Restless Legs Syndrome

Cognitive behavioral therapy for insomnia in restless legs syndrome patients

OBJECTIVES

The purpose of this study was to investigate the effects of cognitive behavioral therapy for insomnia (CBTI) in patients with Restless Legs Syndrome (RLS).

METHODS

This is a randomized controlled study. The patients were sequentially selected and randomly assigned to either a CBTI group or a non-CBTI group. A total of 25 RLS patients with comorbid insomnia were recruited from a tertiary university hospital sleep center. Twelve were assigned to the CBTI group, and 13 were assigned to the non-CBTI group. The CBTI group received 4 sessions of behavioral therapy, while the non-CBTI group received one informative session on sleep hygiene. All patients completed sleep and psychiatric-related questionnaires. In addition, each individual completed a one-week sleep log for collecting subjective sleep data and actigraphy for objective sleep data.

RESULTS

After conducting the CBTI, there were significant improvements in severity of insomnia symptoms, subjective sleep efficiency, total sleep time, latency to sleep onset, wake after sleep onset, objective latency to sleep onset, and anxiety in the CBTI group as compared to the non-CBTI group. The effect of CBTI on sleep-related data was maintained for up to three months.

CONCLUSIONS

CBTI was effective in RLS patients by improving sleep quality and anxiety symptoms. CBTI may be considered in clinical practice for RLS patients with comorbid insomnia.

A critical review of self-care for sleep disturbances: prevalence, profile, motivation, perceived effectiveness and medical provider communication

Objective

This study aims to undertake the first critical review of self-care use among adults with sleep disturbances by focusing on the prevalence of self-care—the self-determined and self-administered use of products or practices—by adults with sleep disturbances.

Methods

A comprehensive search of 2006–2016 international literature in CINAHL, AMED, Medline and EMBASE databases was conducted. The search was confined to empirical research findings regarding sleep disturbances - as indicated by a validated sleep scale/index or clinician diagnosis.

Results

Of the 21 articles included in this review, only three reported on sleep disturbances other than insomnia disorder (ID) or insomnia symptoms (IS). Overall, a high prevalence of self-care use is reported among adults with sleep disturbances, particularly for ID and IS. Self-care products and practices are more likely to be used by adults with sleep disturbances, than those without sleep disturbances. Commonly used self-care products and practices include OTC hypnotics, antihistamines, diphenhydramine products, diet, exercise, painkillers, herbal medicines, vitamins, minerals and dietary supplements, yoga, tai chi, Qigong, meditation, exercise and relaxation.

Conclusions

Many adults with sleep disturbances–particularly ID or IS–frequently use self-care products and practices. Self-care products are also used concomitantly with conventional prescription medications without disclosure to medical professionals. The current literature is of varied methodological caliber, frequently relies on small sample sizes and low-quality data collection therefore further rigorous health services research is required. There is an especial paucity of data regarding self-care for sleep disturbances such as restless legs syndrome and obstructive sleep apnea. Healthcare providers may find it beneficial to actively ask patients about their use of self-care for sleep disturbances to help avoid harmful drug-drug or drug-herb interactions.

Restless legs syndrome and quality of life in pregnant women

OBJECTIVE

In this study, we aimed to determine the extent of restless legs syndrome (RLS) in pregnant women and evaluate the relationship between the syndrome and quality of life.

METHODS

This is a cross-sectional descriptive study. A questionnaire developed by the researcher, the Short Form 36 (SF-36) Questionnaire to measure the quality of life, the International Restless Legs Syndrome Study Group (IRLSSG) Diagnostic Criteria for RLS and the Restless Legs Syndrome Rating Scale were applied to the women to collect the data. A total of 250 pregnant women were included in the study.

RESULTS

The mean age of the women was 28.11 ± 5.59 years and the mean gestational time was 26.26 ± 10.72 weeks. Symptoms of RLS were seen in 46.4 % of the women. The mean for the RLS Violence Rating Score was 20.82 ± 6.61 for the women with RLS. RLS was found to be mild in 5.2 % of the women, moderate in 45.7 %, severe in 40.5 % and very severe in 8.6 %. A statistically significant effect of RLS survival on quality of life was observed.

CONCLUSION

These results indicate that almost half of the pregnant women in this study experienced RLS, and about half of those with RLS experienced severe or very severe RLS. There is a significant relationship between RLS and six domains of SF-36 (physical, role limitations, pain, general health perception, energy/vitality, and mental health).

Neuroendocrine Control of Sleep

Sleep is a phenomenon in animal behavior as enigmatic as it is ubiquitous, and one deeply tied to endocrine function. Though there are still many unanswered questions about the neurochemical basis of sleep and its functions, extensive interactions have been identified between sleep and the endocrine system, in both the endocrine system's effect on sleep and sleep's effect on the endocrine system. Unfortunately, until recent years, much research on sleep behavior largely disregarded its connections with the endocrine system. Use of both clinical studies and rodent models to investigate interactions between neuroendocrine function, including biological sex, and sleep therefore presents a promising area of further exploration. Further investigation of the neurobiological and neuroendocrine basis of sleep could have wide impact on a number of clinical and basic science fields. In this review, we summarize the state of basic sleep biology and its connections to the field of neuroendocrine biology, as well as suggest key future directions for the neuroendocrine regulation of sleep that may significantly impact new therapies for sleep disorders in women and men.

