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Koo BB, Abdelfattah A, Eysa A, Lu L. The Melanocortin and Endorphin Neuropeptides in Patients with Restless Legs Syndrome. Ann Neurol 2024; 95:688-699. [PMID: 38308537 DOI: 10.1002/ana.26876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/13/2023] [Accepted: 01/10/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVE Based upon similarities between the urge to move and sensory discomfort of restless legs syndrome (RLS) and properties of melanocortin hormones, including their incitement of movement and hyperalgesia, we assessed plasma and cerebrospinal fluid (CSF) α-melanocyte-stimulating hormone (α-MSH) and β-endorphin in RLS patients and controls. METHODS Forty-two untreated moderate-to-severe RLS patients and 44 matched controls underwent venipuncture at 19:00, 20:30, and 22:00; 37 RLS and 36 controls had lumbar puncture at 21:30. CSF and plasma were analyzed for pro-opiomelanocortin (POMC), adrenocorticotropin hormone (ACTH), α-MSH, β-MSH, and β-endorphin by immunoassay. RLS severity was assessed by International RLS Study Group Severity Scale. RESULTS RLS participants were 52.7 ± 12.0 years old, 61.9% were women, 21.4% had painful RLS, and RLS severity was 24.8 ± 9.0. Controls had similar age and sex. Plasma ACTH, α-MSH, and β-endorphin were similar between groups. Plasma POMC was significantly greater in RLS than controls (17.0 ± 11.5 vs 12.7 ± 6.1fmol/ml, p = 0.048). CSF ACTH was similar between groups. CSF β-MSH was significantly higher in painful than nonpainful RLS or controls (48.2 ± 24.8 vs 32.1 ± 14.8 vs 32.6 ± 15.2pg/ml, analysis of variance [ANOVA] p = 0.03). CSF α-MSH was higher in RLS than controls (34.2 ± 40.9 vs 20.3 ± 11.0pg/ml, p = 0.062). CSF β-EDP was lowest in painful RLS, intermediate in nonpainful RLS, and highest in controls (8.0 ± 3.4 vs 10.8 ± 3.1 vs 12.3 ± 5.0pg/ml, ANOVA p = 0.049). The ratio of the sum of CSF α- and β-MSH to CSF β-endorphin was highest, intermediate, and lowest in painful RLS, nonpainful RLS, and controls (p = 0.007). INTERPRETATION CSF β-MSH is increased and CSF β-endorphin decreased in RLS patients with painful symptoms. ANN NEUROL 2024;95:688-699.
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Affiliation(s)
- Brian B Koo
- Department of Neurology, Yale University, New Haven, CT, USA
| | | | - Athar Eysa
- Department of Internal Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Lingeng Lu
- Department of Chronic Disease Epidemiology, Yale University, New Haven, CT, USA
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Garcia-Borreguero D, Aragón AG, Moncada B, Romero S, Granizo JJ, Quintas S, Castillo M. Treatment of Sleep, Motor and Sensory Symptoms with the Orexin Antagonist Suvorexant in Adults with Idiopathic Restless Legs Syndrome: A Randomized Double-Blind Crossover Proof-of-Concept Study. CNS Drugs 2024; 38:45-54. [PMID: 38246901 DOI: 10.1007/s40263-023-01055-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND AND OBJECTIVES Current treatment guidelines for restless legs syndrome (RLS) recommend treatment be initiated with non-dopaminergic drugs. Given the potential role of orexins in the pathophysiology of RLS, we performed a pilot, proof-of-concept study to investigate the therapeutic effects of suvorexant, a dual orexin receptor antagonist (DORA), on sleep and sensory/motor symptoms in individuals with idiopathic RLS. METHODS This was a randomized, double-blind, crossover and placebo-controlled study. Inclusion criteria were diagnosis with idiopathic RLS, an International RLS Study Group Severity Rating Scale (IRLS) score > 15, and the absence of significant RLS symptoms before 9 pm. Following washout from any previous central nervous system (CNS)-active drugs, patients were randomized to receive either suvorexant or placebo for two consecutive 2-week treatment periods. Treatment was administered at 9 pm at a fixed dose of 10 mg/day during the first week, and 20 mg during the second week. Primary and coprimary endpoints were wake after sleep onset (WASO) and total sleep time (TST), respectively, while IRLS rating scale score, multiple suggested immobilization tests (m-SIT), and periodic limb movements (PLMs) were secondary endpoints. RLS severity was measured weekly using the IRLS and Clinical Global Improvement (CGI) scales. m-SIT were also performed between 8 pm and midnight at the end of each treatment phase and were followed by a sleep study. RESULTS A total of 41 participants were randomized, 40 of whom completed the study. Compared with placebo, treatment with suvorexant significantly improved RLS symptoms (according to IRLS total score, CGI, and the m-SIT), PLM during sleep, and PLM with arousal. Improvement of RLS symptoms was greater in those who had not been exposed to dopaminergic agents in the past. Sleep architecture also improved with significant changes in TST, WASO, sleep onset latency, sleep efficiency, non rapid-eye movement stage 1 (N1) %, non rapid-eye movement stage 2 (N2) %, and rapid eye movement (REM) %. Suvorexant was well tolerated in RLS, with few and mild adverse events. CONCLUSIONS Our results provide the first proof of evidence of the therapeutic efficacy of DORAs in improving sleep and sensory and motor symptoms in RLS. Given orexin's role in pain and sensory processing, potential mechanisms of action are discussed. CLASSIFICATION OF EVIDENCE The study provides class II evidence supporting the therapeutic efficacy of suvorexant in patients with RLS with sleep disturbance. TRIAL REGISTRATION EudraCT#: 2017-004580-12.
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Affiliation(s)
| | | | - Brian Moncada
- Sleep Research Institute, Calle Padre Damián 44, 28036, Madrid, Spain
| | - Sofia Romero
- Sleep Research Institute, Calle Padre Damián 44, 28036, Madrid, Spain
| | | | - Sonia Quintas
- Sleep Research Institute, Calle Padre Damián 44, 28036, Madrid, Spain
| | - María Castillo
- Sleep Research Institute, Calle Padre Damián 44, 28036, Madrid, Spain
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Nilles C, Amorelli G, Pringsheim TM, Martino D. "Unvoluntary" Movement Disorders: Distinguishing between Tics, Akathisia, Restless Legs, and Stereotypies. Semin Neurol 2023; 43:123-146. [PMID: 36854394 DOI: 10.1055/s-0043-1764164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Tics, stereotypies, akathisia, and restless legs fall at different places on the spectrum of discrete, unwanted and potentially disabling motor routines. Unlike tremor, chorea, myoclonus, or dystonia, this subgroup of abnormal movements is characterized by the subject's variable ability to inhibit or release undesired motor patterns on demand. Though it may be sometimes clinically challenging, it is crucial to distinguish these "unvoluntary" motor behaviors because secondary causes and management approaches differ substantially. To this end, physicians must consider the degree of repetitiveness of the movements, the existence of volitional control, and the association with sensory symptoms, or cognitive-ideational antecedent. This review aims to summarize the current existing knowledge on phenomenology, diagnosis, and treatment of tics, stereotypies, akathisia, and restless leg syndrome.
