[Restless legs syndrome and nocturnal leg pain : Differential diagnosis and treatment]

Pain in the legs belongs to the five most frequent regional pain symptoms. Restless legs syndrome (RLS) presents a particular differential diagnosis for pain in the legs, which is characterized by a nocturnal urge to move the legs often associated with painful sensations in the legs. It is one of the most common neurological disorders and probably the leading cause of nocturnal pain in the legs. In this overview, the diagnosis and therapy of RLS as well as aspects of pain therapy of the disorder are presented. In addition, the differential diagnoses for exclusion of other specific causes of nocturnal pain in the legs are discussed.

[Restless legs syndrome, periodic limb movements, and psychopharmacology]

Restless legs syndrome (RLS) and the often associated periodic limb movement disorder in sleep (PLMD) frequently occur in the general population as a primary disorder. In addition to organic disease, secondary forms are caused by psychotropic medication. Several antidepressants, antipsychotics, lithium, and opioid withdrawal have been shown to induce or exacerbate RLS and PLMD, while several antiepileptics used as mood stabilizers and some benzodiazepines demonstrate therapeutic potential for treating RLS/PLMD. Systematic or controlled studies for evaluating these side effects still do not exist. Among the antidepressants at higher risk of inducing this disorder are selective serotonin reuptake inhibitors, venlafaxine, and some tetracyclic antidepressants. Under medication with some tricyclic substances, periodic limb movements were observed more often. For some antidepressants with differing transmitter profiles such as bupropion RLS/PLMD ameliorating effects or at least neutral effects (Trazodon, Nortriptylin) have been described in small studies. In case of continued of or newly occurring insomnia a thorough history should be taken to identify a possible RLS/PLMD as an intolerable side effect of treatment. A change in medications should be considered if clinically feasible. In case of RLS/PLMD occurring in psychotic patients switching the antipsychotic and additionally using a second line medication such as antiepileptics or a benzodiazepine should be considered.

Are adolescents chronically sleep-deprived? An investigation of sleep habits of adolescents in the Southwest of Germany

BACKGROUND

Adolescent sleep receives increasing attention. Several studies have shown that adolescents generally do not sleep enough. This survey assessed adolescents' sleep patterns, and results were compared with sleep logs.

METHODS

A total of 818 students aged 12-18 attending three different school types were asked to complete a questionnaire, adapted from the 'School Sleep Habits Survey', and filled in a sleep protocol over 2 weeks. Information on sleep patterns and demographic data were obtained additionally.

RESULTS

A total of 601 students completed the questionnaire (i.e. 73.5% return rate), 55.1% female and 44.9% male. Average sleep duration during the week amounted to 8.04+/-0.89 h and 9.51+/-1.65 h on weekends. Sleep duration times on school days decreased from an average 8.64+/-0.83 h for the age category 12-13 years to 7.83+/-0.72 h for students above 16 years. 91.6% of all students slept less than 9.2 h per night during the week. Data from the 153 returned sleep logs showed even lower sleep times (7.75+/-0.82 h for school nights).

CONCLUSIONS

The main hypothesis that students sleep on average considerably less than the recommended 9 h during weekdays was confirmed. Bedtimes changed throughout the week with the latest on Friday and Saturday nights and the least sleep around midweek. There were no significant group differences regarding school type and environment (rural vs. urban). Interestingly, the majority reported only little daytime sleepiness and no impaired performance. Results regarding the consequences of chronic sleep deprivation in the literature are inconclusive. The impact on physiological parameters, especially metabolic functions, requires further investigations.

Cognitive behavioural group therapy to improve patients' strategies for coping with restless legs syndrome: a proof-of-concept trial

BACKGROUND

Restless legs syndrome (RLS) is a usually chronic disorder accompanied by clinically relevant psychosocial impairment. To date, no psychologically based approach is available to improve the coping strategies and quality of life of RLS sufferers.

OBJECTIVE

To develop cognitive behavioural therapy tailored to this disorder (the RELEGS coping therapy programme) and present the results of this proof-of-concept study.

METHODS

Twenty-five patients (five men, 20 women; 15 medicated, 10 unmedicated; mean (SD) age 56.1 (12.3) years) with subjective psychosocial impairment due to RLS participated in one of three consecutive therapy groups. The severity scales (IRLS and RLS-6) indicated moderate to severe RLS symptoms at baseline. Exclusion criteria were secondary RLS, foreseeable change of RLS medication during the study period, serious physical or psychiatric comorbidity, and severe cognitive deficits. Each group took part in eight group sessions (90 min each with a break).