The relationship between restless legs syndrome and bronchial asthma

INTRODUCTION

Restless legs syndrome (RLS) is associated with sleep disorders. However, although sleep disturbance is prevalent in people with asthma, an insufficient number of studies have investigated the relationship between asthma and RLS.

OBJECTIVES

We aimed to determine the extent of the presence of RLS, and the factors related to RLS, in people with asthma.

METHODS

A total of 84 people with asthma and 51 healthy volunteers were enrolled. The diagnosis of RLS was made according to the criteria determined by the International Restless Legs Syndrome Study Group, and the Beck Depression and Beck Anxiety scales were used to assess both groups. The Asthma Control Test™(ACT) was carried out to determine asthma control status.

RESULTS

RLS was detected in 27 (32.1%) of the asthma group and in 8 (15.7%) of the control group. The frequency of RLS was significantly higher in the asthma group than in the control group (P = .034). Although no significant relationship was observed between the presence of RLS and the use of an inhaled steroid, use of a β2 agonist and age; a significant relationship was found between the presence of RLS and, ACT score, symptoms of depression and anxiety and gender (P < .05).

CONCLUSIONS

RLS was more frequent in people with asthma than in healthy individuals, and as asthma control decreased, frequency of RLS increased. It was concluded that it would be useful to evaluate people with asthma, particularly those with symptoms of depression and anxiety, with regard to RLS in order to address, and ultimately improve, their quality of life.

Towards quantitative cutoffs for insomnia: how current diagnostic criteria mischaracterize remission

OBJECTIVE

Although sleep symptoms of insomnia can be quantified, none of the current diagnostic systems stipulate quantitative cutoffs for sleep-onset latency (SOL) or wake time after sleep onset (WASO). Diagnoses are based instead on idiographic patient reports of "difficulty" falling/staying asleep. Therefore, we examined whether remission of insomnia as per the diagnostic criteria results from a normalization of quantitative sleep disturbance, or if it is simply reflective of tolerance to sleep symptoms.

METHODS

This study involved a yearlong prospective investigation of 649 adults (48.1 ± 11.6 years; 69.3% female) with DSM-5-based insomnia. Participants completed measures of sleep disturbance, perceived sleep-related distress, daytime sleepiness, functional impairment, and workplace productivity at baseline and follow-up one year later.

RESULTS

A total of 271 participants no longer met the DSM-5-based insomnia criteria at follow-up. However, 66% of these remitters reported ≥31 min of SOL and/or WASO. Daytime impairment in this subgroup of remitters was no different from that among individuals who met the diagnostic criteria at both baseline and follow-up (ie, chronic insomniacs). By contrast, follow-up impairment was significantly lower (F = 12.3; P < 0.01) among remitters whose sleep disturbance returned below empirically derived quantitative cutoffs (both SOL and WASO <31 min) than in chronic insomniacs.

CONCLUSION

This is the first study on the long-term course of insomnia based on the newly established DSM-5 criteria. A troubling implication of findings is that a majority of insomniacs stop meeting the diagnostic criteria despite continued sleep disturbance and impairment. "Remission" in these cases is attributable instead to tolerance of sleep symptoms. Incorporating quantitative criteria into current diagnoses may offer a more sensitive assay of treatment needs.

Restless Legs Syndrome During Pregnancy and Preterm Birth in Women Referred to Health Centers of Ardabil

Background:

The physiological changes of pregnancy may predispose females to develop restless legs syndrome (RLS). Studies evaluating outcomes of RLS symptoms in pregnancy are scarce.

Objectives:

We examined the risk of preterm birth in pregnant women with and without restless legs syndrome (RLS).

Materials and Methods:

A cohort study included 231 pregnant women attending Ardabil health care centers for prenatal care and delivery in the period of 2010, without any risk factors for preterm delivery and low birth weight. The instruments used were questionnaires about RLS, the Epworth sleepiness scale (ESS), demographic data, and hemoglobin values. Data were analyzed via SPSS software using descriptive statistics, the t-test, χ2, Fisher’s exact test, Pearson’s correlation, and the Mann-Whitney U test.

Results:

RLS complicated 43.7 percent of pregnancies. Sleepiness (ESS score > 8) was reported in 36.4% of the subjects with preterm birth and 35.9% of the term group. No significant correlation was found between the ESS score and the term and preterm groups (P = 0.843). The prevalence of preterm birth in the subjects with and without RLS was 69.7% and 30.3%, respectively: As a result, it significantly increased in the RLS group (P = 0.001).

Conclusions:

Pregnancies complicated by RLS are at increased risk for preterm birth. The improved sleep health of pregnant women could decrease pregnancy complications.

Restless Legs Syndrome/Willis-Ekbom Disease and Growing Pains in Children and Adolescents

Recent studies have shown that restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are common in pediatric population. The diagnostic criteria for Pediatric RLS have recently been updated to simplify and integrate with newly revised adult RLS criteria. Management of RLS and PLMD involves pharmacologic and nonpharmacologic interventions. Children with low iron storage are likely to benefit from iron therapy. Although, there is limited information on pharmacologic therapy, there are emerging literatures showing the effectiveness of dopaminergic medications in the management of RLS and PLMD in children. This article covers clinical evaluation of RLS and PLMD in children and the relationship with growing pains.

