Restless Legs Syndrome

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Restless Legs Syndrome

• Jeffrey D. Gould, MD
• Neurology and Sleep Medicine, PC
• June 2008

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Your Presenter

• Emory University
• Hahnemann University
• Lehigh Valley Hospital
• Pennsylvania Hospital
• MCP-Hahnemann Hospital

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The Presentation

• Restless Legs Syndrome
• Periodic Limb Movement Disorder

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Restless Legs Syndrome (RLS)

• Introduction
• Etiologies (why are we afflicted with this)
• Diagnosis (finding the reasons)
• Treatment (please hurry)
• Conclusions

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Sleep Disorders

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

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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

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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.
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Restless Legs Syndrome (RLS)

• Introduction
• Etiologies (why are we afflicted with this)
• Diagnosis (finding the reasons)
• Treatment (please hurry)
• Conclusions

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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

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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

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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)

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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

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RLS Diagnosis

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

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RLS Evaluation

• Interview and Examination by physician
• Primary Care
• Board Certified Sleep Specialist
• Testing

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Restless Legs Syndrome (RLS)

• Introduction
• Diagnosis (finding the reasons)
• Evaluation
• Treatment (please hurry)
• Conclusions

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RLS Evaluation

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

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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.

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RLS Evaluation

• No need for sleep testing for this problem alone

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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

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RLS Evaluation

• HOWEVER

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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

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Restless Legs Syndrome (RLS)

• Introduction
• Etiologies (why are we inflicted with this)
• Diagnosis (finding the reasons)
• Treatment (please hurry)
• Conclusions

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RLS Treatment

• Alleviating underlying disorder (if discoverable
  or possible)
• Medications
• Non-medication therapies

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RLS Medications

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

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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

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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

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RLS Medications

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

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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

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RLS

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

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RLS Non-medications

• Caffeine
• Decrease to decrease symptoms
• Sleep hygiene
• Adequate amounts of sleep reduce symptoms

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Restless Legs Syndrome (RLS)

• Introduction
• Etiologies (why are we inflicted with this)
• Diagnosis (finding the reasons)
• Treatment (please hurry)
• Conclusions

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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

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RLS

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

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RLS Pearls

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

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RLS Pitfalls

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

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The Presentation

• Restless Legs Syndrome
• Periodic Limb Movement Disorder

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Periodic Limb Movement Disorder

• PLMD
• Is present with RLS
• Requires an explanation

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Periodic Limb Movement Disorder

• Diagnosis
• Treatment

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Periodic Limb Movement Disorder

• Diagnosis
• Talk to your doctor
• Doctor History
• Doctor Physical
• ? Doctor Testing

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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)

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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

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Periodic Limb Movement Disorder

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

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Periodic Limb Movement Disorder

• Diagnosis
• May need blood work
• May need EMG (nerve test)
• May need MRI of the back
• May need sleep study

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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

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Periodic Limb Movement Disorder

• Treatment
• Fix the problem!
• Vitamin deficiency add the vitamin
• Iron deficiency add the iron
• Kidney failure dialysis
• Pregnancy - delivery

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PLMD Pitfalls

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

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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?

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Basal ganglia abnormality causing RLS?
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As seen on PSG

• RLS
• Nothing
• Recurrent ___________
• PLMD
• Movements

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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

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KickStrip
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Conclusions (1/3)

• RLS is a part of a pain syndrome
• RLS can be highly disabling
• RLS correlates with a brain deficiency syndrome

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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

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Conclusions 3/3

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