Nature and variants of idiopathic restless legs syndrome: observations from 152 patients referred to secondary care in the UK

Restless legs syndrome variants: A systematic review

Introduction

Restless Legs Syndrome (RLS) is a clinical syndrome that may manifest itself in non-leg parts of the body as well, called RLS variant, which is considered a distinct entity by some researchers. In this systematic review, we tried to evaluate various clinical features and effective treatments of RLS variants and compare them with that of typical RLS.

Methods

This study was conducted following the PRISMA guideline. The primary search was performed in the data resources of Medline (PubMed), Web of Science, and Scopus, as well as the Google Scholar search engine. The required data were extracted from the studies.

Results

In this review, 1565 studies were initially identified and finally 39 studies were selected. The most common RLS variants were observed to involve hands, head, abdomen, and genitalia. These patients mostly complained of sleep disturbance and feelings of itching, tingling and twitching. Supportive diagnostic criteria of RLS including familial history of RLS, periodic limb movements during sleep (PLMS) and response to treatment with dopaminergic agents were assessed.

Conclusion

It seems that patients with RLS variant can undergo the same diagnostic and therapeutic work-up as patients with conventional RLS. It is suggested that these two disorders fall into the same syndromic spectrum.

Transitory restless arms syndrome in a patient with antipsychotics and antidepressants: a case report

BACKGROUND

Restless arms syndrome (RAS) is characterized by uncomfortable aching or burning sensations in the arms. RAS is regarded as an upper limb variant of restless legs syndrome (RLS). The lack of specific diagnostic criteria makes it difficult to recognize the RAS. Therefore, RAS is usually neglected in clinical practice. Moreover, when a patient was diagnosed with RAS, the adjustment of medications was the first choice for doctors, which may make the patient's condition unstable.

CASE PRESENTATION

A 33-year-old woman was diagnosed with schizophrenia and major depressive disorder. Starting with 0.6 g/d amisulpride, 0.1 g/d quetiapine, 75 mg/d venlafaxine sustained-release tablets, the patient reported symptoms of RAS (itching arms) on the fourth day since the latest hospitalization. After ruling out other factors, her RAS was suspected to be induced by antidepressants or antipsychotics. Without medication adjustment, RAS spontaneously remitted.

CONCLUSIONS

This case suggests that psychiatrists should pay attention to RAS when using antipsychotics and/or antidepressants. Moreover, RAS may be transitory. When a patient manifests RAS, observation may be one choice instead of an immediate medication adjustment.

The Effect of Stretching Exercises on Severity of Restless Legs Syndrome in Patients on Hemodialysis

BACKGROUND

The restless legs syndrome is a sensorimotor disorder that is very common in patients on hemodialysis. Due to pharmacological treatments which have their own side effects, nowadays, studies have turned to non-pharmacological treatments.

OBJECTIVES

The present study aims to assess the effect of stretching exercises on the severity of restless legs syndrome in patients on hemodialysis.

PATIENTS AND METHODS

This clinical trial study was conducted on 33 patients who had been identified using diagnostic criteria from the hemodialysis ward of Hasheminejad Hospital in Tehran. Participants were randomly divided into the intervention group (n = 17) and control group (n = 16). Stretching exercises were performed on legs during the dialysis for half an hour, three times a week for 8 weeks in intervention group. Data were collected by using the international restless legs syndrome study group scale.

RESULTS

The results showed that the majority of participants were suffering from moderate restless legs syndrome. The symptom severity of this syndrome meaningfully changed eight weeks after intervention in the intervention group compared to the control group (P < 0.001).

CONCLUSIONS

The results highlighted the significance of training and performing the stretching exercises during dialysis for the purpose of improving restless legs syndrome symptoms and the quality of care of hemodialysis patients.

Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria--history, rationale, description, and significance

BACKGROUND

In 2003, following a workshop at the National Institutes of Health, the International Restless Legs Syndrome Study Group (IRLSSG) developed updated diagnostic criteria for restless legs syndrome/Willis-Ekbom disease (RLS/WED). These criteria were integral to major advances in research, notably in epidemiology, biology, and treatment of RLS/WED. However, extensive review of accumulating literature based on the 2003 NIH/IRLSSG criteria led to efforts to improve the diagnostic criteria further.

METHODS

The clinical standards workshop, sponsored by the WED Foundation and IRLSSG in 2008, started a four-year process for updating the diagnostic criteria. That process included a rigorous review of research advances and input from clinical experts across multiple disciplines. After broad consensus was attained, the criteria were formally approved by the IRLSSG executive committee and membership.

RESULTS

Major changes are: (i) addition of a fifth essential criterion, differential diagnosis, to improve specificity by requiring that RLS/WED symptoms not be confused with similar symptoms from other conditions; (ii) addition of a specifier to delineate clinically significant RLS/WED; (iii) addition of course specifiers to classify RLS/WED as chronic-persistent or intermittent; and (iv) merging of the pediatric with the adult diagnostic criteria. Also discussed are supportive features and clinical aspects that are important in the diagnostic evaluation.

CONCLUSIONS

The IRLSSG consensus criteria for RLS/WED represent an international, interdisciplinary, and collaborative effort intended to improve clinical practice and promote further research.