The nature of stable insomnia phenotypes

STUDY OBJECTIVES

We examined the 1-y stability of four insomnia symptom profiles: sleep onset insomnia; sleep maintenance insomnia; combined onset and maintenance insomnia; and neither criterion (i.e., insomnia cases that do not meet quantitative thresholds for onset or maintenance problems). Insomnia cases that exhibited the same symptom profile over a 1-y period were considered to be phenotypes, and were compared in terms of clinical and demographic characteristics.

DESIGN

Longitudinal.

SETTING

Urban, community-based.

PARTICIPANTS

Nine hundred fifty-four adults with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition based current insomnia (46.6 ± 12.6 y; 69.4% female).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

At baseline, participants were divided into four symptom profile groups based on quantitative criteria. Follow-up assessment 1 y later revealed that approximately 60% of participants retained the same symptom profile, and were hence judged to be phenotypes. Stability varied significantly by phenotype, such that sleep onset insomnia (SOI) was the least stable (42%), whereas combined insomnia (CI) was the most stable (69%). Baseline symptom groups (cross-sectionally defined) differed significantly across various clinical indices, including daytime impairment, depression, and anxiety. Importantly, however, a comparison of stable phenotypes (longitudinally defined) did not reveal any differences in impairment or comorbid psychopathology. Another interesting finding was that whereas all other insomnia phenotypes showed evidence of an elevated wake drive both at night and during the day, the 'neither criterion' phenotype did not; this latter phenotype exhibited significantly higher daytime sleepiness despite subthreshold onset and maintenance difficulties.

CONCLUSIONS

By adopting a stringent, stability-based definition, this study offers timely and important data on the longitudinal trajectory of specific insomnia phenotypes. With the exception of daytime sleepiness, few clinical differences are apparent across stable phenotypes.

Restless legs syndrome: an underappreciated and distressing problem for haemodialysis patients

Restless legs syndrome is a distressing condition that is more common in patients with end-stage renal failure. Despite the significant impact it has on quality of life and the documented association between restless legs syndrome and increased mortality, limited data regarding the epidemiology of restless legs syndrome in Australian dialysis patients are available. We report a prospective study that assessed the prevalence and factors associated with restless legs syndrome in an in-centre haemodialysis population.

Restless legs syndrome as the initial presentation of multiple sclerosis

The restless legs syndrome (RLS) is a common central nervous system disorder. It is characterized by complaints of unpleasant sensation in the legs occurring during periods of leg inactivity which worsen or only occur in the evening or at night and relieved partially or totally by movement. The RLS may be idiopathic or due to secondary causes. It is associated with several pathological or physiological conditions. Iron metabolism and dysfunctions of the dopaminergic system are the most important factors in the pathophysiology. There are several studies suggesting multiple sclerosis as one of the causes of symptomatic RLS. Here, we report a case of RLS as the initial presentation of MS. The sudden onset of RLS symptoms in our patient suggested the possibility of an underlying cause. His diagnostic evaluation excluded other causes of RLS and his clinical course suggested that RLS was due to MS. MS with the spinal cord involvement is mostly associated with RLS, but any lesion in the hypothalamic-spinal connection may cause disinhibition of lower spinal levels, resulting in RLS. RLS as the initial presentation of MS reflects that the pathophysiology of RLS in MS is related to inflammatory demyelination rather than axonal degeneration.

Approach to and evaluation of sleep disorders

PURPOSE OF REVIEW

This article provides a framework for the clinical assessment of patients with sleep-related complaints and outlines a systematic approach to a sleep-specific history and physical examination, subjective assessment tools, and diagnostic testing modalities.

RECENT FINDINGS

Physical examination findings may suggest the presence of a sleep disorder, and obstructive sleep apnea in particular, but the clinical history remains the most important element of the assessment for most sleep problems. While nocturnal polysomnography in a sleep laboratory remains the gold standard for diagnosis of sleep-disordered breathing, out-of-center testing may be considered when the clinician has a high pretest suspicion for obstructive sleep apnea and the patient has no significant cardiopulmonary, neuromuscular, or other sleep disorders.

SUMMARY

Sleep-related symptoms are common in adult and pediatric patients. A comprehensive sleep history, physical examination with detailed evaluation of the head and neck, and judicious use of sleep-specific questionnaires guide the decision to pursue diagnostic testing. Understanding of the benefits and limitations of various diagnostic modalities is important as the spectrum of testing options increases.

Diseases in patients coming to a sleep center with symptoms related to restless legs syndrome

Study Objective

To explore the profile of patients who visit a sleep center with symptoms that fulfill the four essential criteria for restless legs syndrome (RLS).

Design

A prospective study.

Setting

Outpatients from one sleep disorders clinic in Taiwan.

Participants

1,200 consecutive patients visit sleep disorders clinic with any sleep complaints.

Interventions

After completing a history and physical examination, all participants answered the RLS questionnaire. Subjects who fulfilled the four essential criteria for RLS were referred to a special clinic. A work-up including blood tests, polysomnography, and specialized neurological tests etc. was performed to make the final diagnosis.

Measurements and Results

A total of 1,185 participants were enrolled, and, of these, 131(11.1%) fulfilled the four essential criteria for RLS, and 121 completed the supplemental work-up. Their mean age was 47.6±13.3 and 52.9% were male. Insomnia and snoring were the most common chief complaints. Obstructive sleep apnea syndrome and other diseases were found in 103 patients. Only 18 (14.9%) patients had no comorbid condition and were diagnosed with primary RLS.

