/10000 patient-years) in the RLS-positive group in the propensity-matched cohort. Prevalent RLS was associated with more than twofold higher risk of incident PD (hazard ratio [HR]: 2.57, 95% confidence interval [CI]: 1.95-3.39) compared to RLS-negative patients. Qualitatively similar results were found when we examined the entire 3.5 million cohort: Prevalent RLS was associated with more than twofold higher risk of incident PD (multivariable adjusted HR: 2.81, 95%CI: 2.41-3.27). Conclusion RLS and PD share common risk factors. In this large cohort of US veterans, we found that prevalent RLS is associated with higher risk of incident PD during 8 years of follow-up, suggesting that RLS could be an early clinical feature of incident PD.
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Affiliation(s)
- Szabolcs Szatmari
- Department of Neurology, Sibiu County Emergency Hospital, Sibiu, Romania.,2nd Department of Neurology, Targu Mures Emergency Clinical County Hospital, Targu Mures, Romania.,Szentágothai Doctoral School, Semmelweis University, Budapest, Hungary
| | - Daniel Bereczki
- Szentágothai Doctoral School, Semmelweis University, Budapest, Hungary.,Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Katalin Fornadi
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | | | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.,Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Miklos Z Molnar
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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Khan FH, Ahlberg CD, Chow CA, Shah DR, Koo BB. Iron, dopamine, genetics, and hormones in the pathophysiology of restless legs syndrome. J Neurol 2017; 264:1634-1641. [PMID: 28236139 DOI: 10.1007/s00415-017-8431-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/16/2017] [Accepted: 02/18/2017] [Indexed: 12/16/2022]
Abstract
Restless legs syndrome (RLS) is a common, chronic neurologic condition, which causes a persistent urge to move the legs in the evening that interferes with sleep. Human and animal studies have been used to study the pathophysiologic state of RLS and much has been learned about the iron and dopamine systems in relation to RLS. Human neuropathologic and imaging studies have consistently shown decreased iron in different brain regions including substantia nigra and thalamus. These same areas also demonstrate a state of relative dopamine excess. While it is not known how these changes in dopamine or iron produce the symptoms of RLS, genetic and hormone studies of RLS have identified other biologic systems or genes, such as the endogenous opioid and melanocortin systems and BTBD9 and MEIS1, that may explain some of the iron or dopamine changes in relation to RLS. This manuscript will review what is known about the pathophysiology of RLS, especially as it relates to changes in iron, dopamine, genetics, and hormonal systems.
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Affiliation(s)
- Farhan H Khan
- Lippard Laboratory of Clinical Investigation, Division of Movement Disorders, Department of Neurology, Yale University School of Medicine, Room 710, West Haven VAMC, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Caitlyn D Ahlberg
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Christopher A Chow
- Lippard Laboratory of Clinical Investigation, Division of Movement Disorders, Department of Neurology, Yale University School of Medicine, Room 710, West Haven VAMC, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Divya R Shah
- Lippard Laboratory of Clinical Investigation, Division of Movement Disorders, Department of Neurology, Yale University School of Medicine, Room 710, West Haven VAMC, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Brian B Koo
- Lippard Laboratory of Clinical Investigation, Division of Movement Disorders, Department of Neurology, Yale University School of Medicine, Room 710, West Haven VAMC, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Connecticut Veterans Affairs Medical Center, 950 Campbell Avenue, West Haven, CT, 06516, USA.
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Batool-Anwar S, Li Y, De Vito K, Malhotra A, Winkelman J, Gao X. Lifestyle Factors and Risk of Restless Legs Syndrome: Prospective Cohort Study. J Clin Sleep Med 2017; 12:187-94. [PMID: 26446243 DOI: 10.5664/jcsm.5482] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 08/10/2015] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES To examine the association between modifiable lifestyle factors, and the risk of developing restless legs syndrome (RLS). METHODS This is a Prospective Cohort study of population including 12,812 men participating in Health Professionals Follow-up Study and 42,728 women participating in the Nurses' Health study II. The participants were free of RLS at baseline (2002 for the HPFS and 2005 for the NHS II) and free of diabetes and arthritis through follow-up. RLS was assessed via a set of questions recommended by International Restless Legs Syndrome Study group. The Information was collected on height, weight, level of physical activity, dietary intake, and smoking status via questionnaires. RESULTS During 4-6 years of follow-up, we identified 1,538 incident RLS cases. Participants with normal weight, and who were physically active, non-smoker, and had some alcohol consumption had a lower risk of developing RLS. When we combined the effects of these four factors together, we observed a dose response relationship between the increased number of healthy lifestyle factors and a low risk of RLS: after adjusting for potential confounders the pooled odds ratio was 0.67 (95% CI: 0.47-0.97) for 4 vs.0 healthy factors (p trend < 0.001). In contrast, we did not observe significant associations between caffeine consumption or diet quality as assessed by the Alternate Healthy Eating Index, and altered RLS risk in men and women. CONCLUSIONS Several modifiable lifestyle factors may play an important role in RLS risk.