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Affiliation(s)
- Christelle Nilles
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gabriel Amorelli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tamara M Pringsheim
- Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Mathison Centre for Mental Health Research and Education, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Davide Martino
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Mathison Centre for Mental Health Research and Education, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Liu J, Liu S, Hao L, Liu F, Mu S, Wang T. Uncovering the mechanism of Radix Paeoniae Alba in the treatment of restless legs syndrome based on network pharmacology and molecular docking. Medicine (Baltimore) 2022; 101:e31791. [PMID: 36401463 PMCID: PMC9678500 DOI: 10.1097/md.0000000000031791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Restless legs syndrome (RLS) is a neurological motor disorder with a high prevalence. The treatment efficacy of RLS is unsatisfactory. Radix Paeoniae Alba (RPA) can effectively treat RLS symptoms such as the discomfort of the legs. RPA has great potential for the development of new medications for RLS. Hence, we explored the mechanism of RPA in the treatment of RLS using network pharmacology and molecular docking. The active components and targets of RPA were obtained from the Traditional Chinese Medicine System Pharmacology database and analysis platform and PharmMapper platform. The RLS-related targets were found in GeneCards, OMIM, DrugBank, and DisGeNET databases. The overlapping targets of RPA and RLS were then collected. The "active components-overlapping targets" network was built, and network topology analysis was performed. Furthermore, Cytoscape 3.9.1 software was used to screen the key components of RPA in the treatment of RLS. Protein-protein interaction was performed using the Search Tool for the Retrieval of Interacting Genes. The gene ontology functions and Kyoto Encyclopedia of Genes and Genomes signaling pathways were analyzed using ClusterProfiler, PathView, and other R packages to reveal the main mechanism of RPA in treating RLS. Component and protein structures were downloaded from the Traditional Chinese Medicine System Pharmacology and Protein Data Bank databases, respectively. The AutoDock 4.2.6 software was used for molecular docking. A total of 12 active components and 109 targets of RPA, as well as 2387 RLS-related targets, were collected. Following that, 47 overlapping targets were obtained. Furthermore, 5 key components and 12 core targets were screened. The results of gene ontology functions were as follows: 2368 biological processes, 264 molecular functions, and 164 cellular components. A total of 207 Kyoto Encyclopedia of Genes and Genomes signaling pathways were obtained, including the lipid and atherosclerosis pathway, the endocrine resistance pathway, the prolactin signaling pathway, and the IL-17 signaling pathway. The components and the core targets completed molecular docking stably. RPA has multi-component, multi-target, and multi-pathway characteristics in treating RLS, which could provide a basis for future research and improve clinical efficacy.
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Affiliation(s)
- Jun Liu
- Department of Gastroenterology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Institute of Digestive Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Suxian Liu
- Department of Gastroenterology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Institute of Digestive Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Liansheng Hao
- Department 2 of Bone Trauma, Liaocheng Hospital of Traditional Chinese Medicine, Liaocheng, China
| | - Fangfang Liu
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Shengkai Mu
- Department 2 of Bone Trauma, Liaocheng Hospital of Traditional Chinese Medicine, Liaocheng, China
| | - Tengteng Wang
- Department of Acupuncture, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- * Correspondence: Tengteng Wang, Department of Acupuncture, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200032, China (e-mail: )
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van der Veen S, Caviness JN, Dreissen YE, Ganos C, Ibrahim A, Koelman JH, Stefani A, Tijssen MA. Myoclonus and other jerky movement disorders. Clin Neurophysiol Pract 2022; 7:285-316. [PMID: 36324989 PMCID: PMC9619152 DOI: 10.1016/j.cnp.2022.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/29/2022] [Accepted: 09/11/2022] [Indexed: 11/27/2022] Open
Abstract
Myoclonus and other jerky movements form a large heterogeneous group of disorders. Clinical neurophysiology studies can have an important contribution to support diagnosis but also to gain insight in the pathophysiology of different kind of jerks. This review focuses on myoclonus, tics, startle disorders, restless legs syndrome, and periodic leg movements during sleep. Myoclonus is defined as brief, shock-like movements, and subtypes can be classified based the anatomical origin. Both the clinical phenotype and the neurophysiological tests support this classification: cortical, cortical-subcortical, subcortical/non-segmental, segmental, peripheral, and functional jerks. The most important techniques used are polymyography and the combination of electromyography-electroencephalography focused on jerk-locked back-averaging, cortico-muscular coherence, and the Bereitschaftspotential. Clinically, the differential diagnosis of myoclonus includes tics, and this diagnosis is mainly based on the history with premonitory urges and the ability to suppress the tic. Electrophysiological tests are mainly applied in a research setting and include the Bereitschaftspotential, local field potentials, transcranial magnetic stimulation, and pre-pulse inhibition. Jerks due to a startling stimulus form the group of startle syndromes. This group includes disorders with an exaggerated startle reflex, such as hyperekplexia and stiff person syndrome, but also neuropsychiatric and stimulus-induced disorders. For these disorders polymyography combined with a startling stimulus can be useful to determine the pattern of muscle activation and thus the diagnosis. Assessment of symptoms in restless legs syndrome and periodic leg movements during sleep can be performed with different validated scoring criteria with the help of electromyography.
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Affiliation(s)
- Sterre van der Veen
- Department of Neurology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, The Netherlands,Expertise Centre Movement Disorders Groningen, University Medical Centre Groningen (UMCG), Groningen, The Netherlands
| | - John N. Caviness
- Department of Neurology, Mayo Clinic Arizona, Movement Neurophysiology Laboratory, Scottsdale, AZ, USA
| | - Yasmine E.M. Dreissen
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Christos Ganos
- Movement Disorders and Neuromodulation Unit, Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Abubaker Ibrahim
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes H.T.M. Koelman
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Ambra Stefani
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marina A.J. Tijssen
- Department of Neurology, University of Groningen, University Medical Centre Groningen (UMCG), Groningen, The Netherlands,Expertise Centre Movement Disorders Groningen, University Medical Centre Groningen (UMCG), Groningen, The Netherlands,Corresponding author at: Department of Neurology, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 30.001, 9700 RB Groningen, The Netherlands.
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Khachatryan SG, Ferri R, Fulda S, Garcia-Borreguero D, Manconi M, Muntean ML, Stefani A. Restless legs syndrome: Over 50 years of European contribution. J Sleep Res 2022; 31:e13632. [PMID: 35808955 PMCID: PMC9542244 DOI: 10.1111/jsr.13632] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 11/28/2022]
Abstract
Restless legs syndrome (RLS) is a sensorimotor neurological disorder characterised by an urge to move the limbs with a circadian pattern (occurring in the evening/at night), more prominent at rest, and relieved with movements. RLS is one of the most prevalent sleep disorders, occurring in 5%-10% of the European population. Thomas Willis first described RLS clinical cases already in the 17th century, and Karl-Axel Ekbom described the disease as a modern clinical entity in the 20th century. Despite variable severity, RLS can markedly affect sleep (partly through the presence of periodic leg movements) and quality of life, with a relevant socio-economic impact. Thus, its recognition and treatment are essential. However, screening methods present limitations and should be improved. Moreover, available RLS treatment options albeit providing sustained relief to many patients are limited in number. Additionally, the development of augmentation with dopamine agonists represents a major treatment problem. A better understanding of RLS pathomechanisms can bring to light novel treatment possibilities. With emerging new avenues of research in pharmacology, imaging, genetics, and animal models of RLS, this is an interesting and constantly growing field of research. This review will update the reader on the current state of RLS clinical practice and research, with a special focus on the contribution of European researchers.