Conclusions

Symptoms of RLS are common in patients with sleep complaints. Even in a sleep clinic, using a questionnaire approach for identification of RLS has a low positive predictive value. Clinicians should pay attention to the limitations of the 4-item questionnaire in diagnosis of RLS and also the importance of a careful differential diagnosis to identify possible secondary causes of RLS.

The sleep-immunity relationship

Research models show a strong interrelationship between sleep quality and immune function. The proinflammatory cytokines, interleukin-1, interleukin-6, and tumor necrosis factor α are classified as official sleep-regulatory substances. However, sleep-promoting properties are also possessed by several other immune and proinflammatory cellular classes. This article reviews the current physiologic evidence for the prominent somnogenic and sleep-regulatory properties inherent to these immune substances. Clinical examples of this relationship are discussed from the perspective of infectious and primarily immune-related conditions associated with significant sleep disruption and from the perspective of immune dysregulation associated with several primary sleep disorders.

ADMET considerations for restless leg syndrome drug treatments

INTRODUCTION

Restless legs syndrome (RLS) is a common neurological disorder that might impair nocturnal rest causing decreased alertness, depressed mood, reduced job performance, and poor quality of life. In patients affected by severe RLS, a pharmacological treatment is mandatory.

AREAS COVERED

The present review is based on a search using PubMed from 1994 to 2012. It is focused on the Absorption, Distribution, Metabolism, Elimination and Toxicology (ADMET) characteristics of the most used medications for RLS. In particular, the ADMET characteristics of dopaminergic agents, anticonvulsants able to improve neuropathic pain, and iron were discussed.

EXPERT OPINION

Clinical trials have showed that non-ergolic dopamine agonists are efficacious and safe for patients affected by moderate to severe idiopathic RLS. However, no head-to-head study has compared the long-term effects of the three dopamine agonists approved by the FDA for RLS (ropinirole, pramipexole, and rotigotine). Moreover, further studies should investigate the extended-release formulation of ropinirole and pramipexole in RLS patients affected by all day long distressing symptoms. A standardized treatment for symptomatic forms of RLS is lacking. Randomized, placebo-controlled trials should be performed at least in RLS patients with peripheral neuropathic and chronic kidney disease. Concerning RLS due to iron deficiency, a head-to-head study comparing efficacy, safety and compliance of oral iron versus intravenous one seems to be needed.

Should we screen for iron deficiency anaemia? A review of the evidence and recent recommendations

Worldwide, over 1.6 billion people are anaemic. The prevalence of anaemia and contribution of iron deficiency to this burden is heterogeneous between different populations. Iron deficiency anaemia (IDA) is associated with impaired development in children, adverse effects on cognitive and physical performance in adults, and poorer maternal and infant outcomes in pregnancy. Causes of anaemia other than iron deficiency are important in developed countries and where malaria, thalassaemia or haemoglobinopathy are prevalent. Haemoglobin is the most commonly used screening test for iron deficiency, but may have inadequate sensitivity and specificity to determine iron status in many settings. Screening for anaemia during pregnancy is widely recommended. In children, studies evaluating screening programs have found problems with implementation, acceptability and follow-up of testing, and most international authorities do not support this practice. Nevertheless, certain groups with a particularly high pre-test probability of IDA may benefit from testing following clinical evaluation. Further research is required to define the role of screening and improve available tests for IDA in both developed and developing settings. In this review, the rationale, evidence, experience and expert guidelines regarding screening for IDA, especially among pregnant and paediatric populations, will be evaluated.

Role of gabapentin enacarbil XR in restless legs syndrome

Gabapentin enacarbil XR is a new extended-release formulation which attempts to overcome the reduced efficacy of shorter-acting gabapentin, with sustained delivery over a 24-hour period. It is a gabapentin prodrug which is efficiently and rapidly converted to gabapentin during active transport throughout the length of the intestine via high-capacity monocarboxylate type 1 nutrient transporters unlike its predecessor, which is absorbed via low-capacity transporters largely confined to the upper intestinal region. Its lack of saturable absorption allows for dose-proportional absorption and hence increased bioavailability. Several clinical trials addressing its efficacy in moderate to severe restless legs syndrome (RLS) demonstrate improvements in the International RLS Rating Scale after a 2-week to 3-month period. Open-label studies of 52 weeks' duration showed maintenance of symptom reduction with once-daily administration of the extended-release formulation. The most commonly reported treatment-emergent adverse effects were somnolence and dizziness. Although the incidence of emergent adverse effects is high, it is comparable with that of gabapentin. No studies thus far have documented augmentation as an issue, unlike that observed with most dopaminergic agents. In addition, both dopamine precursors and agonists have not been shown to increase slow wave sleep or improve overall sleep architecture consistently despite improvement in the periodic leg movement index, in contrast with gabapentin enacarbil. Presently, gabapentin enacarbil has not been approved by the Therapeutic Goods Administration or Medsafe for use in RLS. The cost of this medication may also be a potential barrier for many patients. Future comparative efficacy studies with gabapentin, first-line dopaminergic agents, rotigotine, being the other once daily RLS medication, and pregabalin, the structural analog of gabapentin, will be necessary.