RESULTS

At the end of the treatment, both the RLS-related quality of life and the mental health status of the subjects had improved significantly (QoL-RLS scale: from 28.6 (12.8) to 23.4 (13.1); SCL-90-R: from 51.3 (37.0) to 45.9 (32.9)). The improvement remained at follow-up 3 months later. Subjective ratings of RLS severity had improved at the end of therapy and at follow-up. Psychometric scales not specific for RLS-related impairment remained unaffected by the treatment.

CONCLUSIONS

The study establishes the feasibility and high acceptance of the newly devised therapy programme. The application of RLS-oriented specific psychological strategies is a step toward an integrated treatment approach in RLS.

Das distale posttraumatische Ödem - Symptom einer sympathischen Reflexdystrophie (M. Sudeck)?

The present paper describes various mechanisms, possibly being involved in the development of the posttraumatic, distally generalized edema. New ideas point to a special importance of the sympathetic vasoconstrictor system for this clinical phenomenon, since this system could induce an enhanced venoconstriction at the exit of the capillary bed, which would result in an edema producing diminished venous return. Since the distally generalized edema is an initially and very commonly occurring symptom of reflex sympathetic dystrophy (M. Sudeck), the observation of such an edema should lead one to look for further symptoms of this disorder, especially for the typical triad of autonomic (sympathetic), motor, and sensory disturbances.

[Generalized anxiety disorder with comorbidity. Treatment with pregabalin]

The efficacy of pregabalin in treating generalized anxiety disorder (GAD) has been shown in recent studies. Our experience and case reports in the present publication indicate that pregabalin can be an effective therapeutic option for patients with GAD and comorbid psychiatric disorders. Treatment with pregabalin should also be considered in patients with partial remission of GAD or intolerability of SSRI or SNRI.

Effective cabergoline treatment in idiopathic restless legs syndrome

OBJECTIVE

To assess the efficacy and safety of the dopamine agonist cabergoline (CAB) in patients with restless legs syndrome (RLS).

METHODS

Patients with moderate to severe RLS were randomized into four groups receiving placebo, 0.5 mg, 1 mg, or 2 mg CAB once daily in a double-blind, placebo-controlled, multicenter dose-finding trial followed by an open long-term extension trial of 47 weeks. Efficacy was assessed with the RLS-6 scales and International RLS Study Group severity scale (IRLS).

RESULTS

A total of 85 patients (age 56 +/- 10 years, 71% females) were treated. Severity of RLS-6 scale symptoms during the night (the primary endpoint) was markedly improved by all CAB doses compared to placebo (placebo: -1.4 +/- 3.1, 0.5 mg CAB: -4.2 +/- 3.0 [p = 0.0082], 1.0 mg CAB: -4.0 +/- 2.9 [p = 0.0040], 2.0 mg CAB: -4.8 +/- 3.7 [p = 0.0026]). Similar results were found for the RLS severity at bedtime and during the day, IRLS, and satisfaction with sleep. A stable, clinically relevant improvement was achieved in all efficacy measures (severity during the night: change between last assessment and baseline: -5.6 +/- 2.5, rate of remission: 71.2%) throughout 1 year with a mean CAB dose of 2.2 mg per day. During long-term treatment, 6 of 66 treated patients were affected (n = 2) or possibly affected (n = 4) by mild augmentation. Under CAB therapy up to 1 year, 11 of 85 patients discontinued treatment due to a drug-related adverse event.

CONCLUSIONS

Cabergoline is an efficacious and well-tolerated option for the treatment of restless legs symptoms during the night and the day.

Ruptured intrasellar superior hypophyseal artery aneurysm presenting with pure subdural haematoma. Case report

SUMMARY

Subdural haemorrhage from a ruptured intracranial aneurysm is a well-known entity when associated with subarachnoid haemorrhage. However, haemorrhage confined only to the subdural space is rare because there are limited anatomical sites where extravasation can be purely subdural. We report the rare case of a patient who suffered pure subdural haematoma after the rupture of a left superior hypophyseal artery aneurysm located within the sella turcica. The patient was treated with endovascular coil embolization of the aneurysm. Angiography immediately after treatment and one month later revealed complete obliteration of the aneurysm. Six months after treatment, the patient remained symptom free.