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Affiliation(s)
- Samson G Khachatryan
- Department of Neurology and Neurosurgery, National Institute of Health, Yerevan, Armenia.,Sleep Disorders Center, Somnus Neurology Clinic, Yerevan, Armenia
| | | | - Stephany Fulda
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | | | - Mauro Manconi
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland.,Department of Neurology, University Hospital, Inselspital, Bern, Switzerland
| | - Maria-Lucia Muntean
- Center for Parkinson's Disease and Movement Disorders, Paracelsus-Elena Klinik, Kassel, Germany
| | - Ambra Stefani
- Sleep Disorders Clinic, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Bellur S, Thota SS, Raj JP, Kallarakal TK, Nadig R. Prevalence And Predictors of Restless Leg Syndrome in Adolescent and Young Adults in Bengaluru City, India - a Cross Sectional Study. Neuroepidemiology 2022; 56:298-305. [PMID: 35671733 DOI: 10.1159/000525336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/31/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Restless leg syndrome (RLS) is a sensorimotor disease characterized by an urge to move the legs, often caused by uncomfortable and unpleasant sensations in the legs. It affects the quality of sleep which in turn affects scholastic performance in children and predisposes them to cardiovascular diseases in the long run. Hence, the primary aim of this study was to assess the prevalence and predictors of RLS, poor sleep quality and excessive daytime sleepiness (EDS) Methods: This was a cross sectional observational study conducted between September 2017 and March 2020 in Bengaluru, India including all consenting Pre - university college, Degree college, and Higher secondary school students. After parental consent and assent (if applicable) was obtained, a semi-structured standardized pilot tested questionnaire consisting of the RLS diagnostic criteria, Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS) and questions on sleep hygiene was administered. The prevalence was expressed as proportions and 95% confidence intervals (95% CI). Regression analysis was done to determine the predictors. RESULTS The overall prevalence (95CI; frequency) of students with RLS, poor sleep quality and EDS in our study population was 8.36% (7.54, 9.24; n=1544/4211), 36.67% (35.21, 38.14; n=1544/4211) and 39.87% (38.39, 41.37; n=1679/4211), respectively. PSQI and Epworth score were the significant predictors of RLS. Age, Epworth score, knowledge score and the number of unacceptable sleep habits were the significant predictors of sleep quality. Female gender, PSQI, RLS, knowledge score and the number of unacceptable sleep habits were the significant predictors of EDS. CONCLUSIONS The prevalence of RLS, those with poor sleep quality and EDS among adolescents and young adults was higher when compared to the historical data of general population in the same city.
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Affiliation(s)
| | | | - Jeffrey Pradeep Raj
- Department of Pharmacology, St. John's Medical College Hospital, Bengaluru, India
| | - Tomy K Kallarakal
- School of Commerce, Finance and Accountancy, Christ University, Bengaluru, India
| | - Raghunandan Nadig
- Department of Neurology, St. John's Medical College Hospital, Bengaluru, India
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Garcia-Borreguero D, Garcia-Malo C, Granizo JJ, Ferré S. A Randomized, Placebo-Controlled Crossover Study with Dipyridamole for Restless Legs Syndrome. Mov Disord 2021; 36:2387-2392. [PMID: 34137476 PMCID: PMC8530834 DOI: 10.1002/mds.28668] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/26/2021] [Accepted: 04/29/2021] [Indexed: 01/25/2023] Open
Abstract
Background New pharmacological targets are needed for restless legs syndrome. Preclinical data suggest that a hypoadenosinergic state plays an important pathogenetic role. Objective The objective of this study was to determine whether inhibitors of equilibrative nucleoside transporters, for example, dipyridamole, could provide effective symptomatic treatment. Methods A 2‐week double‐blind, placebo‐controlled crossover study assessed the efficacy of dipyridamole (possible up‐titration to 300 mg) in untreated patients with idiopathic restless legs syndrome. Multiple suggested immobilization tests and polysomnography were performed after each treatment phase. Severity was assessed weekly using the International Restless Legs Rating Scale, Clinical Global Impression, and the Medical Outcomes Study Sleep scale. The primary end point was therapeutic response. Results Twenty‐eight of 29 patients recruited were included. International Restless Legs Rating Scale scores improved from a mean ± standard deviation of 24.1 ± 3.1 at baseline to 11.1 ± 2.3 at the end of week 2, versus 23.7 ± 3.4 to 18.7 ± 3.2 under placebo (P < 0.001). Clinical Global Impression, Medical Outcomes Study Sleep, and Multiple Suggested Immobilization Test scores all improved (P < 0.001). The mean effective dose of dipyridamole was 217.8 ± 33.1 mg/d. Sleep variables improved. The mean periodic leg movement index at the end of treatment with dipyridamole was 8.2 ± 3.5 versus. 28.1 ± 6.7 under placebo. Side effects (dipyridamole vs placebo) included abdominal distension (18% vs. 7%), dizziness (10.7% vs 7.1%), diarrhea, and asthenia (each 7.1% vs 3.6%). Conclusions Dipyridamole has significant therapeutic effects on both sensory and motor symptoms of restless legs syndrome and on sleep. Our findings confirm the efficacy of dipyridamole in restless legs syndrome predicted from preclinical studies and support a key role of adenosine in restless legs syndrome. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
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Affiliation(s)
| | | | - Juan José Granizo
- Department of Clinical Epidemiology, Hospital Universitario Infanta Cristina, Instituto de Investigaciones Sanitarias Puerta de Hierro, Madrid, Spain
| | - Sergi Ferré
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, Maryland, USA
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Cederberg KLJ, Walters AS, Amara AW, Braley TJ, Schuetz ML, Mathison BG, Motl RW. Validity and reliability of the suggested immobilization test for measurement of restless legs syndrome severity in adults with multiple sclerosis. Sleep Med 2021; 84:343-351. [PMID: 34242924 DOI: 10.1016/j.sleep.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/02/2021] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE/BACKGROUND Adults with multiple sclerosis (MS) often present with conditions that mimic restless legs syndrome (RLS), thereby adding complexity into the assessment of RLS severity. The current gold-standard measures of RLS severity rely on a fixed seven-day time frame, which limits the ability of these measures for studying acute changes in RLS severity. The present study examined if subjective and objective scores from the suggested immobilization test (SIT) provide a valid and reliable acute measure of RLS severity in persons with MS. PATIENTS/METHODS Participants with MS and RLS (n = 20) and MS without RLS (n = 20) were matched by age, gender, and disability. All participants completed validated questionnaires for RLS severity followed by the SIT, conducted at 18:00 (±15 min) on the same day of the week for two consecutive weeks. Participants wore accelerometer devices for seven nights to capture periodic limb movements (PLMs) during the night. RESULTS Self-reported RLS severity during the SIT had excellent construct validity and convergent validity, but moderate test-retest reliability. Device-measured PLMs, while not themselves a direct measure of RLS severity, were significantly associated with PLMs during the night and had excellent test-retest reliability during the SIT in adults with MS. CONCLUSIONS Our results suggest that the SIT represents a valid acute measure for capturing self-reported sensory aspects of RLS severity and should be considered in future research and clinical practice as a standardized acute measure of subjective RLS severity in adults with MS who present with RLS.