'You never told me I would turn into a gambler': a first person account of dopamine agonist--induced gambling addiction in a patient with restless legs syndrome

Dopaminergic agents are commonly used and effective treatments for restless legs syndrome (RLS), a disabling sensorimotor disorder. Less known are some of the potentially disabling side effects of these treatments, particularly iatrogenic gambling addiction, as is described here. Here the authors present a 62-year-old man, with a 20-year history of RLS, who developed gambling addiction while on dopaminergic treatment. He was not forewarned of this side effect, nor was he ever screened for gambling behaviours prior to or during treatment. Eight months after discontinuation of dopaminergic treatment and after 10 sessions of cognitive-behavioural therapy for gambling addiction, his gambling behaviours have partially resolved. To our knowledge, this is the first ever first person account of this condition. To prevent the devastating consequences of gambling addiction or to minimise its impact by early intervention, the authors call for clinicians involved in treatment of RLS to follow these simple measures: screen patients for gambling behaviours prior to the onset and during dopaminergic treatment; forewarn patients of this potential side effect; and if patients screen positive, refer them to specialist gambling treatment services, in addition to making necessary changes to their medication regime.

Restless legs syndrome, periodic leg movements, and periodic limb movement disorder in children

The characteristic symptoms of restless legs syndrome (RLS) have been known for hundreds of years and were first reported in medicine in the 1600s. Clinicians must consider potential mimics, comorbid, and associated conditions when evaluating children with RLS symptoms. The traditional differentiation of RLS from periodic limb movement disorder (PLMD) is noted in children as well as adults. Because current pediatric RLS research is sparse, this article provides the most up-to-date evidence-based as well as consensus opinion-based information on the subject of childhood RLS and PLMD. Prevalence, pathophysiology, diagnosis, treatment, and clinical associations are discussed.

Alterations in pain responses in treated and untreated patients with restless legs syndrome: associations with sleep disruption

OBJECTIVE

There has been recent interest in characterizing potential abnormalities of pain processing in patients with sleep disorders such as Restless Legs Syndrome (RLS). The aim of this study was to evaluate psychophysical responses to noxious heat and pressure stimuli in both treated and untreated RLS patients, compared to matched controls.

METHODS

This study is a cross-sectional group comparison of RLS patients with matched controls. A total of 31 patients (15 treated, 16 untreated) with a confirmed diagnosis of RLS were compared to 18 controls with no history of RLS or related sleep disorders.

RESULTS

RLS patients (both treated and untreated) demonstrated reduced pain thresholds and reported greater clinical pain relative to controls. Moreover, RLS patients demonstrated enhanced temporal summation of heat pain (p<.05), which may reflect aberrant central nervous system facilitation of pain transmission. Both treated and untreated RLS patients reported disrupted sleep relative to controls, and mediation analyses suggested that the reduced pain thresholds in RLS were attributable to sleep disturbance. However, the effect of RLS on the magnitude of temporal summation of heat pain was independent of sleep disturbance.

CONCLUSIONS

These findings suggest that central nervous system pain processing may be amplified in RLS, perhaps partially as a consequence of sleep disruption. RLS patients, even those whose symptoms are managed pharmacologically, may be at elevated long-term risk for the development or maintenance of persistent pain conditions. Further studies in larger samples could help to improve the prospects for pain management in RLS patients.

Nondrug-related aspect of treating Ekbom disease, formerly known as restless legs syndrome

Ekbom disease (EKD), formerly known as restless legs syndrome (RLS) has affected and bothered many people over the centuries. It is one of the most prevalent neurological disorders in Europe and North-America, affecting about 10% of the population. The main characteristics are the strong urge to move, accompanied or caused by uncomfortable, sometimes even distressing, paresthesia of the legs, described as a "creeping, tugging, pulling" feeling. The symptoms often become worse as the day progresses, leading to sleep disturbances or sleep deprivation, which leads to decreased alertness and daytime functions. Numerous studies have been conducted assessing the efficacy of dopaminergic drugs, opioids, and other pharmacologic agents in alleviating EKD symptoms. However, there is also a growing body of evidence demonstrating the effectiveness of nonpharmacologic treatments including life style changes, physical activity programs, pneumatic compression, massage, near-infrared light therapy, and complementary therapies. The working mechanisms behind these alternatives are diverse. Some increase blood flow to the legs, therefore reducing tissue hypoxia; some introduce an afferent counter stimulus to the cortex and with that "close the gate" for aberrant nerve stimulations; some increase dopamine and nitric oxide and therefore augment bio-available neurotransmitters; and some generate endorphins producing an analgesic effect. The advantages of these treatments compared with pharmacologic agents include less or no side effects, no danger of augmentation, and less cost.

Update in restless legs syndrome

PURPOSE OF REVIEW

Although restless legs syndrome (RLS) is a disorder recognized in the medical literature since the 17th century, there have only recently been significant clinical and scientific advances in diagnosis, epidemiology and understanding the disorder, mainly due to the advent of dopaminergic treatment.

RECENT FINDINGS

Recent discoveries have uncovered the iron-dopamine connection in RLS and the basic dopaminergic pathology related to the RLS symptoms. These have led to new understanding of the morbidity of RLS and the many conditions associated with RLS, which have also supported new approaches to treatment. These developments are each briefly described here.

SUMMARY

Although there has been progress in understanding, diagnosing and treating RLS, it remains an underdiagnosed and undertreated condition severely impairing functioning of patients with moderate-to-severe disease. Much work is needed to improve on current, as well as other novel therapies.

