Restless Legs Syndrome: A common disorder, but rarely diagnosed and barely treated - an Indian experience

Chronic dizziness in restless legs syndrome (RLS) patients responsive to levodopa or dopamine agonists

Apart from the legs, restless legs syndrome (RLS) also affects the arms, head, neck, face, oral cavity, genital area, abdomen, intestines and bladder. RLS is also linked to several comorbid diseases, including headache disorders. Its association with dizziness has never been explored. We are reporting on two patients with RLS who also had a history of chronic dizziness. The treatment with levodopa or dopamine agonists completely alleviated both RLS and dizziness. We propose that RLS-like symptoms in the head may be experienced as dizziness and that dizziness may be part of the symptom complex of RLS. A large number of patients with chronic dizziness remain undiagnosed in clinical practice. We suggest exploring the history of RLS in patients presenting with chronic dizziness. Such patients may respond to levodopa or dopamine agonists. Because the response was seen in only two patients, a prospective placebo-controlled trial is needed to confirm these findings.

Prevalence and clinical correlates of restless legs syndrome in psychiatric patients: A cross-sectional study from North India

Background

Restless legs syndrome (RLS) is a neuro-sensorimotor disorder which is scarcely researched and is commonly missed in routine psychiatry practice.

Aim

To evaluate the prevalence of RLS and its correlates in patients with anxiety, depression, and somatoform disorders.

Methods

A cross-sectional single-center study was undertaken in patients aged 18-65 years suffering from ICD-10 (International Statistical Classification of Diseases-10th edition) diagnosis of anxiety, depressive, and somatoform disorders. RLS was evaluated by using diagnostic criteria of International Restless Legs Syndrome Study Group (IRLSSG) and severity measured on IRLSSG scale. Depression and anxiety were rated on Hamilton Depression and Anxiety Rating Scales respectively, insomnia severity measured by Insomnia Severity Index (ISI), and quality of life measured by WHO Quality of Life-Brief version (WHO-QOL BREF) scale. Serum ferritin levels were measured for evaluating iron deficiency.

Results

The rate of RLS was 66.7%, 50%, and 48% in patients with depressive, anxiety, and somatoform disorders, respectively, with no significant inter-group difference. Nearly one-third of patients suffered from severe to very severe symptoms of RLS, and quality of life was poorest in those with depressive disorders. RLS was significantly higher in females (P = 0.019), who were married (P = 0.040), diagnosed with severe depression (P = 0.029), and abused benzodiazepines (P = 0.045). On binary logistic regression, female gender and presence of clinical insomnia predicted occurrence of RLS.

Conclusion

The prevalence of RLS is very high in patients with common psychiatric disorders which is often missed. Clinical enquiry and examination for reversible causes such as iron deficiency may assist in its diagnosis and improve clinical outcome.

Modification and Validation of a Diagnostic Questionnaire for Restless Legs Syndrome: Modified-Restless Legs Syndrome Diagnostic Questionnaire (m-RLS-DQ)

Background

Diagnostic questionnaire that are available for restless legs syndrome does not include items related to RLS mimics and, hence, increases chances of false positive cases. This study aimed at modification and validation of RLS-diagnostic Questionnaire.

Methods

During modification, additional items were identified, developed, and subjected to evaluation by experts. Experts were requested to validate the content of each item. Based on their responses, content validity indices (average and universal agreement) were calculated. It was then translated to Hindi and validated in a clinical population that included patients with RLS, somatic symptoms disorder, anxiety, other RLS mimics, and osteoarthritis. In addition, a group of healthy controls was also included. Face, concurrent, and discriminant validities were calculated.

Results

Among 209 subjects, nearly 40 subjects had clinical diagnosis of RLS, osteoarthritis, somatic-symptoms-disorder, and anxiety disorder, each. In addition, 16 patients had other RLS mimics (akathisia, varicose veins, BFS, leg-cramps, chronic insomnia) and 30 were healthy controls. After multiple revisions, content validity indices achieved a score of 1 for m-RLS-DQ. Sensitivity and specificity of m-RLS-DQ v. 1.4 for the diagnosis of RLS were 94.9% and 94.1%, respectively. For the diagnosis of RLS, PPV was 78.7%, and NPV was 98.7% with an accuracy of 94.3%. Less than one fourth of participants having chronic insomnia, somatic symptoms disorder, anxiety disorder, and knee osteoarthritis were found to be false positive on m-RLS-DQ; however, none of the healthy controls were found positive on m-RLS-DQ. Concurrent validity with clinical diagnosis of RLS was 0.83 (P < 0.001). Discriminant validity with somatic symptoms disorder was -0.14 (P = 0.03) and with osteoarthritis -0.24 (P < 0.001).

