Restless Legs Syndrome

1
Restless Legs Syndrome

• Fad, Fact, or Fiction??

2
RLS Definition

• A disorder characterized by an almost
  irresistible urge to move, usually associated
  with disagreeable leg sensations, worse during
  inactivity, often interfering with sleep.

3
Primary Features(IRLSSG Criteria)

• Desire to move the limbs, usually associated with
  paresthesias/dysesthesias
• Motor restlessness
• Symptoms worse at rest, partially relieved by
  activity
• Symptoms worse in the evening or at night

4
Uncomfortable Sensations

• Creepy, crawly, tingly
• Like worms or bugs crawling under the skin
• Painful, burning, or achy
• Like water running over the skin
• Sometimes indescribable

5
Restlessness

• Voluntary-patients choose to move to relieve
  discomfort
• Involuntary-patients feel compelled to move and
  almost cannot resist it (as a tic)

6
Rest and Activity

• Activity variably, temporarily, and partially
  relieves the discomfort
• Patients develop habits and behaviors to relieve
  discomfort (Nightwalkers)

7
Circadian Variability

• Symptoms typically peak between midnight and 4
  Am..
• Circadian rhythm of symptoms persists even in
  unconventional sleep /wake cycles

8
Additional Features

• Sleep disturbance and its consequences
• Involuntary movements while awake
• Generally chronic course

9
RLS Vs PLMS

• RLS is a symptom
• RLS is diagnosed in the physicians office
• 80 of people who have RLS will have PLMs

• PLMs are an electromyographic finding
• PLMs are diagnosed in the sleep laboratory
• 30 of individuals who have PLMs have RLS
  symptoms

10
Clinical Importance of PLMs in Relation to RLS

• PLMs are neither necessary nor sufficient to
  make the diagnosis of RLS
• Asymptomatic PLMs do not require treatment

11
Pathogenesis of RLS

• Primary or idiopathic
• Secondary

12
Primary RLS

• No identifiable predisposing factor
• Tends to occur in families
• May be genetic

13
Secondary RLS

• Iron-deficiency anemia
• Uremia (20-40 of dialysis patients)
• Pregnancy (up to 27)
• Neurological lesions
• both spinal cord and peripheral nerve lesions
• Drug-induced
• tricyclics, SSRIs, lithium, dopamine
• blockers (e.g., neuroleptics), xanthines

14
Associated Conditions

• Diabetes
• Parkinsons disease
• Rheumatoid arthritis

15
Differential Diagnosis

• Neuropathy
• Lumbar disk disease/spinal stenosis
• Depression and other causes of insomnia
• Arthritis
• Vascular disease
• Akesthesia

16
Pathogenesis

• RLS is a neurologic movement disorder
• Location of the lesion is not known
• Some evidence points to spinal cord abnormalities
  in patients with PLMs

17
Consequences of RLS

• Discomfort
• Sleep disturbance
• Excessive daytime somnolence

18
Assessment-Making the Dx

• History
• Physical examination
• Laboratory tests

19
History 4 Cardinal Features

• Unpleasant sensations
• Motor restlessness
• Precipitated by inactivity Relieved with
  activity
• Worse in evening or night

20
Historical Assessment in RLS

• Diabetes, anemia, medications, renal status and
  other associated conditions
• Duration of symptoms
• Other affected family members
• Precipitating and relieving factors (new
  medications, lifestyle changes)

21
Physical Examination in RLS

• Careful neurological examination (to look for
  Parkinson's, neuropathy, weakness)
• No objective findings for RLS

22
Laboratory Evaluation of RLS

• Polysomnography is not indicated in evaluation of
  RLS!
• Serum ferritin
• Screen for uremia
• Screening for diabetes
• Other tests for potential secondary causes if
  suspected

23
Nonpharmacologic Treatment

• Listen, support, and validate
• Reconsider medications known to exacerbate RLS
  (Lithium, SSRIs, tricyclics, dopamine
  antagonists)
• Not helpful sclerotherapy, electrical
  stimulation
• Possibly beneficial in some patients hot baths,
  delayed sleep time/rise time, exercise, avoid
  alcohol and nicotine

24
Support and Validation

• Sleep Thief, by Virginia Wilson. Galaxy Books,
  1996.
• Restless Legs Syndrome Foundation (RLSF)
  www.RLS.org

25
Pharmacologic Treatment

• Dopaminergic medications
• Benzodiazepines
• Opioids
• Anticonvulsants
• Others

26
Treatment Considerations

• Age of patient
• Combination strategies
• Distribution/frequency/severity of symptoms
• No drug has FDA approval for use in RLS
  (off-label use)
• Treatment is symptomatic, not curative
• In general, smaller doses are used than in other
  conditions

27
Iron Therapy

• Replace iron in patients with serum ferritin
  levels below 50 mcg/L

28
Dopaminergic Medications

• carbidopa-levodopa (Sinemet Ò)
• 25-100 CR-100/400 CR qhs
• bromocriptine (Parlodel Ò)
• 5-15 mg
• pergolide (Permax Ò)
• 0.05 qhs, increasing by 0.05 q 3 days
• pramipexole (Mirapex Ò)
• 0.125-1.0 mg qhs

Disadvantages augmentation, rebound, nausea,
insomnia
29
Benzodiazepines

• clonazepam (Klonipin Ò)
• 0.5-4.0
• lorazepam ( Ativan Ò)
• temazepam (RestorilÒ)
• 15-30 mg
• diazepam (Valium Ò)
• 5-10 mg

Disadvantages tolerance, somnolence, confusion,
worsened snoring/SDB
30
Opioids

• propoxyphene (Darvon Ò)
• 130-520 mg/day
• codeine
• 15-240 mg/day
• methadone (Dolophine Ò)
• 5-30 mg/day
• hydrocodone
• tramadol hydrochloride (Ultram Ò)

Disadvantages tolerance, constipation
31
Anticonvulsants

• gabapentin (Neurontin Ò)
• 100-2700mg/day
• carbamazepine (Tegretol Ò)

Disadvantages daytime sedation
32
Others

• clonidine
• baclofen
• vitamin B 12
• vitamin E
• magnesium

33
Conclusions

• RLS is common, treatable, and underdiagnosed
• The pathophysiology of RLS is unknown
• RLS can be both secondary and idiopathic
• The diagnosis is made by history
• Treatment is mainly pharmacologic