Prevalence of restless legs syndrome in blood donors

Iron deficiency anemia has been linked to restless legs syndrome (RLS) and regular blood donation may lead to iron deficiency. It has been reported that blood donations may be associated with RLS. A recent study from Sweden found that 25% of the women donors were affected by RLS. However, this type of study has not been replicated in the United States. We conducted a study in our blood donation unit between September and October 2008. To identify those with RLS, we used the RLS diagnostic index questionnaire by Benes et al. The proportion of blood donors with RLS was estimated and the number of blood donations and hemoglobin levels were compared according to RLS status. One hundred and fifty one patients were interviewed; 7 patients who donated only platelets were excluded, leaving 144 patients for analysis. There were 13 (9.0%, 95% confidence interval [CI]: 4.9-14.9%) patients with RLS. Of these, 7 (4.9%, 95% CI: 2.0-9.8%) had possible RLS and 6 (4.2%, 95% CI: 1.5-8.9%) had major or clinically relevant RLS. There was no dramatic association between RLS and number of blood donations or hemoglobin level (all P >or= 0.21). In our sample of blood donors in the United States, the prevalence of major RLS was 4%. We could not demonstrate an association between RLS and the frequency of blood donation or hemoglobin level in our relatively small sample; a larger sample is needed to better identify any associations.

Excessive sleepiness: under-recognized and essential marker for sleep/wake disorder management

BACKGROUND

Research during the past few decades has provided substantial evidence indicating that excessive sleepiness (ES) and associated sleep/wake disorders can result in significant morbidity and mortality. However, symptomatology (e.g., ES) and the relationships among common morbidities (e.g., cardiovascular disease, metabolic disorders, mood impairment) and sleep/wake disorders remain under-recognized in clinical practice, particularly in primary care. Yet assessment of sleep/wakefulness and associated symptoms can often be easily conducted in the primary care setting, providing valuable information to facilitate the diagnosis and management of sleep/wake disorders.

OBJECTIVE

To provide a conceptual and educational framework that helps primary care physicians comprehensively assess, differentially diagnosis, and appropriately manage patients presenting with ES or ES-related sleep/wake disorders.

METHODS

Comprised of six sleep specialists and six primary care physicians, the Sleep/Wake Disorders Working Group (SWG) used a modified, two-round Delphi approach to create and harmonize consensus recommendations for the assessment, diagnosis, treatment, and ongoing management of patients with common sleep/wake disorders related to ES.

RESULTS

After a review of the relevant literature, the SWG arrived at consensus on a number of clinical recommendations for the assessment and management ES and some of the most commonly associated sleep/wake disorders. Ten consensus statements – five each for assessment/diagnosis and treatment/ongoing care – were created for ES, insomnia, obstructive sleep apnea, circadian rhythm disorders, restless legs syndrome, and narcolepsy.

CONCLUSION

ES and ES-related sleep/wake disorders are commonly encountered in the primary care setting. By providing an educational framework for primary care physicians, the SWG hopes to improve patient outcomes by emphasizing recognition, prompt diagnosis, and appropriate ongoing management of ES and associated sleep/wake disorders.

All the wrong moves: a clinical review of restless legs syndrome, periodic limb movements of sleep and wake, and periodic limb movement disorder

Restless legs syndrome, periodic limb movements in sleep, and periodic limb movement disorder are a group of conditions that merit awareness from the medical community. These disorders are commonly encountered yet are often confused and misdiagnosed by health care professionals. It is imperative that health care providers are able to recognize these conditions to accurately diagnose, manage, and appropriately refer patients.

Advances in the science of genomics in restless legs syndrome

Restless legs syndrome (RLS) is a sleep and movement disorder that affects up to 15% of the population across the lifespan. Many health care providers have doubted its validity as an illness and are uncertain as to the implications of health care outcomes. The cause of RLS is unknown. Common treatment options include dopaminergics, benzodiazepines, and opioids; however, the pharmacogenetic mechanisms of treatment are unknown. One of the greatest genetic discoveries in 2007 was the identification of genetic variance associated with RLS. There is, however, a lack of knowledge related to RLS and its genetic basis. Therefore, the purposes of this article are to (a) provide information about the science of clinical care related to RLS; (b) present a systematic review of the literature on the status of genetics/genomics of RLS, including the discovery of associated genetic variance; and (c) identify implications of the current state of the science for health care providers and biobehavioral researchers. With the continuing genetic discoveries in RLS, health care providers, specifically nurses who play a major role in research, genetic counseling, and education, need to understand the implications of this sleep and movement disorder for patients across the lifespan.

Association between serum ferritin level and fibromyalgia syndrome

BACKGROUND/OBJECTIVES

Iron is essential for a number of enzymes involved in neurotransmitter synthesis. Analysis of cerebrospinal fluid in fibromyalgia syndrome (FMS) has shown a reduction in the concentration of biogenic amine metabolites, including dopamine, norepinephrine and serotonin. This study aimed to investigate the association of ferritin with FMS.

SUBJECTS/METHODS

A total of 46 patients with primary FMS participated in this case-control study, and 46 healthy females who were age matched to the patients were used as the control group. Venous blood samples collected from all subjects were used to evaluate serum ferritin, vitamin B12 and folic acid levels.