Das Restless-legs-Syndrom im Kindesalter

The diagnostic criteria of restless legs syndrome were defined in 1995 by the International Restless Legs Syndrome Study Group (IRLSSG). In light of the latest scientific evidence and increasing clinical experience, the diagnostic criteria were revised in a consensus workshop. Participants of the workshop considered the development of new diagnostic criteria especially important for the following subgroups: (1) for children and (2) for the cognitively impaired elderly. The common characteristic of both groups lies in their difficulty in expressing subjective symptoms adequately. This considerably impedes the diagnosis of restless legs syndrome. In 2002, a proposal for diagnostic criteria of restless legs syndrome in childhood was formulated by members of the study groups "Movement Disorders and Sleep" and "Paediatrics" of the German Sleep Society. The proposal was partially incorporated into the diagnostic criteria for restless legs syndrome in childhood suggested by the IRLSSG. The current criteria are recommendations to enhance further research and must be validated by clinical studies. The following article gives an overview of published studies on restless legs syndrome in childhood, reviews the proposals for diagnostic criteria, and summarizes the peculiarities to be considered in diagnosing restless legs syndrome in children.

[Algorithms for diagnosis and therapy of sleep disorders in general practice]

Complaints of insomnia, i.e. problems to fall asleep or maintain asleep and/or non-restorative sleep are very common in general practice. This article presents the clinical algorithm non-restorative sleep which was devised by the German Society for Sleep Research and Sleep Medicine. This algorithm presents a guideline for the diagnosis and the treatment of insomnia.

Sleep and the cholinergic rem sleep induction test in patients with primary alcoholism

Sleep disturbances of alcoholics while actively drinking and at the beginning of, and during, abstinence were frequently reported. Recently, Gillin et al. (1994) showed that a high "REM sleep pressure" at the time of admission to a 1-month inpatient alcohol treatment program predicted the relapse in nondepressed patients with primary alcoholism at 3 months following hospital discharge. We investigated 24 patients with primary alcoholism after 2-3 weeks abstinence in the sleep laboratory; in 15 of these patients the cholinergic REM sleep induction test (CRIT) with 10 mg galanthamine was performed additionally. In comparison with an age- and sex-matched healthy control group, patients had a heightened "REM sleep pressure" including shortened REM latency and increased REM density. A decrease of serotonergic neurotransmission is proposed as being the neurochemical mechanism to explain the results in alcoholic subjects. Follow-up investigations will clarify whether the sleep abnormalities in alcoholism are state- or trait-markers and whether they are suitable to predict the relapse risk.

Irving S. Cooper and the early surgical management of movement disorders. Video history

Irving S. Cooper was a pioneer in the field of functional neurosurgery. During his very productive and controversial career, he proposed the surgical treatment of Parkinson disease (PD) by ligating the anterior choroidal artery to control tremor and rigidity. Subsequently, he developed seminal techniques for chemopallidectomy and cryothalamectomy for PD. He also attempted to use electrical stimulation of the cerebellum or the thalamus to treat spasticity. Cooper continued his work on brain stimulation until his death in 1985. He made video recordings of nearly all of his patients during his tenure (1977-1985) at New York Medical College. Cooper's clinical video recordings were reviewed, and selected footage was compiled into a video history of Cooper's surgical management of various movement disorders. Included are pre-, post-, and some intraoperative recordings that Cooper made to document his treatment of patients with PD, tremor, Wilson disease, cerebral palsy, chorea, dystonia musculorum deformans, and some rarer entities.

A double-blind, randomized and placebo-controlled study on the polysomnographic withdrawal effects of zopiclone, zolpidem and triazolam in healthy subjects

Rebound effects after withdrawal from hypnotics are believed to trigger their chronic use and to enhance the risk of tolerance and dependence. It was the purpose of this study to investigate the acute polysomnographic withdrawal effects after a 4 week treatment with standard doses of the non-benzodiazepine hypnotics zopiclone and zolpidem compared with triazolam and placebo. Healthy male subjects between 22 and 35 years of age participated in a parallel study design. They received either zopiclone 7.5 mg (n=11), zolpidem 10 mg (n=11), triazolam 0.25 mg (n=10) or placebo (n=7) over 4 weeks in randomized and double-blind order. Sleep EEG was registered during 2 nights before treatment under placebo, on days 1, 27 and 28 of treatment and on days 29,30,41 and 42 under placebo. Total sleep time and sleep efficiency were lower in the 1st night after discontinuation of triazolam (p < 0.05, t-test). After withdrawal from zopiclone or zolpidem slight but not significant rebound effects concerning sleep continuity were observed. Self-rating scales showed minimal rebound insomnia after discontinuation of all three hypnotics. In the placebo group no changes of sleep parameters were observed. Assuming that rebound insomnia is part of a withdrawal reaction, this study indicates that the risks of tolerance and dependency are low when administering zopiclone or zolpidem at the recommended doses.

Magnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study

Periodic limb movements during sleep (PLMS), with or without symptoms of a restless legs syndrome (RLS), may cause sleep disturbances. The pharmacologic treatments of choice are dopaminergic drugs. Their use, however, may be limited due to tolerance development or rebound phenomena. Anecdotal observations have shown that oral magnesium therapy may ameliorate symptoms in patients with moderate RLS. We report on an open clinical and polysomnographic study in 10 patients (mean age 57 +/- 9 years; 6 men, 4 women) suffering from insomnia related to PLMS (n = 4) or mild-to-moderate RLS (n = 6). Magnesium was administered orally at a dose of 12.4 mmol in the evening over a period of 4-6 weeks. Following magnesium treatment, PLMS associated with arousals (PLMS-A) decreased significantly (17 +/- 7 vs 7 +/- 7 events per hour of total sleep time, p < 0.05). PLMS without arousal were also moderately reduced (PLMS per hour of total sleep time 33 +/- 16 vs 21 +/- 23, p = 0.07). Sleep efficiency improved from 75 +/- 12% to 85 +/- 8% (p < 0.01). In the group of patients estimating their sleep and/or symptoms of RLS as improved after therapy (n = 7), the effects of magnesium on PLMS and PLMS-A were even more pronounced. Our study indicates that magnesium treatment may be a useful alternative therapy in patients with mild or moderate RLS-or PLMS-related insomnia. Further investigations regarding the role of magnesium in the pathophysiology of RLS and placebo-controlled studies need to be performed.

A 19-h spontaneous sleep period in idiopathic central nervous system hypersomnia

Reports of prolonged sleep periods in idiopathic central nervous system hypersomnia, as shown by ad libitum sleep recordings, are rare. A patient with idiopathic hypersomnia with extremely long sleep periods and sleep drunkenness after awakening is described. Polysomnographic recordings showed a spontaneous sleep period of 19.4 h and a normal Multiple Sleep Latency Test. These polysomnographic findings are clearly abnormal but essentially different form those of narcolepsy. Unlike narcolepsy, 'idiopathic hypersomnia' does not seem to be a distinct clinical entity but a category for different heterogenous subtypes.

Impact of experimentally induced serotonin deficiency by tryptophan depletion on sleep EEG in healthy subjects

The tryptophan depletion test is a research strategy to investigate the functional consequences of decreasing the brain serotonin metabolism. Because serotonin is involved in sleep regulation and the regulation of affective states, we studied the acute polysomnographic effects of tryptophan depletion and expected to induce similar changes of sleep EEG as observed in depressed patients. A total of 12 healthy subjects (mean age 34 +/- 3 years) had eight polysomnograms, divided in two blocks of 4 consecutive nights. After one adaptation and 1 baseline night, subjects received a low-protein diet on day 3 and 4 until midday. On day 4 at 18.00 h, they drank an amino acid mixture either devoid of tryptophan or containing 2.3 g of tryptophan (placebo control) in randomized and double-blind order, resulting in an 85% decrease (tryptophan depletion) and a 144% increase (placebo control) of serum tryptophan at 22.00 h. After tryptophan depletion but not placebo, significant effects on sleep EEG were observed in terms of decreased non-rapid eye movement (non-REM) stage 2, increase of wake %, and of rapid eye movement (REM) density compared with baseline. REM latency was not altered, however the first and second REM period interval were significantly shorter after tryptophan depletion. This study underlines the impact of the serotonergic system on sleep maintenance and on REM sleep.

Clinical significance of computed tomography in early aneurysm surgery

The significance of computer tomographic findings for the analysis of complications or the course and prognosis after early aneurysm surgery was analyzed on the basis of 100 patients consecutively operated on for ruptured cerebral aneurysms. Intracerebral or extended intraventricular hematomas were a poor prognostic sign. An acute hydrocephalus had a negative effect only on the early course but not on the final results. Nearly all (94) of the patients presented postoperatively with a cerebral volume increase either by CSF release, edema, and/or vasoparalysis. A correlation with the final result could not be observed. Twenty-two patients presented with ischemic infarction in the postoperative CT scan, one had hemorrhagic infarction. In 19 of the 22 cases the cause of the infarction could be related to the surgical trauma. In 10 cases it remained asymptomatic. In only one case vasospasm was responsible for a symptomatic infarction. The findings show that early surgical repair of a ruptured cerebral aneurysm is an effective method to prevent rebleeding and ischemic infarction by vasospasm. The hemorrhage and the operation, however, are followed by a large number of visible morphological lesions in the CT scan.

