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Restless Legs Syndrome The Most Common Condition Youve Never Heard of Ayman Krayem, MBChB, ABIM, FCCP Consultant in Pulmonary & Sleep Medicine Chair, Jeddah.

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Presentation on theme: "Restless Legs Syndrome The Most Common Condition Youve Never Heard of Ayman Krayem, MBChB, ABIM, FCCP Consultant in Pulmonary & Sleep Medicine Chair, Jeddah."— Presentation transcript:

1 Restless Legs Syndrome The Most Common Condition Youve Never Heard of Ayman Krayem, MBChB, ABIM, FCCP Consultant in Pulmonary & Sleep Medicine Chair, Jeddah Sleep Medicine Club KAMC-Jeddah

2 Restless Legs Syndrome the most common condition youve never heard of


4 Definitions 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.

5 Willis T. The London practice of physick London: Bassett and Crooke; Historical References for RLS Therefore to some, on being a bed, they betake themselves to sleep, presently in the arms and legs, leaping and contractions of the tendons, and so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.

6 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). Historical References

7 Common 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.

8 Common 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.

9 Terms Used to Describe RLS Sensations

10 Primary 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 cause Sleep Med 2003; 4: 101–19.

11 Symptoms of RLS Follow Circadian Rhythm Hening W et al, Sleep 22:

12 Associated Features Periodic Limb Movements in sleep Sleep disturbance, especially difficulty in sleep initiation. Positive family history Onset at any age Chronic and progressive course with remissions.

13 RLS Severity Scale 10 Questions –Specific to leg discomfort, movement –Effects on sleep –Overall quality of life 0-4 rating of various symptoms for each question; 0= none – 4 = very severe 0-10 mild moderate severe31-40 very severe

14 Distribution of RLS Scores Neurology 2005;65:239–246 n = 731

15 Differential Diagnosis of RLS Leg cramps Peripheral neuropathy Varicose veins Intermittent claudication Neuroleptic-induced akathisia

16 Symptomatic Restless Legs Iron deficiency –Hemoglobin Normal but Low Ferritin Uremia, Caffeine, Nicotine Diabetes Peripheral neuropathy or radiculopathy Fibromyalgia Rheumatoid arthritis Pregnancy Vitamin D Deficiency

17 RLS Epidemiology Affects 5-10% of population. ? Increased in French Canadians (Lavigne G & Montplaisir J Sleep 1994; 17:739-43) Prevalence increase with age Women more affected than men

18 RLS Prevalence in France n = 10,263 Neurology 2005;65:239–246

19 RLS Prevalence in France n = 10,263 MenWomen

20 Prevalence in Germany n = 431 Arch Intern Med 2004; 164: 196–202.

21 Symptoms in a US population Arch Intern Med 2000; 160: 2137–41.


23 Genetics of Restless Legs Syndrome Familial nature first described by Ekbom Complex inheritance 3 major loci identified –12q - French Canadian –14q - Italian, Canadian –9p - 2 US Families

24 RLS Pathophysiology Central Nervous system dysfunction –Cortical – subcortical – spinal cord Brain Dopaminergic function. Iron Metabolism

25 Brain Iron Insufficiency Restless Legs Syndrome CNS Dopamine Abnormalities Iron-Dopamine Model of RLS

26 Ferritin Levels: Correlate with RLS but not PLMS

27 Iron-Dopamine Model of RLS Earley CJ et al Neurology 2000; 54: control RLS

28 MRI Measurement of Brain Iron in RLS Patients Iron content is reduced in both red nucleus and substantia nigra for RLS patients compared to controls Allen RP et al; Neurology 2001;56:263-65

29 Neurology 2003;61:304–309 Impaired Brain Iron Acquisition in Restless Legs Syndrome: Neuropathologic Examination ControlRLS Marked reduction in ferritin in substantia nigra of RLS brain

30 5 secs

31 15 secs

32 30 secs

33 Periodic Limb Movements Characteristic limb movements 0.5 – 10 sec duration movements Recur 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)

34 Disease of Conditions Associated with PLMS Narcolepsy REM Sleep Behavior Disorder Neurodegenerative Disorders Tourettes Syndrome Peripheral Neuropathy End Stage Renal Disease Pregnancy Post Traumatic Stress Disorder Obstructive Sleep Apnea Antidepressants (exceptions: bupropion trazodone)

35 Most people are asymptomatic Most people are asymptomatic Poor association between PLMS and sleepiness Poor association between PLMS and sleepiness One third of patients with PLMS have RLS One third of patients with PLMS have RLS Needs PSG for diagnosis Needs PSG for diagnosis Periodic Limb Movement Syndrome

36 Treatment of RLS and PLMS Varies according to the clinical course. Co-morbid medical conditions. Presence or absence of associated pain. Individualize Therapy!!

37 Pharmacologic Rx for RLS Dopamine receptor agonists and dopamine precusors. Opioids Benzodiazepines Anticonvulsants Other

38 Pharmacologic Rx for RLS



41 Iron supplements as Rx for RLS Check serum ferritin levels Add iron in patients with serum ferritin < 50mg/L Ideal supplement not known May take several months to be effective May be poorly tolerated

42 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.

43 Manifestations of Augmentation Increase in RLS symptom severity during treatment: - -Frequency of symptoms or earlier symptoms. - -Duration of symptoms - -Number of body parts affected - -Intensity Most 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.

44 Conclusion RLS is common but under-diagnosed Consequences: Insomnia, bed partners separation, depression & sexual dysfunction Diagnosis: History Workup: Iron, Vitamin D, Folic Acid, Vitamin B12 Management: Replacement, Specific Drug Therapy (Dopanergic)

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