RESULTS

The mean serum ferritin levels in the fibromyalgia (FM) and control groups were 27.3+/-20.9 and 43.8+/-30.8 ng/ml, respectively, and the difference was statistically significant (P=0.003). Binary multiple logistic regression analysis with age, body mass index, smoking status and vitamin B12, as well as folic acid and ferritin levels showed that having a serum ferritin level <50 ng/ml caused a 6.5-fold increased risk for FMS.

CONCLUSIONS

Our study implicates a possible association between FM and decreased ferritin level, even for ferritin in normal ranges. We suggest that iron as a cofactor in serotonin and dopamine production may have a role in the etiology of FMS.

Update on the management of restless legs syndrome: existing and emerging treatment options

Restless legs syndrome (RLS) is a sensorimotor disorder, characterized by a circadian variation of symptoms involving an urge to move the limbs (usually the legs) as well as paresthesias. There is a primary (familial) and a secondary (acquired) form, which affects a wide variety of individuals, such as pregnant women, patients with end-stage renal disease, iron deficiency, rheumatic disease, and persons taking medications. The symptoms reflect a circadian fluctuation of dopamine in the substantia nigra. RLS patients have lower dopamine and iron levels in the substantia nigra and respond to both dopaminergic therapy and iron administration. Iron, as a cofactor of dopamine production and a regulator of the expression of dopamine type 2-receptor, has an important role in the RLS etiology. In the management of the disease, the first step is to investigate possible secondary causes and their treatment. Dopaminergic agents are considered as the first-line therapy for moderate to severe RLS. If dopaminergic drugs are contraindicated or not efficacious, or if symptoms are resistant and unremitting, gabapentin or other antiepileptic agents, benzodiazepines, or opioids can be used for RLS therapy. Undiagnosed, wrongly diagnosed, and untreated RLS is associated with a significant impairment of the quality of life.

Restless Legs Syndrome in shift workers: A cross sectional study on male assembly workers

Background

Restless Legs Syndrome (RLS) is a common neurological movement disorder characterized by symptoms that follow a circadian pattern. Night and rotating shift work schedules exert adverse effects on functions of the human body by disturbing circadian rhythms, and they are known to cause sleep disturbances and insomnia. In this paper, we investigate the possible association between shift work and RLS.

Methods

This cross sectional study was conducted in an automobile manufacturing factory in Tehran, Iran. A total of 780 male assembly workers were recruited in three groups, each with 260 workers: workers on a permanent morning shift (A) and two different rotating shift schedules (B and C) with morning, afternoon and night shifts. We used the international RLS study group criteria for diagnosis of RLS, and the severity scale for severity assessment in subjects with RLS. Self administered questionnaires were used to gather information on age, smoking, work history, medical condition, and existence and severity of RLS symptoms.

Results

The prevalence of RLS was significantly higher in rotational shift workers (15%) than workers with permanent morning work schedule (8.5%). In workers suffering from RLS, we found greater mean values of age and work experience, higher percentages of drug consumption, smoking, and co-morbid illnesses compared with subjects who did not have RLS, although these differences were statistically significant only for age, work experience and drug consumption.

Conclusion

Rotational shift work acts as a risk or exacerbating factor for Restless Legs Syndrome.

Treatment of restless legs syndrome with iron infusion therapy

Initially, the patient in this case received CPAP for sleep apnea and pramipexole for RLS. Her symptoms failed to resolve, which led to consultation with a sleep specialist who recommended diagnostic studies that identified an underlying iron/ferritin deficiency. After receiving IV iron therapy, the patient's RLS symptoms resolved. Only about one-quarter of patients with RLS symptoms receive an appropriate diagnosis, and thus, many are treated less than optimally. Agents used to treat RLS have been heavily advertised, and patients may request a prescription from their health care provider. This case reaffirms the importance of the medical history and diagnostic studies when evaluating a patient with symptoms of RLS. Screening first for iron/ferritin deficiency may prevent subjecting patients to the potential side effects of unnecessary medications.

Diagnosis and management of restless legs syndrome in children

Recent published evidence suggests that restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are common condition in children and adolescents. It is likely that if left untreated, RLS and PLMD may lead to adverse cardiovascular and neurocognitive consequences. However, the diagnosis of RLS and PLMD in children is challenging, particularly because children are relatively unable to describe typical RLS symptoms. The International Restless Legs Study Group has recently published consensus criteria for the diagnosis of RLS and PLMD in children. In addition to clinical description of RLS symptoms, supportive evidence including the presence of clinical sleep disturbances, documented periodic limb movements in sleep from overnight sleep study and family history of restless legs syndrome may be required. Few if any controlled studies have addressed the management of RLS and PLMD, which may involve both non-pharmacologic and pharmacologic approaches. In this context, the importance of avoidance of aggravating factors and good sleep hygiene cannot be overemphasized. Children with evidence of low-iron storage, i.e., low-serum ferritin and/or iron levels may likely benefit from iron therapy. While there is overall limited experience regarding the use of dopaminergic agents in children with RLS and PLMD, published reports suggesting efficacy of compounds such as levodopa, ropinirole, pramipexole and pergolide have emerged. Other medications including benzodiazepine, anti-convulsants, alpha-adrenergic and opioid medications have not been adequately studied in children. Children with RLS and PLMD should have regular follow-up visits to evaluate clinical improvement and to monitor adverse effects from the selected therapy. Based on aforementioned findings, it is clear that a substantial research effort is needed to evaluate the pathophysiology, clinical presentation, treatment modalities, and overall long-term outcome of children with RLS and PLMD.

