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Restless Legs Syndrome

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Symptoms of restless legs syndrome are worse during rest or inactivity. ... Unable to keep legs still. Improves with moving the limb(s) ... – PowerPoint PPT presentation

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Title: Restless Legs Syndrome


1
Restless Legs Syndrome
  • Jeffrey D. Gould, MD
  • Neurology and Sleep Medicine, PC
  • June 2008

2
Your Presenter
  • Emory University
  • Hahnemann University
  • Lehigh Valley Hospital
  • Pennsylvania Hospital
  • MCP-Hahnemann Hospital

3
The Presentation
  • Restless Legs Syndrome
  • Periodic Limb Movement Disorder

4
(No Transcript)
5
Restless Legs Syndrome (RLS)
  • Introduction
  • Etiologies (why are we afflicted with this)
  • Diagnosis (finding the reasons)
  • Treatment (please hurry)
  • Conclusions

6
Sleep Disorders
  • The common disorders
  • Obstructive sleep apnea
  • Restless Legs Syndrome
  • (Psychophysiologic) Insomnia
  • Parasomnias

7
(No Transcript)
8
Restless Legs Syndrome (RLS)
  • RLS present in 2 to 5 of the entire population
    (recent suggestion 10)
  • Women more than men (previously )
  • Usual onset at middle age
  • May be children or advanced elderly

9
Migraine is More Common than Asthma Diabetes
Combined
Disease Prevalence in the US Population
Data from the Centers for Disease Control and
Prevention, US Census Bureau, and the Arthritis
Foundation.
10
Restless Legs Syndrome (RLS)
  • Introduction
  • Etiologies (why are we afflicted with this)
  • Diagnosis (finding the reasons)
  • Treatment (please hurry)
  • Conclusions

11
RLS Dx.
  • The uncontrollable urge to move the legs
    accompanied or caused by uncomfortable and
    unpleasant sensations in the legs
  • Symptoms of restless legs syndrome are worse
    during rest or inactivity.
  • Symptoms are partially or totally relieved by
    movement.
  • Restless legs syndrome is worse at night

12
RLS Diagnosis
  • Patient History
  • Chronic, may worsen over time
  • Creeping, crawling, aching, restless
  • Ants under the skin
  • Bubbles moving under the surface
  • May be uni- or bilateral legs
  • May involve arms
  • Not the face…

13
RLS Diagnosis
  • Patient History
  • Uncomfortable, crescendo sensation
  • Unable to keep legs still
  • Improves with moving the limb(s)
  • At its worst near bedtime or fatigued
  • No longer go to social events (theater, movies,
    lectures)

14
RLS Diagnosis
  • History (continued)
  • Prepare legs for bed (not always after
    awakenings)
  • Leg twitching or movements
  • Periodic limb movements of sleep A.K.A. Periodic
    limb movement disorder (PLMD)
  • Previously diagnosed pregnancy, anemia, uremia,
    nerve damage, back pain, ADD

15
RLS Diagnosis
  • Physical examination
  • Near constant leg movement or shifting
  • May have evidence of nerve damage
  • May have normal examination

16
RLS Evaluation
  • Interview and Examination by physician
  • Primary Care
  • Board Certified Sleep Specialist
  • Testing…

17
Restless Legs Syndrome (RLS)
  • Introduction
  • Diagnosis (finding the reasons)
  • Evaluation
  • Treatment (please hurry)
  • Conclusions

18
RLS Evaluation
  • Blood work including
  • Vitamin levels (B12, Folate)
  • Iron levels (storage level Ferritin)
  • Hormone levels
  • Pregnancy (?)

19
RLS Dx
  • Etiology search
  • Blood work
  • ? Iron Deficiency (Relatively low ferritin level)
  • Below 50 suggestive
  • Below 18 relatively absolute association
  • ? Nerve damage (and causes for)
  • ? Radiculopathies
  • ? Pregnancy
  • Medications
  • SSRIs / SNRIs
  • TCADs
  • Benzos.

20
RLS Evaluation
  • No need for sleep testing for this problem alone…

21
RLS Evaluation
  • Sleep testing and RLS
  • Not compatible because
  • RLS only takes place while a person is awake
  • Not paid for by insurance
  • Sleep testing and Periodic Limb Movement Disorder
    (PLMD)
  • Compatible because
  • PLMD takes place only while asleep

22
RLS Evaluation
  • HOWEVER

23
RLS Evaluation
  • Sleep studies
  • During periods of wakefulness
  • Can demonstrate excessive muscle activation in
    the lower extremities through leg leads
  • Patient information
  • Aching, creeping, crawling, restless
  • Jimmy legs

24
(No Transcript)
25
Restless Legs Syndrome (RLS)
  • Introduction
  • Etiologies (why are we inflicted with this)
  • Diagnosis (finding the reasons)
  • Treatment (please hurry)
  • Conclusions

26
RLS Treatment
  • Alleviating underlying disorder (if discoverable
    or possible)
  • Medications…
  • Non-medication therapies

27
RLS Medications
  • Usually dosed before sleep
  • Dopamine containing medications
  • Dopamine agonists
  • Anti-epileptics
  • Iron supplementation

28
RLS Medications
  • Dopamine containing
  • Dopamine
  • Levodopa-Carbidopa (Sinemet)
  • Sinemet CR
  • Parcopa
  • Dopamine agonists
  • Pramipexole (Mirapex) (0.125 mg- 3mg)
  • Ropinerole (Requip) (0.25mg- 3mg)
  • NO LONGER USED PERMAX

29
RLS Medications
  • Dopamine containing
  • Sinemet, Parcopa, Levodopa-Carbidopa
  • Watch for tardive dyskinesia
  • Unusual movements which develop after years of
    therapy
  • High risk of rebound and augmentation
  • Require alteration medication dosages
  • Watch for dizziness and nausea