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Affiliation(s)
- Salma Batool-Anwar
- Division of Sleep Medicine, Department of Medicine (SB), Brigham and Women's Hospital, Boston, MA
| | - Yanping Li
- Harvard Medical School, Channing Division of Network Medicine, Boston, MA.,Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, and Department of Nutrition, Harvard University School of Public Health, Boston, MA
| | - Katerina De Vito
- Harvard Medical School, Channing Division of Network Medicine, Boston, MA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine UCSD La Jolla, La Jolla, CA
| | - John Winkelman
- Department of Psychiatry/Sleep Medicine, Massachusetts General Hospital, Boston, MA
| | - Xiang Gao
- Harvard Medical School, Channing Division of Network Medicine, Boston, MA.,Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, and Department of Nutrition, Harvard University School of Public Health, Boston, MA.,Department of Nutritional Science, the Pennsylvania State University, University Park, PA
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Simon JP, Debout C, Bertran F, Kerouanton A, Schaeffer S, Chapon F. Restless legs syndrome associated with exercise intolerance: Data from a retrospective observational clinical neuromuscular center study. Rev Neurol (Paris) 2013; 169:663-9. [PMID: 24011981 DOI: 10.1016/j.neurol.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 04/26/2013] [Accepted: 05/23/2013] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- J-P Simon
- Service de médecine physique et réadaptation, Côte de Nacre, centre de compétences des pathologies neuromusculaires, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France
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Aras G, Kadakal F, Purisa S, Kanmaz D, Aynaci A, Isik E. Are we aware of restless legs syndrome in COPD patients who are in an exacerbation period? Frequency and probable factors related to underlying mechanism. COPD 2012; 8:437-43. [PMID: 22149404 DOI: 10.3109/15412555.2011.623737] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A few previous studies have reported that the patients with chronic obstructive pulmonary disease (COPD) have a 29.1% to 36.8% frequency of restless legs syndrome (RLS). In this study, we observed RLS symptoms in patients experiencing COPD exacerbation to better understand the relationship between the many clinical parameters of COPD and the presence of RLS and to attract the attention of specialists on the association between the two conditions. Twenty-two male patients in COPD exacerbation; 17 healthy individuals were evaluated in this study. The patients were evaluated using the 2003 RLS symptom criteria outlined by the International Restless Legs Syndrome Study Groups (IRLSSG). The Pittsburgh Sleep Quality Index and Epworth daytime sleepiness scale were used to assess the sleep quality of patients. The RLS symptoms were correlated with blood levels of laboratory and clinical parameters. Statistical analyses were performed using SPSS 17.0 statistical software packet. The Pittsburgh Sleep Quality Index and Epworth daytime sleepiness scale scores were increased in COPD patients and correlated significantly with RLS symptoms. It was found that 54.5% of COPD patients with acute exacerbations were observed to have RLS symptoms. The Pittsburgh Sleep Quality Index was significantly higher in COPD patients with RLS symptoms compared to COPD patients without RLS symptoms (p < 0.05). We did not observe any significant difference in the previously reported metabolic and clinical parameters associated with RLS in COPD patients with and without RLS. RLS symptoms increase during COPD exacerbation and lead to decreased sleep quality.
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Affiliation(s)
- Gulfidan Aras
- Yedikule Chest Disease and Surgery Education and Research Hospital, Istanbul, Turkey.
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:207-27. [DOI: 10.1097/spc.0b013e32833e8160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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