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Affiliation(s)
- Katie L J Cederberg
- Department of Psychiatry and Behavioral Sleep Medicine, Stanford University, Stanford, CA, USA.
| | - Arthur S Walters
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | - Amy W Amara
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tiffany J Braley
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Morgan L Schuetz
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brianna G Mathison
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert W Motl
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
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Buchfuhrer MJ, Baker FC, Singh H, Kolotovska V, Adlou B, Anand H, de Zambotti M, Ismail M, Raghunathan S, Charlesworth JD. Noninvasive neuromodulation reduces symptoms of restless legs syndrome. J Clin Sleep Med 2021; 17:1685-1694. [PMID: 33949942 DOI: 10.5664/jcsm.9404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Restless legs syndrome (RLS) is a common neurological disorder characterized by an uncontrollable nocturnal urge to move the legs and often associated with chronic sleep disturbances. The most common treatments for RLS are medications that can have debilitating side-effects. Here, we evaluated a novel alternative modality of RLS treatment, noninvasive bilateral electrical stimulation of the common peroneal nerve. METHODS To assess the impact of this noninvasive peripheral nerve stimulation (NPNS) approach on RLS symptomatology, we conducted a multi-site randomized crossover study comparing NPNS to sham. RLS patients with moderate to severe RLS (n=37) self-administered NPNS and sham nightly for 14 days per treatment in randomized order. RESULTS NPNS resulted in a reduction in RLS severity of 6.81 points on the International RLS Rating Scale (IRLS) relative to 3.38 for sham (p<0.01) and a 66% clinically significant responder rate on the Clinical Global Impressions-Improvement (CGI-I) scale compared to 17% for sham (p<0.01). Subgroup analysis indicated that medication-resistant and medication-naïve participants both exhibited similarly robust responses. There were no moderate or serious device-related adverse events. CONCLUSIONS These results suggest that NPNS could be a promising alternative to pharmacological therapies for RLS and could provide a solution for medication-resistant RLS patients and for medication-naïve RLS patients who are unwilling or unable to take medication. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Noninvasive Peripheral Nerve Stimulation for Restless Legs Syndrome; Identifier: NCT04700683; URL: https://clinicaltrials.gov/ct2/show/NCT04700683.
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Affiliation(s)
- Mark J Buchfuhrer
- Stanford University School of Medicine, Stanford, CA; Private Practice, Downey, CA
| | - Fiona C Baker
- Center for Health Sciences, SRI International, Menlo Park, CA
| | | | - Viktoriia Kolotovska
- Sleep Medicine Specialists of California, San Ramon, CA.,Noctrix Health, Inc., Oakland, CA
| | | | | | | | - Mehvish Ismail
- Center for Health Sciences, SRI International, Menlo Park, CA
| | - Shriram Raghunathan
- Stanford University School of Medicine, Stanford, CA; Private Practice, Downey, CA
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Garcia-Malo C, Romero-Peralta S, Cano-Pumarega I. Restless Legs Syndrome - Clinical Features. Sleep Med Clin 2021; 16:233-247. [PMID: 33985650 DOI: 10.1016/j.jsmc.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Restless legs syndrome (RLS) is one of the most common neurologic conditions, with an estimated prevalence in European and North American heritage populations of about 2% to 5%. Because RLS diagnosis is essentially clinical, a careful evaluation of the symptoms is mandatory. It is important to exclude RLS mimics and evaluate factors that could exacerbate RLS symptoms. It is mandatory to evaluate systemic iron parameters, because the initial treatment depends on this result. Other complementary tests could help support the diagnosis or exclude mimics. The decision about when and how to treat should be carefully tailored to each patient.
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Affiliation(s)
- Celia Garcia-Malo
- Sleep Research Institute, Calle del Padre Damián, 44, Madrid 28036, Spain.
| | - Sofia Romero-Peralta
- Sleep Research Institute, Calle del Padre Damián, 44, Madrid 28036, Spain; Sleep Unit, Respiratory Department, Hospital de Guadalajara, Guadalajara, Spain
| | - Irene Cano-Pumarega
- Sleep Research Institute, Calle del Padre Damián, 44, Madrid 28036, Spain; Sleep Unit, Respiratory Department, Hospital Ramón y Cajal, IRYCIS, CIBERES, Madrid, Spain
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Abstract
Early-onset restless legs syndrome has a relatively high prevalence in pediatrics, is highly familial, and is often preceded by a diagnosis of periodic limb movement disorder or childhood insomnia. Diagnostic criteria are derived but not equal to those of the adult syndrome and are adapted according to children's age and linguistic competence. Diagnosis requires parents or caregivers to participate; video-polysomnographic nocturnal recording, although not mandatory, may help confirm dubious cases. The syndrome severely impacts children's sleep and cognitive-behavioral abilities. Iron supplementation is currently the most used and viable therapeutic option.
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Affiliation(s)
- Rosalia Silvestri
- Department of Clinical and Experimental Medicine, Sleep Medicine Center, University of Messina, AOU G Martino, Pad. H, Via Consolare Valeria 1, Messina, Messina 98125, Italy.
| | - Lourdes M DelRosso
- Seattle Children's Hospital, OC.7.720 - Pulmonary, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
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Garcia-Malo C, Peralta SR, Garcia-Borreguero D. Restless Legs Syndrome and Other Common Sleep-Related Movement Disorders. Continuum (Minneap Minn) 2020; 26:963-987. [PMID: 32756231 DOI: 10.1212/con.0000000000000886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW In this article, the different sleep-related movement disorders are discussed with special attention given to restless legs syndrome (RLS). RECENT FINDINGS The differential diagnosis of sleep-related movement disorders can often be challenging; therefore, it is essential to have accurate information to make a correct diagnosis. This article focuses on RLS, highlighting the change in the paradigm of initial treatment, the role played by iron (pathophysiologic and therapeutic), and how to approach possible complications occurring with long-term treatment. SUMMARY RLS is one of the most common neurologic conditions, and it is common in clinical practice to find patients experiencing symptoms suggestive of RLS. Neurologists must be careful and thorough in the diagnosis, excluding RLS mimics. The decisions regarding which specific sleep-related movement disorder is present and how it should be treated are important because in certain cases, especially in RLS, adverse effects and long-term complications are frequently reported with the use of certain drugs.