Predictors of restless legs syndrome in pregnancy: a hospital based cross sectional survey from Pakistan

Restless legs syndrome (RLS) is more common in pregnant women. The objective of our study was to determine frequency of RLS in pregnant women and predictors of RLS in pregnancy in Pakistan. All pregnant women admitted at The Aga Khan University Hospital for delivery from June to July 2005 were enrolled. Eighty-one of 271 (30%) interviewed women fulfilled the diagnostic criteria of RLS. One hundred seventeen (43%) of the subjects dropped their haemoglobin during the pregnancy. No significant difference in haemoglobin drop was noted between the RLS group and healthy group. On multivariate analysis family history of RLS (OR: 8.43, CI: 2.32-30.57, p value<0.001), history of RLS in prior pregnancy (OR: 53.74, CI: 6.72-429.8, p value<0. 001), history of RLS in past even when non-pregnant (OR: 12.91, CI: 3.34-49.87, p value<0.001) and haemoglobin of 11g/dL or less (OR: 2.05, CI: 1.04-4.04, p value 0.036) were found to be independent predictors of RLS during pregnancy. Subgroup analysis revealed that family history of RLS (OR: 3.06, CI: 1.2-7.83, p value 0.019) and anemia (OR: 1.89, CI: 0.96-3.71, p value 0.06) were associated with de novo RLS, and family history of RLS (OR: 12.39, CI: 4.45-35.54, p value<0.001) and multiparity (OR: 6.84, CI: 2.15-21.71, p value 0.001) were predictors of pre-existing RLS.

Pneumatic compression devices are an effective therapy for restless legs syndrome: a prospective, randomized, double-blinded, sham-controlled trial

BACKGROUND

Pharmacotherapy for restless legs syndrome (RLS) may be ineffective or complicated by side effects. Uncontrolled series using pneumatic compression devices (PCDs) have been shown to reduce symptoms of RLS. We sought to assess the efficacy of PCDs as a nonpharmacologic treatment for RLS.

METHODS

We performed a prospective, randomized, double-blinded, sham-controlled trial of individuals with RLS. Subjects wore a therapeutic or sham device prior to the usual onset of symptoms for a minimum of 1 h daily. Measures of severity of illness, quality of life, daytime sleepiness, and fatigue were compared at baseline and after 1 month of therapy.

RESULTS

Thirty-five subjects were enrolled. Groups were similar at baseline. Therapeutic PCDs significantly improved all measured variables more than shams. Restless Legs Severity Score improved from 14.1 +/- 3.9 to 8.4 +/- 3.4 (p = 0.006) and Johns Hopkins Restless Legs Scale improved from 2.2 +/- 0.5 to 1.2 +/- 0.7 (p = 0.01). All quality of life domains improved more with therapeutic than sham devices (social function 14% vs 1%, respectively; p = 0.03; daytime function 21% vs 6%, respectively, p = 0.02; sleep quality 16% vs 8%, respectively, p = 0.05; emotional well-being 17% vs 10%, respectively, p = 0.15). Both Epworth sleepiness scale (6.5 +/- 4.0 vs 11.3 +/- 3.9, respectively, p = 0.04) and fatigue (4.1 +/- 2.1 vs 6.9 +/- 2.0, respectively, p = 0.01) improved more with therapeutic devices than sham devices. Complete relief occurred in one third of subjects using therapeutic and in no subjects using sham devices.

CONCLUSION

PCDs resulted in clinically significant improvements in symptoms of RLS in comparison to the use of sham devices and may be an effective adjunctive or alternative therapy for RLS.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00479531.

Restless legs syndrome in patients with chronic obstructive pulmonary disease

OBJECTIVE

To evaluate the prevalence of restless legs syndrome (RLS) in patients with chronic obstructive pulmonary disease (COPD) and the relationship between RLS and clinical/laboratory findings of COPD.

METHODS

One hundred and thirty-four COPD patients without secondary causes of RLS were included. Thirty-nine (29.1%) patients were diagnosed with RLS and classified as Group 1. The control group consisted of 65 age-matched COPD patients without RLS. Group 1 was divided into subgroups according to the Johns Hopkins Severity (JHS) scale. Patients with a score of 0, 1, or 2 were classified as JHS 0-2 and those with a score of 3 as JHS 3. Group 1 and the control group and subgroups were compared for clinical and laboratory characteristics.

RESULTS

We found that the duration of COPD was longer and that airway obstruction, hypercapnia, and hypoxia were more evident in patients with RLS than those without. Similar differences were also detected between JHS subgroups 3 (more severe) and 0-2. Polyneuropathy frequency was significantly higher in Group 1 compared to controls. However, Group 1 subgroups showed a similar frequency of polyneuropathy. In a multivariate analysis, hypercapnia made a significant independent contribution to both JHS 0-2 and JHS 3 patients when RLS severity was set as the dependent variable. Polyneuropathy and the duration of COPD were significant independent variables for patients in the JHS 3 subgroup. Polyneuropathy was the strongest predictor for the JHS 3 patients.

CONCLUSIONS

We conclude that RLS is frequent in COPD, particularly in patients with severe hypoxemia/hypercapnia and in late stages of the disease.