Sympathetic muscle nerve activity during sleep in man

Muscle sympathetic activity (MSA) was recorded in the peroneal nerve during sleep in 14 sleep-deprived healthy subjects. Continuous noninvasive recordings of finger blood pressure were obtained in 7 subjects. In light sleep (stage 2 sleep) the number of sympathetic bursts/min decreased to 90 +/- 8% (mean +/- SEM) and total MSA (= burst/min x mean burst area) to 89 +/- 5% of the awake value (P less than 0.05, n = 14). In deep sleep (stage 3-4) total MSA decreased further, to 71 +/- 8% of the awake value (n = 5). There was no close correlation between variations of depth of sleep and variations of sympathetic activity but during continuously deepening sleep MSA decreased progressively with time. In stage 2 sleep, high amplitude K complexes were accompanied by short-lasting increases of sympathetic activity. Since these increases of MSA were not preceded by decreases of diastolic blood pressure, which is known to evoke increased sympathetic nerve traffic in muscle nerves, we suggest that K complex related increases of MSA are signs of arousal which elicit both cortical EEG phenomena and activation of cerebral sympathetic centres. During desynchronized (REM) sleep, total MSA increased to 124 +/- 12% of the value in awake state (n = 5). The increases occurred mainly in short irregular periods, often related to rapid eye movements and there was an inverse relationship between the duration of the desynchronized sleep and the increase of total MSA. Our findings are similar to the data obtained in animal experiments and may partly explain changes of blood pressure during synchronized and desynchronized sleep reported previously in man.

[Neurologic aspects of clinical manifestations, pathophysiology and therapy of reflex sympathetic dystrophy (causalgia, Sudeck's disease)]

The symptomatology of reflex sympathetic dystrophy (RSD), a diagnostic term which today includes causalgia and M. Sudeck, is characterized clinically by a triad of autonomic (sympathetic), motor and sensory disturbances. They develop following a noxious event--though independent of its nature and location--in a generalized distribution pattern at the distal site of the affected extremity. Pathophysiologically, a complex disturbance of the sympathetic vasoconstrictor system is involved, which mediates the dominant symptoms of RSD, namely the spontaneous pain and the swelling. This disturbance is thought to be initiated by nociceptive impulses, occurring in conjunction with the preceding noxious event, and to be maintained reflexly, in a form of a vicious circle, by means of the typical pain sensation accompanying the RSD-syndrome. From these ideas, an important part of the RSD therapy is deduced; i.e. the early interruption of the neuronal sympathetic activity by means of a sympathetic blockade. Such a blockade can interrupt the pain and at the same time also the vicious circle of RSD. Altogether, for the RSD syndrome there are relevant neurological aspects with respect to its clinical symptomatology, its pathophysiology and its therapy.

[New viewpoints on the clinical picture, diagnosis and pathophysiology of reflex sympathetic dystrophy (Sudeck's disease)]

Reflex sympathetic dystrophy can be elicited by various factors (e. g. trauma, herpes zoster, myocardial infarction). Independent of kind and site of a lesion, symptoms occur most often in the whole distal part of the affected extremity. There in most cases, a triad of autonomic, motor and sensory disturbances can be found clinically. For early diagnosis--beside clinical investigation--a comparative measurement of skin temperatures on both sides of finger or toe tips, respectively, is recommended. Hereby the clinical finding of a warmer or colder extremity can be proved, which supplies evidence of a disturbed skin blood flow. In case, the above mentioned triad and a disturbance of skin circulation is found, diagnosis of sympathetic reflex dystrophy can be made with great certainty. With regard to the underlying pathophysiology, symptoms can be explained at this time satisfactory only by the assumption of a vicious circle. Starting from a painful event (e.g. trauma, mark in a plaster cast, nerve lesion or myocardial infarction) a functional disturbance of the sympathetic nervous system is initiated. This results in a disturbance of the circulation in all of the affected tissues (skin, muscle, bone and joint), which finally gives rise to an abnormal excitation of afferent receptors, particularly of nociceptors. This excitation maintains the disturbance of the sympathetic nervous system at central nervous level (vicious circle). The most relevant pathomechanism in this process seems to be the occurrence of an imbalance between the activity of sympathetic vasoconstrictor neurons supplying arteries and those, supplying veins. A sympatholytic therapy, if applied in time, is able to cut off the vicious circle, which may lead to a restitutio ad integrum. Further investigations will show to what extent psychological factors are involved in developing the central nervous disturbance of the sympathetic nervous system and may also show if in addition the motor system is affected.