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Romero-Peralta S, Cano-Pumarega I, García-Borreguero D. Emerging Concepts of the Pathophysiology and Adverse Outcomes of Restless Legs Syndrome. Chest 2020; 158:1218-1229. [PMID: 32247713 DOI: 10.1016/j.chest.2020.03.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 02/15/2020] [Accepted: 03/13/2020] [Indexed: 01/05/2023] Open
Abstract
Restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED), is a common neurological disorder affecting up to 5% to 10% of the population, but it remains an underdiagnosed condition. RLS/WED is characterized by uncomfortable sensations, mainly in the legs, which appear during inactivity and worsen in the evening or at night. The prevalence of RLS/WED and periodic leg movements (PLMs) is increased in patients with sleep-disordered breathing, particularly in those with OSA, the most common sleep disorder encountered in sleep centers. New advances in the pathophysiology of RLS/WED have shown important implications for various genetic markers, neurotransmitter dysfunction, and iron deficiency. A practical approach to RLS/WED management includes an accurate diagnosis, the identification of reversible contributing factors, and the use of nonpharmacological therapies, including iron substitution (oral or IV) therapy. Many pharmacological agents are effective for the treatment of RLS/WED. Until recently, the first-line treatment of RLS/WED consisted of low-dose dopamine agonists (DA). However, given the fact that DAs cause high rates of augmentation of symptoms, international guidelines recommend that whenever possible the initial treatment of choice should be an α2δ ligand, and avoidance of dopaminergic agents unless absolutely necessary. If necessary, the lowest effective dose should be used for only the shortest possible time. The symptoms of RLS/WED can disrupt the quality of sleep as well as the quality of life. IV iron therapy may be considered in patients with refractory RLS. A better understanding of RLS/WED pathophysiology will allow patients to receive tailored therapy, resulting in an improved quality of life.
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Affiliation(s)
- Sofía Romero-Peralta
- Sleep Research Institute, Madrid; Sleep Unit, Respiratory Department, Hospital Universitario Guadalajara, Guadalajara
| | - Irene Cano-Pumarega
- Sleep Research Institute, Madrid; Sleep Unit, Respiratory Department, Hospital Universitario Ramón y, Madrid, Spain
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Shaygannejad V, Sadeghi Bahmani D, Soleimani P, Mirmosayyeb O, Barzegar M, Amra B, Brand S. Comparison of prevalence rates of restless legs syndrome, self-assessed risks of obstructive sleep apnea, and daytime sleepiness among patients with multiple sclerosis (MS), clinically isolated syndrome (CIS) and Neuromyelitis Optica Spectrum Disorder (NMOSD). Sleep Med 2019; 70:97-105. [PMID: 32276200 DOI: 10.1016/j.sleep.2019.11.1266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/13/2019] [Accepted: 11/27/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prevalence rates for restless legs syndrome (RLS) and risk of Obstructive Sleep Apnea (OSA) in individuals with Neuromyelitis Optica Spectrum Disorder (NMOSD) and Clinically Isolated Syndrome (CIS) are unknown. The aims of the present study were to assess symptoms of RLS and self-assessed risks of OSA in individuals with NMOSD and CIS, to compare these prevalence rates with those of persons with multiple sclerosis (MS), and to associate RLS and OSA with expanded disability status scale (EDSS) scores, daytime sleepiness, fatigue, paresthesia, and medication. METHODS A total of 495 individuals (mean age = 34.92 years, 84.9% females) were assessed. Of these, 24 had NMOSD, 112 had CIS and 359 had MS. Trained neurologists ascertained individuals' neurological diagnoses, assessed their EDSS scores, and conducted a clinical interview to assess RLS. Additionally, participants completed questionnaires covering sociodemographic information, risks of snoring and OSA, daytime sleepiness, fatigue, paresthesia and medication. RESULTS Prevalence rates of RLS were 45.8% in NMOSD, 41.1% in CIS, and 28.7% in MS. Prevalence rates of self-assessed risks of OSA were 8.3% in NMOSD, 7.7% in CIS, and 7.8% in MS; these rates were not significantly different. Across the entire sample and within the diagnostic groups, RLS and OSA scores were unrelated to EDSS, daytime sleepiness, fatigue or medication. CONCLUSIONS Individuals with NMOSD, CIS and MS have high prevalence rates for RLS and self-assessed risks of obstructive sleep apnea syndrome (OSAS), which are unrelated to EDSS, daytime sleepiness, fatigue, paresthesia, or medication. Sleep issues should be monitored during routine check-ups for individuals with NMOSD and CIS.
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Affiliation(s)
- Vahid Shaygannejad
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Dena Sadeghi Bahmani
- University of Basel, Psychiatric Clinics (UPK), Center of Affective, Stress and Sleep Disorders (ZASS), Basel, Switzerland; Departments of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, USA; University of Basel, Psychiatric Clinics (UPK), Center of Old Age Psychiatry (ZAP), Basel, Switzerland; Kermanshah University of Medical Sciences (KUMS), Sleep Disorders Research Center, Kermanshah, Iran
| | - Parisa Soleimani
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Mirmosayyeb
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran
| | - Mehran Barzegar
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Babak Amra
- Pulmonary Unit, Department of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Serge Brand
- University of Basel, Psychiatric Clinics (UPK), Center of Affective, Stress and Sleep Disorders (ZASS), Basel, Switzerland; Kermanshah University of Medical Sciences (KUMS), Sleep Disorders Research Center, Kermanshah, Iran; Kermanshah University of Medical Sciences (KUMS), Substance Abuse Prevention Research Center, Health Institute, Kermanshah, Iran; University of Basel, Department of Sport, Exercise, and Health, Division of Sport Science and Psychosocial Health, Basel, Switzerland; Tehran University of Medical Sciences, School of Medicine, Tehran, Iran
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Reduced response to gabapentin enacarbil in restless legs syndrome following long-term dopaminergic treatment. Sleep Med 2019; 55:74-80. [DOI: 10.1016/j.sleep.2018.11.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/04/2018] [Accepted: 11/26/2018] [Indexed: 11/20/2022]
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Kerr S, Bentley A, Dafkin C, McKinon W. Disconnect between sensory and motor features of restless legs syndrome during the suggested immobilization test. Sleep Biol Rhythms 2018. [DOI: 10.1007/s41105-018-00202-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Winkelman JW, Jaros MJ. Predictors of clinical response in a double-blind placebo controlled crossover trial of gabapentin enacarbil for restless legs syndrome. Sleep Med 2018; 48:1-7. [DOI: 10.1016/j.sleep.2018.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/27/2018] [Accepted: 04/11/2018] [Indexed: 11/17/2022]