Conclusion

m-RLS-DQ is a valid instrument with acceptable psychometric properties, which can be used for the screening as well as diagnosis of RLS in clinical practice and research studies.

Restless Legs Syndrome across the Lifespan: Symptoms, Pathophysiology, Management and Daily Life Impact of the Different Patterns of Disease Presentation

Restless legs syndrome is a common but still underdiagnosed neurologic disorder, characterized by peculiar symptoms typically occurring in the evening and at night, and resulting in sleep disruption and daily functioning impairment. This disease can affect subjects of all age ranges and of both sexes, manifesting itself with a broad spectrum of severity and deserving special attention in certain patient categories, in order to achieve a correct diagnosis and an effective treatment. The diagnosis of restless legs syndrome can be challenging in some patients, especially children and elderly people, and an effective treatment might be far from being easy to achieve after some years of drug therapy, notably when dopaminergic agents are used. Moreover, the pathophysiology of this disorder offers an interesting example of interaction between genetics and the environment, considering strong iron metabolism involvement and its interaction with recognized individual genetic factors. Therefore, this syndrome allows clinicians to verify how lifespan and time can modify diagnosis and treatment of a neurological disorder.

Sleep and sleep disorders in pregnancy

Pregnancy is associated with a number of physiologic changes in the body including hormonal, anatomical, and mechanical. These changes alter many physiologic functions including sleep. The literature suggests that a number of women develop changes in duration, pattern, and quality of sleep during pregnancy. In addition, these changes also pave the way for expression of sleep disorders (e.g., insomnia, obstructive sleep apnea, and restless legs syndrome). Change in sleep and appearance of sleep disorders not only influence pregnant women, but also have negative influences on the fetus and outcomes of pregnancy. However, optimal management of these disorders may reverse adverse consequences. In this chapter, risk factors, clinical presentation, and management of insomnia, obstructive sleep apnea, and restless legs syndrome during pregnancy are discussed in view of the available literature.

Is Restless Legs Syndrome Associated with an Increased Risk of Mortality? A Meta-Analysis of Cohort Studies

Background

Restless legs syndrome (RLS) is a common sleep disorder,. although controversial, growing evidence relates the presence of RLS to an increased risk of mortality, mainly due to cardiovascular events. The aim of this article was to review the role of RLS as a risk factor of mortality according to independent cohort studies.

Methods

We performed a literature review via PubMed database for articles relating RLS and mortality. We used the random-effects model to calculate the pooled effect estimates on mortality. Heterogeneity between studies was assessed using quantitative and qualitative analysis.

Results

Out of 100 articles identified, 13 were finally included. Although studies were heterogeneous (p = 0.001), no significant publication bias was found. When all cohort studies were considered, the random-effects model yielded a significantly increased risk of mortality in RLS versus non-RLS patients (13 studies, hazard ratio [HR] = 1.52, 95% confidence interval [CI] 1.28-1.80). However, this association was not statistically significant when only cohort studies using the international RLS diagnostic criteria were considered (5 studies, HR = 1.63, 95% CI 0.94-2.81).

Discussion

The results of this meta-analysis suggest that RLS seems to be a risk factor of mortality, although this association is conditioned by the diagnostic criteria used in the studies. Future long-term follow-up standardized mortality studies are needed to address this important question that carries potential impact on population global health.

Comorbidities, treatment, and pathophysiology in restless legs syndrome

Restless legs syndrome, also known as Willis-Ekbom disease, is a common neurological condition whose manifestation is affected by complex environmental and genetic interactions. Restless legs syndrome can occur on its own, mostly at a young age, or with comorbidities such as cardiovascular disease, diabetes, and arterial hypertension, making it a difficult condition to properly diagnose. However, the concept of restless legs syndrome as being two entities, primary or secondary to another condition, has been challenged with genetic data providing further insight into the pathophysiology of the condition. Although dopaminergic treatment was formerly the first-line therapy, prolonged use can result in a serious worsening of symptoms known as augmentation. Clinical studies on pregabalin, gabapentin enacarbil, oxycodone-naloxone, and iron preparations have provided new treatment options, but most patients still report inadequate long-term management of symptoms. Studies of the hypoxic pathway activation and iron deficiency have provided valuable information about the pathophysiology of restless legs syndrome that should now be translated into new, more effective treatments for restless legs syndrome.

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.

