3Definitions RLS = Restless Legs Syndrome PLM = Periodic Limb Movements PLMS = PLM in sleep: characteristic movement that occur during sleep.PLMW = PLM in wake (usually seen as part of a nocturnal PSG)PLMD = PLM disorder: a sleep disorder based on a finding of PLMS (Usually < 5/hr of sleep) with an associated sleep dysfunction that cannot be otherwise explained.
4Historical References for RLS “Therefore to some, on being a bed, they betake themselves to sleep, presently in the arms and legs, leaping and contractions of the tendons, and so great a restlessness and tossing of their members ensue that the diseased are no more able to sleep than if they were in the place of the greatest torture.”Willis T. The London practice of physick London: Bassett and Crooke; 1685.
5Historical References Wittmaack T. Pathologie und therapie der sensibilitat neurosen Liepzig: Schafer; “anxietas tibiarum” Felt to be of hysterical origin.Ekbom K. Acta Med Scand. 1944;118: Asthenia crurum paraesthetica (irritable legs).
6Common Characteristics Of Restless Legs Syndrome Unpleasant sensations in the legs (sometimes the arms as well).often described as creeping, crawling, tingling, pulling, or rarely painful.Leg sensations are relieved by walking, stretching, knee bends, massage, or hot or cold baths.Leg discomfort occurs when lying down or sitting for prolonged periods of time.
7Common Characteristics Of Restless Legs Syndrome The symptoms are worse in the evening and during the night.Involuntary leg (and occasionally arm) movements while asleep;Difficulty falling asleep or staying asleep;Sleepiness or fatigue during the daytime;Cause of discomfort not detected by medical tests;Family members with similar symptoms.
9Primary Features of RLS Essential for Diagnosis A sensation of an urge to move the limbs (usually legs) accompanied by uncomfortable or unpleasant sensation .Motor restlessness to reduce sensation.Onset or worsening of symptoms when at rest.Marked circadian variation in occurrence or severity of symptoms (night time)No other identifiable causeSleep Med 2003; 4: 101–19.
10Symptoms of RLS Follow Circadian Rhythm Hening W et al, Sleep 22:901-915 1999
11Associated Features Periodic Limb Movements in sleep Sleep disturbance, especially difficulty in sleep initiation.Positive family historyOnset at any ageChronic and progressive course with remissions.
12RLS Severity Scale 10 Questions Specific to leg discomfort, movement Effects on sleepOverall quality of life0-4 rating of various symptoms for each question; 0= none – 4 = very severe0-10 mild moderate21-30 severe very severe
13Distribution of RLS Scores Neurology 2005;65:239–246
14Differential Diagnosis of RLS Leg crampsPeripheral neuropathyVaricose veinsIntermittent claudicationNeuroleptic-induced akathisia
15Symptomatic Restless Legs Iron deficiencyHemoglobin Normal but Low FerritinUremia, Caffeine, NicotineDiabetesPeripheral neuropathy or radiculopathyFibromyalgiaRheumatoid arthritisPregnancyVitamin D Deficiency
16RLS Epidemiology Affects 5-10% of population. ? Increased in French Canadians (Lavigne G & Montplaisir J Sleep 1994; 17:739-43)Prevalence increase with ageWomen more affected than men
17RLS Prevalence in France n = 10,263 Neurology 2005;65:239–246
32Periodic Limb Movements Characteristic limb movements0.5 – 10 sec duration movementsRecur periodically (every 4 to 90 sec)Must occur in a series of 4 or more in any sleep or wake state.Diagnosis of PLMD with the above and:- > 5 h in children, >15/h in adults- Clinical Sleep Disturbance or Daytime Fatigue- Not better explained by another disorder- Cannot diagnose RLS and PLMD at same time (ICSD)
40Iron supplements as Rx for RLS Check serum ferritin levelsAdd iron in patients with serum ferritin < 50mg/LIdeal supplement not knownMay take several months to be effectiveMay be poorly tolerated
41Vitamin D deficiency is associated with Restless Legs Syndrome Vitamin D deficiency is associated with Restless Legs Syndrome. Ayman Krayem, FCCP, Siraj Wali, FCCP, Afnan Shukr, MBBS, Ayah Boudal, MBBS, Ahmad Alsaiari, MBBS. (Abstract) Poster # 704. American Academy of Sleep Medicine annual meeting, June 1-5, 2013, Biltmore, USA.
42Manifestations of Augmentation Increase in RLS symptom severity during treatment:Frequency of symptoms or earlier symptoms.Duration of symptomsNumber of body parts affectedIntensityMost commonly during treatment with L-DOPA and estimated to occur in 27-82% of cases.Not reported during treatment with opiates, anticonvulsants or other dopaminergic drugs.
43Conclusion RLS is common but under-diagnosed Consequences: Insomnia, bed partners separation, depression & sexual dysfunctionDiagnosis: HistoryWorkup: Iron, Vitamin D, Folic Acid, Vitamin B12Management: Replacement, Specific Drug Therapy (Dopanergic)