30
RLS Medications
  • Dopamine agonists
  • Mirapex, Requip
  • Low risk of tardive dyskinesia
  • Low risk of augmentation
  • Risk of nausea / dizziness
  • Long titration needed
  • Impulsivity ( 3)

31
RLS
  • Anti-epileptics
  • Gabapentin (Neurontin)
  • Does not interact with other medications
  • Frequently used for neuropathic pain
  • Not a powerful regimen
  • Pregabalin (Lyrica)
  • (see above) More powerful than gabapentin
  • Clonazepam (Klonopin)
  • Works less to reduce movements than reduce
    awakenings

32
RLS
  • Iron supplementation
  • ? Cause of iron depletion
  • Stomach lack of absorption
  • Excessive bleeding
  • Excessive menses
  • Other including stool
  • Supplementation by…
  • Mouth (3x day)
  • IV

33
RLS Non-medications
  • Caffeine
  • Decrease to decrease symptoms
  • Sleep hygiene
  • Adequate amounts of sleep reduce symptoms

34
Restless Legs Syndrome (RLS)
  • Introduction
  • Etiologies (why are we inflicted with this)
  • Diagnosis (finding the reasons)
  • Treatment (please hurry)
  • Conclusions

35
RLS
  • Medication Pearls
  • Need to assess for reason
  • Can add medications from other classes
  • Medication Pitfalls
  • Side-effects
  • Dopamine / agonists dizziness/ nausea/ (TD)/
    augmentation
  • Anti-epileptics mental slowing/ drug
    interactions
  • Iron constipation/ stomach pain/ chronic use

36
RLS
  • Non-medication therapies
  • Stretching
  • Lifestyle changes
  • Less caffeine
  • No /or less tobacco
  • Quinine (in diet tonic water)
  • Practically not a medication

37
RLS Pearls
  • May be associated with OSA
  • Often assoc. with PLMD
  • Increases with increasing age

38
RLS Pitfalls
  • May not be seen until after OSA treatment (may
    worsen after OSA Tx)
  • May resist treatment
  • PLMD may exist without RLS

39
The Presentation
  • Restless Legs Syndrome
  • Periodic Limb Movement Disorder

40
Periodic Limb Movement Disorder
  • PLMD
  • Is present with RLS
  • Requires an explanation…

41
Periodic Limb Movement Disorder
  • Diagnosis
  • Treatment

42
Periodic Limb Movement Disorder
  • Diagnosis
  • Talk to your doctor
  • Doctor History
  • Doctor Physical
  • ? Doctor Testing

43
Periodic Limb Movement Disorder
  • Diagnosis
  • Obvious kicking during sleep
  • Spontaneous awakenings at night for no clear
    reason
  • Covers off bed
  • Suggestion of RLS
  • (Fatigue, tired, out-of-energy)

44
Periodic Limb Movement Disorder
  • Diagnosis
  • Blood work
  • ? Iron Deficiency (Relatively low ferritin level)
  • Below 50 suggestive
  • Below 18 relatively absolute association
  • ? Nerve damage (and causes for)
  • ? Radiculopathies
  • ? Pregnancy

45
Periodic Limb Movement Disorder
  • Medications causing PLMD
  • Tricyclic Antidepressants
  • Amitriptyline, Nortriptyline, others
  • Selective Serotonin Reuptake Inhibitors
  • Paxil, Wellbutrin, Zoloft, others
  • SNRIs
  • Effexor, Cymbalta

46
Periodic Limb Movement Disorder
  • Diagnosis
  • May need blood work
  • May need EMG (nerve test)
  • May need MRI of the back
  • May need sleep study

47
PLMD PSG
  • RLS seen while awake (?)
  • PLMD Slow muscle contractions (0.5-2 sec
    duration) every 30 sec may not disrupt sleep
  • More likely to not awaken if due to meds

48
Periodic Limb Movement Disorder
  • Treatment
  • Fix the problem!
  • Vitamin deficiency add the vitamin
  • Iron deficiency add the iron
  • Kidney failure dialysis
  • Pregnancy - delivery

49
PLMD Pitfalls
  • May not been seen until OSA treated
  • Usually with severe OSA
  • May worsen with OSA treatment
  • ? Responsible for pediatric symptoms

50
RLS / PLMD Pathophysiology
  • Why do certain medications work?
  • Iron deficiency in the basal ganglia leading to
    relative dopamine depletion?
  • Why continuation of PLMD after para and
    quadraplegia?
  • Where do anti-epileptics work to reduce the
    problem?
  • Association of idiopathic neuropathy pain and
    RLS?

51
Basal ganglia abnormality causing RLS?
52
As seen on PSG
  • RLS
  • Nothing
  • Recurrent ___________
  • PLMD
  • Movements

53
The Future
  • More widespread evaluation
  • Greater study of the reason for RLS / PLMD
  • Greater study of newer medications
  • Anti-epileptics (Lyrica, Trileptal, Carbatrol,
    others)
  • More direct testing devices…

54
KickStrip
55
Conclusions (1/3)
  • RLS is a part of a pain syndrome
  • RLS can be highly disabling
  • RLS correlates with a brain deficiency syndrome

56
Conclusions (2/3)
  • PLMD occurs with RLS
  • Multiple etiologies can produce the problems
  • Multiple meds can reduce the problem
  • Need to treat to reduce patient suffering in
    forms of insomnia, pain, excessive fatigue and
    social dysfunction

57
Conclusions 3/3
  • PLMD associated with increased risk of
    sleep-related jumps in blood pressure and heart
    rate
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