Nerve Decompression and Restless Legs Syndrome: A Retrospective Analysis

Introduction

Restless legs syndrome (RLS) is a prevalent sleep disorder affecting quality of life and is often comorbid with other neurological diseases, including peripheral neuropathy. The mechanisms related to RLS symptoms remain unclear, and treatment options are often aimed at symptom relief rather than etiology. RLS may present in distinct phenotypes often described as “primary” vs. “secondary” RLS. Secondary RLS is often associated with peripheral neuropathy. Nerve decompression surgery of the common and superficial fibular nerves is used to treat peripheral neuropathy. Anecdotally, surgeons sometimes report improved RLS symptoms following nerve decompression for peripheral neuropathy. The purpose of this retrospective analysis was to quantify the change in symptoms commonly associated with RLS using visual analog scales (VAS).

Methods

Forty-two patients completed VAS scales (0–10) for pain, burning, numbness, tingling, weakness, balance, tightness, aching, pulling, cramping, twitchy/jumpy, uneasy, creepy/crawly, and throbbing, both before and 15 weeks after surgical decompression.

Results

Subjects reported significant improvement among all VAS categories, except for “pulling” (P = 0.14). The change in VAS following surgery was negatively correlated with the pre-surgery VAS for both the summed VAS (r = −0.58, P < 0.001) and the individual VAS scores (all P < 0.01), such that patients who reported the worst symptoms before surgery exhibited relatively greater reductions in symptoms after surgery.

Conclusion

This is the first study to suggest improvement in RLS symptoms following surgical decompression of the common and superficial fibular nerves. Further investigation is needed to quantify improvement using RLS-specific metrics and sleep quality assessments.

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 in Egyptian medical students using a validated Arabic version of the Restless Legs Syndrome Rating Scale

OBJECTIVE

Restless legs syndrome (RLS) is a common movement disorder that has a variable prevalence and impact reported from different countries and specific populations. The current study validated an Arabic version of the International Restless Legs Syndrome Study Group (IRLSSG) rating scale (IRLS) and investigated the prevalence and impact of RLS in medical students at Ain Shams University in Cairo.

METHODS

Translation of IRLS was done according to standard recognized guidelines provided by the publisher. A total of 389 medical students (217 female and 172 male) participated in the study and answered four questions to detect RLS as proposed by the IRLSSG. Subjects who answered positively the first three questions were recruited for face-to-face interview to exclude RLS mimics and to answer the IRLS.

RESULTS

A total of 46 subjects (11.8%; 27 female and 19 male) met the four criteria for RLS. Of these, 39 subjects (10%) had idiopathic RLS. Five subjects (1.3%) and two subjects (0.5%) reported association with history of anemia and diabetes mellitus respectively. Their mean total IRLS score was 16.33 ± 5.3, with moderate severity (11.62 ± 3.9) and low impact (3.1 ± 1.8). The prevalence of individuals who had two or more episodes of RLS of at least moderate severity per week was 5.9%.

CONCLUSION

In this specific population of Egyptian medical students, a within-average prevalence of RLS was found with low impact on quality of life similar to worldwide reported populations. RLS sufferers were of high prevalence among this cohort. The Arabic version of IRLS is reliable and valid for further research in Arabic countries.

What patients do to counteract the symptoms of Willis-Ekbom disease (RLS/WED): Effect of gender and severity of illness

Objectives:

This study was carried out to assess different counteracting strategies used by patients with idiopathic Willis-Ekbom disease (RLS/WED). Whether these strategies were influenced by gender or disease severity was also assessed.

Materials and Methods:

A total of 173 patients of idiopathic RLS/WED were included in this study. Their demographic data was recorded. Details regarding the RLS/WED and strategies that they used to counteract the symptoms were asked. The severity of RLS/WED was measured with the help of the Hindi version of international restless legs syndrome severity rating scale. They were asked to provide the details regarding the relief obtained from all the strategies they used on three-point scale: no relief, some relief, and complete relief.

Results:

Of the patients, 72% were females. Mean age of the subjects in this study was 39.6 ± 12.6 years, and male subjects were older than females. Four common strategies were reported by the patients to counter the sensations of RLS/WED: moving legs while in bed (85.5%), asking somebody to massage their legs or massaging legs themselves (76.9%), walking (53.2%), and tying a cloth/rope tightly on the legs (39.3%). Of all the patients who moved their legs, 6.7% did not experience any relief, 64.2% reported some relief, and 28.4% reported complete relief. Similarly, of all the patients who used “walking” to counteract symptoms, 50% reported complete relief, 44.5% reported some relief, and the rest did not experience any relief. Many of these patients reported that massage and tying a cloth/rope on legs brought greater relief than any of these strategies. Tying cloth on the leg was more common among females as compared to males (45.9% females vs. 23.5% males; χ² = 7.54; P = 0.006), while patients with moderately severe to severe RLS/WED reported “moving legs in bed” (79.3% in mild to moderate RLS/WED; 91.8% in severe to very severe RLS; χ² = 5.36; P = 0.02).