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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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Garcia-Borreguero D, Guitart X, Garcia Malo C, Cano-Pumarega I, Granizo JJ, Ferré S. Treatment of restless legs syndrome/Willis-Ekbom disease with the non-selective ENT1/ENT2 inhibitor dipyridamole: testing the adenosine hypothesis. Sleep Med 2018; 45:94-97. [DOI: 10.1016/j.sleep.2018.02.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/15/2017] [Accepted: 02/14/2018] [Indexed: 01/20/2023]
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Praharaj SK, Gupta R, Gaur N. Clinical Practice Guideline on Management of Sleep Disorders in the Elderly. Indian J Psychiatry 2018; 60. [PMID: 29535472 PMCID: PMC5840912 DOI: 10.4103/0019-5545.224477] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Ravi Gupta
- Department of Psychiatry and Sleep Medicine, Himalayan Institute of Medical Sciences, Doiwala, Dehradun
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Treatment of restless legs syndrome with the selective AMPA receptor antagonist perampanel. Sleep Med 2017; 34:105-108. [PMID: 28522077 DOI: 10.1016/j.sleep.2017.03.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/06/2017] [Accepted: 03/08/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Perampanel is a selective, noncompetitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA) antagonist that has been approved for the treatment of partial seizures. Here we report on the first open study evaluating its efficacy in idiopathic restless legs syndrome (RLS). METHODS The study was designed as a prospective two-month open trial. Twenty-two previously untreated patients diagnosed with idiopathic RLS began treatment with 2 mg perampanel, which was increased to 4 mg at week four if clinically necessary. Multiple Suggested Immobilization Tests (mSITs) followed by polysomnography were performed at baseline and at week eight. Severity ratings were performed every two weeks by means of the IRLS scale, and Clinical Global Index (CGI) subscale. The main endpoint was therapeutic response, defined as a 50% improvement in IRLS total score. RESULTS Twenty patients completed the study. During the 8-week treatment period, the IRLS score improved from a mean (±standard deviation (SD)) 23.7 ± 4.2 to 11.5 ± 5.3. Twelve of 20 patients were full responders (improvement 50% in IRLS total score), and four responded partially. The mean effective dose of perampanel at the end of treatment was 3.8 mg/day. Treatment with perampanel also resulted in an improvement in the mean (±SD) periodic leg movement index from 27.8 ± 6.9 to 4.36 ± 2.0. Perampanel was well tolerated. The main side effects were dizziness, somnolence, headache, and irritability. CONCLUSION These preliminary results suggest that perampanel has significant therapeutic effects on both sensory and motor symptoms. If confirmed by future controlled studies, perampanel might become a promising alternative to existing dopaminergic treatments due to its glutamatergic mechanism of action. The study provides class IV evidence supporting the therapeutic effects of perampanel in RLS/WED.
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Congiu P, Fantini ML, Milioli G, Tacconi P, Figorilli M, Gioi G, Pereira B, Marrosu F, Parrino L, Puligheddu M. F-Wave Duration as a Specific and Sensitive Tool for the Diagnosis of Restless Legs Syndrome/Willis-Ekbom Disease. J Clin Sleep Med 2017; 13:369-375. [PMID: 28095964 DOI: 10.5664/jcsm.6482] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 11/16/2016] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVES Restless legs syndrome, also known as Willis-Ekbom disease (RLS/WED), is a frequent condition, though its pathophysiology is not completely understood. The diagnosis of RLS/WED relies on clinical criteria, and the only instrumental tool, the suggested immobilization test, may lead to equivocal results. Recently, neurophysiological parameters related to F-wave duration have been proposed as a diagnostic aid. The aim of this study is to assess and compare the diagnostic values of these parameters in diagnosis of RLS/WED. METHODS Fifteen women affected by primary RLS/WED and 17 age- and sex- matched healthy subjects. A complete electroneurographic evaluation, including nerve conduction studies (NCS), cutaneous silent period (CSP), and F-wave parameters, namely amplitude, F-wave duration (FWD), and the ratio between FWD and duration of the corresponding compound muscle action potential (FWD/CMAPD). RESULTS No subject showed alterations of the NCS. However, FWD and FWD/CMAPD of both upper and lower limbs were significantly longer in patients than controls. Tibial FWD/CMAPD best discriminated RLS/WED patients from controls. A cutoff of 2.06 yielded a sensitivity of 69.2%, a specificity of 94.1%, a positive predictive power of 90%, and a negative predictive power of 80% (area under the curve = 0.817; 95% confidence interval = 0.674-0.959). The combination of ulnar or tibial FWD/CMAPD increases the sensitivity (85.7%) while slightly decreasing the specificity (87.5%, positive predictive value: 85.7%, negative predictive value: 87.5%). CONCLUSIONS Lower limb FWD/CMAPD ratio may represent a supportive diagnostic tool, especially in cases of evening lower leg discomfort of unclear interpretation.
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Affiliation(s)
| | | | | | | | | | - Gioia Gioi
- Sleep Disorders Center, University of Cagliari, Italy
| | - Bruno Pereira
- Biostatistics Unit (DRCI), CHU Clermont-Ferrand, France
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Shin JW, Koo YS, Lee BU, Shin WC, Lee SK, Cho YW, Jung KY. Prevalence and Characteristics of Periodic Limb Movements during Sleep in Korean Adult Patients with Restless Legs Syndrome. J Clin Sleep Med 2016; 12:1089-97. [PMID: 27306390 DOI: 10.5664/jcsm.6042] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 05/11/2016] [Indexed: 12/25/2022]
Abstract
STUDY OBJECTIVES The aim of this study was to investigate the prevalence and characteristics of periodic limb movements during sleep (PLMS) in Korean patients with restless legs syndrome (RLS). METHODS Unmedicated adult patients with idiopathic RLS (n = 354) who underwent polysomnography at three major sleep centers in tertiary hospitals were included. Characteristics of PLMS in RLS were analyzed using the time structure of polysomnographically recorded leg movements and periodicity indices (PIs). RLS severity and subjective sleep quality were assessed. RESULTS Out of 354 patients with idiopathic RLS (mean age: 52.9 ± 12.0 years), 150 patients (42.3%) had RLS with a PLMS index greater than 15 events/h, and 204 (57.9%) had a PLMS index greater than 5 events/h. The distribution of inter-LM intervals was bimodal, and high PIs (0.86 ± 0.10) were observed in patients with RLS and PLMS (PLMS index > 15 events/h). The PLMS index was positively correlated with age (r = 0.228; p < 0.001), the periodic limb movements in wakefulness index (r = 0.455, p < 0.001) and arousal index (r = 0.174, p = 0.014), but not with RLS severity and parameters of sleep quality. In multivariate analysis, age and male gender were independently associated with PLMS > 15 events/h. CONCLUSIONS The prevalence of PLMS in Korean patients with RLS was lower than that observed in Western countries, but the characteristics of PLMS were not different. Ethnic differences and/or different genetic backgrounds may contribute to the varying prevalence of PLMS in RLS.