Conclusion:

Patients with RLS/WED use a variety of strategies to counteract symptoms. These strategies may be influenced by gender, disease severity, and cultural practices.

Restless leg syndrome in diabetics compared with normal controls

Introduction. Restless leg syndrome (RLS) is a common sleep disorder which is characterized by urge to move the legs accompanied by disturbing and uncomfortable leg sensation during night and rest. This common condition affects 7–10% of general population and is frequently unrecognized, misdiagnosed, and poorly managed. Several clinical conditions like diabetes have been associated with secondary form of RLS. This study analyzed the frequency and possible risk factor for RLS development in diabetic patient. Material and Methods. This descriptive case-control study was done on 140 consecutive outpatient diabetics and age, sex, and body mass index matched control group. RLS was diagnosed by criteria of the International RLS Study Group. Results. Prevalence of RLS was 28.6% in diabetes and 7.1% in control group (P = 0.001). Sex difference was not significant and with rising duration of diabetes prevalence of RLS was not increased. Discussion. With regarding significant association between RLS and diabetes and its negative impact on quality of life/health outcome/sleep/daytime activity/cognitive function/ and mental state of diabetic patient/higher awareness of RLS among physicians and related health worker suggested.

Demographic and clinical characteristics of patients with restless legs syndrome in spine clinic

Objective

The restless legs syndrome (RLS) is a common disorder affecting up to 5% to 15% of the general population, in which the incidence increases with age, and includes paresthesia in the legs. The purpose of this study is to investigate the incidence of RLS in spine center and to review clinical manifestations of this syndrome and its current treatments.

Methods

Over a period of a year, retrospective medical record review and lumbar magnetic resonance images were performed on 32 patients with RLS in spine clinic who were diagnosed by National Institutes of Health criteria. Affected limbs were classified as five. Two grading systems were used in the evaluation of neural compromises.

Results

The incidence of RLS was 5.00% (32/639). There were 16 males (50%) and 16 females (50%). The median age at diagnosis was 55.4 years (range, 25-93 years). There are no correlation between the affected limbs of RLS and neural compromises on the lumbar spine.

Conclusion

The RLS is a clearly common neurologic disorder of the limbs, usually the legs. The awareness of this syndrome can help reduce diagnostic error; thereby, avoiding the morbidity and expense associated with unnecessary studies or inappropriate treatments in RLS patients.

Restless Eating, Restless Legs, and Sleep Related Eating Disorder

Restless legs syndrome (RLS) often presents with a primary complaint of sleep initiation difficulty with only ambiguous allusions to motor symptoms. This may result in the condition being misdiagnosed as a psychophysiological insomnia. Further, nocturnal eating is common in RLS and like the classic motor symptoms, patients will describe an inability to initiate sleep until their urge (to eat) is addressed. Restless nocturnal eating arises, intensifies, and subsides in parallel to motor symptoms. Once misdiagnosed as psychophysiological insomnia, RLS patients are frequently treated with benzodiazepine receptor agonists. The CNS actions of these sedating agents, suppression of memory and executive function, unleash predisposed amnestic behaviors. In the case of RLS this would be expected to include the inappropriate ambulatory and eating behaviors of sleep related eating disorder (SRED). The evidence and implications of a link between the restless eating of RLS and SRED is presented here.

A study examining depression in restless legs syndrome

BACKGROUND

Distress is known to occur in RLS subjects consequent to symptoms. However, studies regarding prevalence of depression in RLS are scarce. This study was conducted to find out prevalence of depression in RLS patients and to explore possible underlying factors.

METHOD

112 consecutive RLS subjects presenting to sleep-clinic were included in this study. History regarding RLS, depression and sleep-disturbances was sought. Depression and insomnia were diagnosed using DSM-IV-TR criteria. Subjects were specifically asked whether they had depressive episodes in past one year. Severity of RLS and insomnia was measured using Hindi versions of IRLS and ISI, respectively. Family history of depression and RLS was also asked.

RESULTS

One year prevalence of depression was 41.8%. MDD was reported by 33% and dysthymia by 8.8%. Both the groups were comparable with respects to demographic and clinical features, viz., age, gender, duration, severity and family history of RLS. Duration, number of episodes and severity of insomnia were comparable between groups, so was the family history of depression. In 37.8% of the subjects with MDD, depressive symptoms preceded RLS while in 51.4% of them, they followed onset of RLS. Total duration of RLS symptoms did not correlate with total duration of depression (r(2)=0.07; P=0.64).

CONCLUSION

Clinical depression is seen in more than a third of RLS patients. Depression is not affected by clinical picture of RLS and it is not consequent to sleep disturbance. Perhaps, it is a co-morbid condition.