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Affiliation(s)
- Jung-Won Shin
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Yong Seo Koo
- Department of Neurology, Korea University Medical Center Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byeong Uk Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Won Chul Shin
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Sang Kun Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Won Cho
- Department of Neurology, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Republic of Korea
| | - Ki-Young Jung
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Ipsiroglu OS, Beyzaei N, Berger M, Wagner AL, Dhalla S, Garden J, Stockler S. "Emplotted Narratives" and Structured "Behavioral Observations" Supporting the Diagnosis of Willis-Ekbom Disease/Restless Legs Syndrome in Children with Neurodevelopmental Conditions. CNS Neurosci Ther 2016; 22:894-905. [PMID: 27292821 PMCID: PMC5095767 DOI: 10.1111/cns.12564] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/12/2016] [Accepted: 04/17/2016] [Indexed: 11/29/2022] Open
Abstract
Background Willis‐Ekbom disease/restless legs syndrome (WED/RLS) seems to be a frequent cause of intractable chronic insomnia (ICI) but is under‐recognized in children/adolescents with neurodevelopmental conditions (NDCs), as many patients do not have the ability to express the underlying “urge‐to‐move”. In light of this, we aim to develop a protocol for behavioral observations supporting the diagnosis of WED/RLS. Methods We investigated 26 pediatric patients (age 1–16 years, median 8) with NDCs, ICI and evidence of familial WED/RLS employing (1) “emplotted narratives” for description of the various “urge‐to‐move” presentations and (2) self‐description and “behavioral observations” during a “suggested clinical immobilization test” (SCIT). Results Parental narratives reflected typical WED/RLS‐related “urge‐to‐move” symptoms during day‐, bed‐, and nighttime in all patients. Fifteen out of 26 patients could describe the “urge‐to‐move” during the SCIT. Ten out of 26 patients, unable to describe their symptoms due to cognitive disabilities, showed patterns of “relieving‐movements” upon observation. Sensory processing abnormalities were reported in all patients, with tactile sensitivities (26/26) (including shifted pain threshold) as the most common sensory domain. Conclusion “Emplotted narratives” and structured “behavioral observations” support recognition of familial WED/RLS associated movement patterns and provide a useful tool for the diagnosis of WED/RLS in children with NDCs in a clinical office setting.
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Affiliation(s)
- Osman S Ipsiroglu
- Sleep/Wake-Behaviour Clinic & Research Lab, Division of Developmental Pediatrics, Department of Pediatrics, Faculty of Medicine, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Nadia Beyzaei
- Sleep/Wake-Behaviour Clinic & Research Lab, Division of Developmental Pediatrics, Department of Pediatrics, Faculty of Medicine, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Mai Berger
- Sleep/Wake-Behaviour Clinic & Research Lab, Division of Developmental Pediatrics, Department of Pediatrics, Faculty of Medicine, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alexandra L Wagner
- Sleep/Wake-Behaviour Clinic & Research Lab, Division of Developmental Pediatrics, Department of Pediatrics, Faculty of Medicine, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Sophia Dhalla
- Sleep/Wake-Behaviour Clinic & Research Lab, Division of Developmental Pediatrics, Department of Pediatrics, Faculty of Medicine, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Garden
- Sleepdreams Professional Sleep Consultants, Inc. and Capilano University, North Vancouver, BC, Canada
| | - Sylvia Stockler
- Division of Biochemical Diseases, Department of Pediatrics, Faculty of Medicine, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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Garcia-Borreguero D, Allen R, Hudson J, Dohin E, Grieger F, Moran K, Schollmayer E, Smit R, Winkelman J. Effects of rotigotine on daytime symptoms in patients with primary restless legs syndrome: a randomized, placebo-controlled study. Curr Med Res Opin 2016; 32:77-85. [PMID: 26569149 DOI: 10.1185/03007995.2015.1103216] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This 12 week double-blind, placebo-controlled study (ClinicalTrials.gov: NCT01569464) was conducted to evaluate the effects of rotigotine transdermal patch on daytime symptoms in patients with idiopathic restless legs syndrome (RLS). METHODS Adult patients with moderate-to-severe RLS were randomized to rotigotine (optimal dose: 1-3 mg/24 h) or placebo. A modified four-assessment version (4:00 pm, 6:00 pm, 8:00 pm, and 10:00 pm) of the Multiple Suggested Immobilization Test (m-SIT) was performed at baseline and end of 4 week maintenance (EoM). Primary study outcomes were change from baseline to EoM in International Restless Legs Syndrome Rating Scale (IRLS) and in average of means for the m-SIT Discomfort Scale (m-SIT-DS) (combined average of mean values from each of the individual assessments). Secondary outcomes included average of means of Periodic Limb Movement during Wakefulness Index (PLMWI; PLM/hour) for the combination of m-SIT. RESULTS A total of 150 patients were randomized and 137 (rotigotine: 92/101 [91.1%]; placebo: 45/49 [91.8%]) completed maintenance. All 150 randomized patients were assessed for efficacy. At EoM, mean change in IRLS was -14.9 ± 9.3 with rotigotine vs. -12.7 ± 7.6 with placebo (ANCOVA, LS mean treatment difference [95% CI]: -0.27 [-2.96, 2.42]; p = 0.8451). Changes in average of means of m-SIT-DS values of each individual SIT were comparable with rotigotine (-2.68 ± 2.31) vs. placebo (-2.62 ± 2.61) (ANCOVA, LS mean treatment difference [95% CI]: 0.07 [-0.61, 0.75]; p = 0.8336) and comparable reductions in PLMWI were observed in both treatment groups (8.34 [-8.50, 25.17]; p = 0.3290). Rotigotine was generally well tolerated. Application site reactions (rotigotine: 20 patients [19.8%]; placebo: 4 [8.2%]) and nausea (16 [15.8%]; 3 [6.1%]) were the most common AEs. CONCLUSIONS Rotigotine was beneficial in improving overall RLS symptom severity (assessed by IRLS) and RLS symptom severity at various times of the day (m-SIT-DS); however, superiority to placebo was not established.
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Affiliation(s)
| | - Richard Allen
- b b Department of Neurology , Johns Hopkins Bayview Medical Center , Baltimore , MD , USA
| | - John Hudson
- c c FutureSearch Trials of Neurology , Austin , TX , USA
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Kumru H, Vidal J, Benito J, Barrio M, Portell E, Valles M, Flores C, Santamaria J. Restless leg syndrome in patients with spinal cord injury. Parkinsonism Relat Disord 2015; 21:1461-4. [DOI: 10.1016/j.parkreldis.2015.10.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 09/29/2015] [Accepted: 10/05/2015] [Indexed: 11/28/2022]
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Garcia-Borreguero D, Benitez A, Kohnen R, Allen R. Augmentation of restless leg syndrome (Willis-Ekbom disease) during long-term dopaminergic treatment. Postgrad Med 2015; 127:716-25. [PMID: 26077324 DOI: 10.1080/00325481.2015.1058140] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED), is a common sensorimotor disorder that can generally be effectively managed in the primary care clinic. However, some treatment complications may arise. According to the recommendations of the International Restless Legs Syndrome Study Group, non-ergot dopamine-receptor agonists have over the past years been one of the first-line treatments for patients with RLS/WED requiring pharmacological therapy. Augmentation is the main complication of long-term dopaminergic treatment of RLS/WED and is defined as an overall worsening of symptoms beyond pretreatment levels in patients who experienced an initial positive therapeutic response. Once identified on the basis of its characteristic clinical features, augmentation requires careful management. In order to provide clinicians with a comprehensive understanding of this common treatment complication, this review discusses the clinical features of augmentation, and its differentiation from morning rebound, symptom fluctuations and natural disease progression. Reported incidences of augmentation in clinical trials of dopaminergic RLS/WED therapies are summarized. Finally, the hypothetical pathophysiology of augmentation and the current recommendations for management of patients with augmented RLS/WED symptoms are discussed.
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Wijemanne S, Jankovic J. Restless legs syndrome: clinical presentation diagnosis and treatment. Sleep Med 2015; 16:678-90. [PMID: 25979181 DOI: 10.1016/j.sleep.2015.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 02/28/2015] [Accepted: 03/02/2015] [Indexed: 12/27/2022]
Abstract
Restless legs syndrome (RLS) is a circadian disorder of sensory-motor integration that may be related to genetically determined dysregulation of iron transport across the blood-brain barrier. Dopamine agonists (DAs) have been considered the first-line therapy, but with the growing appreciation of problems associated with long-term treatment, particularly augmentation and impulse control disorder, alpha-2-delta drugs, such as gabapentin, are now considered the first line of treatment in patients with troublesome RLS. Opioids can be considered as an alternative therapy, particularly in patients with DA-related augmentation. In more severe cases, a combination therapy may be required. Intravenous iron therapy may be considered on those patients with refractory RLS.
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Affiliation(s)
- Subhashie Wijemanne
- Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA.
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An update on restless legs syndrome (Willis-Ekbom disease): clinical features, pathogenesis and treatment. Curr Opin Neurol 2015; 27:493-501. [PMID: 24978636 DOI: 10.1097/wco.0000000000000117] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW In recent years, there have been a number of advances in the field of restless legs syndrome (RLS) or Willis-Ekbom disease (WED). Here, we review recent studies pertaining to the diagnosis and clinical features, pathogenesis, and treatment of RLS/WED. RECENT FINDINGS Recent studies have added a temporal dimension to RLS/WED epidemiology by examining both the incidence and persistence rates in different populations. Diagnostic criteria have been modified to increase sensitivity, and new guidelines take into account recently published studies of different drug classes. SUMMARY Recent epidemiological findings have shown that RLS/WED is a common neurological disorder that affects up to 5% of the adult population in Western countries. In moderate and severe cases, RLS/WED has a strong impact on sleep and quality of life and can involve an increased cardiovascular risk. Diagnosis is made clinically by confirming the presence of the five essential criteria. However, in difficult cases objective tests such as the multiple suggested immobilization test (m-SIT) can be used. The pathophysiology is partially known, with several risk polymorphisms (BTBD-9 (BTB (POZ) domain containing 9), MEIS-1 (Meis homeobox 1), protein tyrosine phosphatase, receptor type, D, and others) playing an important role, along with dopaminergic and iron dysfunctions. The disorder frequently requires long-term treatment with low-dose dopamine agonists or α2δ ligands. Dopamine agonists are usually effective but the main complication, RLS/WED augmentation, can arise.
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Restless legs syndrome in patients with sequelae of poliomyelitis. Parkinsonism Relat Disord 2014; 20:1056-8. [DOI: 10.1016/j.parkreldis.2014.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 06/13/2014] [Accepted: 06/17/2014] [Indexed: 11/19/2022]
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Klingelhoefer L, Cova I, Gupta S, Chaudhuri KR. A review of current treatment strategies for restless legs syndrome (Willis-Ekbom disease). Clin Med (Lond) 2014; 14:520-4. [PMID: 25301914 PMCID: PMC4951962 DOI: 10.7861/clinmedicine.14-5-520] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Restless legs syndrome (RLS), recently renamed Willis-Ekbom disease (WED), is a common movement disorder. It is characterised by the need to move mainly the legs due to uncomfortable, sometimes painful sensations in the legs, which have a diurnal variation and a release with movement. Management is complex. First, centres should establish the severity of RLS using a simple 10-item RLS severity rating scale (IRLS). They should also exclude secondary causes, in particular ensuring normal iron levels. Mild cases can be managed by lifestyle changes, but patients with a IRLS score above 15 usually require pharmacological treatment. Dopaminergic therapies remain the mainstay of medical therapies, with recent evidence suggesting opioids may be particularly effective. This article focuses on the different treatment strategies in RLS, their associated complications and ways to manage them.
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Affiliation(s)
- Lisa Klingelhoefer
- National Parkinson Foundation International Centre of Excellence, King's College Hospital and King's College, London, UK and resident, Department of Neurology, Technical University Dresden, Dresden, Germany
| | - Ilaria Cova
- National Parkinson Foundation International Centre of Excellence, King's College Hospital and King's College, London, UK
| | - Sheena Gupta
- National Parkinson Foundation International Centre of Excellence, King's College Hospital and King's College, London, UK
| | - Kallol Ray Chaudhuri
- National Parkinson Foundation International Centre of Excellence, King's College Hospital and King's College, London, UK
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Wali S, Shukr A, Boudal A, Alsaiari A, Krayem A. The effect of vitamin D supplements on the severity of restless legs syndrome. Sleep Breath 2014; 19:579-83. [DOI: 10.1007/s11325-014-1049-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/29/2014] [Accepted: 08/05/2014] [Indexed: 11/27/2022]
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Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria--history, rationale, description, and significance. Sleep Med 2014; 15:860-73. [PMID: 25023924 DOI: 10.1016/j.sleep.2014.03.025] [Citation(s) in RCA: 917] [Impact Index Per Article: 91.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/23/2014] [Accepted: 03/25/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND In 2003, following a workshop at the National Institutes of Health, the International Restless Legs Syndrome Study Group (IRLSSG) developed updated diagnostic criteria for restless legs syndrome/Willis-Ekbom disease (RLS/WED). These criteria were integral to major advances in research, notably in epidemiology, biology, and treatment of RLS/WED. However, extensive review of accumulating literature based on the 2003 NIH/IRLSSG criteria led to efforts to improve the diagnostic criteria further. METHODS The clinical standards workshop, sponsored by the WED Foundation and IRLSSG in 2008, started a four-year process for updating the diagnostic criteria. That process included a rigorous review of research advances and input from clinical experts across multiple disciplines. After broad consensus was attained, the criteria were formally approved by the IRLSSG executive committee and membership. RESULTS Major changes are: (i) addition of a fifth essential criterion, differential diagnosis, to improve specificity by requiring that RLS/WED symptoms not be confused with similar symptoms from other conditions; (ii) addition of a specifier to delineate clinically significant RLS/WED; (iii) addition of course specifiers to classify RLS/WED as chronic-persistent or intermittent; and (iv) merging of the pediatric with the adult diagnostic criteria. Also discussed are supportive features and clinical aspects that are important in the diagnostic evaluation. CONCLUSIONS The IRLSSG consensus criteria for RLS/WED represent an international, interdisciplinary, and collaborative effort intended to improve clinical practice and promote further research.
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