Restless leg syndrome, periodic limb movements, febrile seizures and Attention deficit hyperactivity disorder in an Indian family

Restless leg syndrome (RLS) is a common neurological disorder which can affect individuals of all age groups and incidence increasing with age. It can cause severe sleep disruption and negatively impact quality of life of an individual. Its diagnosis is clinical, based on essential criteria of International RLS Study Group. It can be idiopathic or associated with various medical and other neurological disorders. Idiopathic RLS can be sporadic or may have a familial inheritance, with several genetic loci been reported till date. RLS has a strong association with periodic limb movements, both sleep and awake. Very few studies of familial RLS/Periodic limb movements in sleep and their associations have been reported. We report an Indian family with autosomal dominant RLS/PLMS, with RLS and PLMS as well as psychiatric disorders, febrile seizures and Attention Deficit Hyperactivity Disorder in different family members, over three generations.

Pediatric restless legs syndrome: analysis of symptom descriptions and drawings

The specific aims of this study were to collect and analyze detailed symptom descriptions from patients with pediatric restless legs syndrome, ages 6 to 17 years, as well as assess symptom impact and the usefulness of drawings. Trained qualitative interviewers conducted face-to-face audio-recorded interviews of children and adolescents who met criteria for definite restless legs syndrome. Thirty-three patients in 3 age groups used 16 different categories of descriptors for restless legs sensations, with a mean of 3 or more categories used per patient in each age group. "Need to move/kick," "pain/hurts," "uncomfortable/cannot get comfortable," and "like bugs or ants/crawling" were the most common descriptors. Two-thirds reported daytime sensations, and nearly half had arm involvement. They described impact on sleep, cognitive function, and affect. Drawings provided useful diagnostic information. These detailed empirical data will be useful in clinical practice, as well as in the development of formal diagnostic tools and severity measures.

Probable RBD is increased in Parkinson's disease but not in essential tremor or restless legs syndrome

OBJECTIVE

Compare the frequency of REM sleep behavior disorder (RBD) and excessive daytime sleepiness (EDS) in Parkinson's disease (PD), restless legs syndrome (RLS), essential tremor (ET), and control subjects.

METHODS

Subjects enrolled in a longitudinal clinicopathologic study, and when available an informant, completed the Mayo Sleep Questionnaire, which asks "Have you ever been told that you act out your dreams?", and the Epworth Sleepiness Scale (ESS).

RESULTS

Probable RBD (based on informant response to the questionnaire) was much more frequent in PD (34/49, 69%, P < 0.001) than in RLS (6/30, 20%), ET (7/53, 13%), or control subjects (23/175, 13%), with an odds ratio of 11 for PD compared to controls. The mean ESS and the number of subjects with an ESS ≥ 10 was higher in PD (29/60, 48%, P < 0.001) and RLS (12/39, 31%, P < 0.001) compared with ET (12/93, 13%) and Controls (34/296, 11%).

CONCLUSIONS

Probable RBD is much more frequent in PD with no evidence to suggest an increase in either RLS or ET. Given the evidence that RBD is a synucleinopathy, the lack of an increased frequency of RBD in subjects with ET or RLS suggests the majority of ET and RLS subjects are unlikely to be at increased risk for developing PD.

Update on the management of restless legs syndrome: existing and emerging treatment options

Restless legs syndrome (RLS) is a sensorimotor disorder, characterized by a circadian variation of symptoms involving an urge to move the limbs (usually the legs) as well as paresthesias. There is a primary (familial) and a secondary (acquired) form, which affects a wide variety of individuals, such as pregnant women, patients with end-stage renal disease, iron deficiency, rheumatic disease, and persons taking medications. The symptoms reflect a circadian fluctuation of dopamine in the substantia nigra. RLS patients have lower dopamine and iron levels in the substantia nigra and respond to both dopaminergic therapy and iron administration. Iron, as a cofactor of dopamine production and a regulator of the expression of dopamine type 2-receptor, has an important role in the RLS etiology. In the management of the disease, the first step is to investigate possible secondary causes and their treatment. Dopaminergic agents are considered as the first-line therapy for moderate to severe RLS. If dopaminergic drugs are contraindicated or not efficacious, or if symptoms are resistant and unremitting, gabapentin or other antiepileptic agents, benzodiazepines, or opioids can be used for RLS therapy. Undiagnosed, wrongly diagnosed, and untreated RLS is associated with a significant impairment of the quality of life.

Restless legs syndrome in patients on hemodialysis: symptom severity and risk factors

Background and Purpose

Restless legs syndrome (RLS) is a sleep disorder that frequently occurs in dialysis patients, which disturbs the sleep and reduces the quality of life. The aim of this study was to determine the risk factors for RLS in dialysis patients.

Methods

Patients who visited any of four outpatient dialysis clinics between September 2005 and May 2006 were included in this study. The diagnosis of RLS and the severity assessment were made using the criteria described by the International Restless Legs Syndrome Study Group. We collected basic demographic data, clinical information, and laboratory findings, and then analyzed their association with various aspects of RLS using univariate and multivariate analyses.

Results

RLS was present in 46 (28.0%) of 164 dialysis patients. We found no significant risk factor for inducing RLS. The predialysis serum blood urea nitrogen (BUN) level in the dialysis patients with RLS was significantly correlated with RLS symptom severity.

Conclusions

Predialysis BUN is related to RLS symptom severity. Further studies on the underlying mechanism are needed.

[Restless-legs syndrome]

Restless-legs syndrome (RLS) is a sensorimotor disorder, characterized by an irresistible urge to move the legs usually accompanied or caused by uncomfortable and unpleasant sensations. It begins or worsens during periods of rest or inactivity, is partially or totally relieved by movements and is exacerbated or occurs at night and in the evening. RLS sufferers represent 2 to 3% of the general population in Western countries. Supportive criteria include a family history, the presence of periodic-leg movements (PLM) when awake or asleep and a positive response to dopaminergic treatment. The RLS phenotypes include an early onset form, usually idiopathic with a familial history and a late onset form, usually secondary to peripheral neuropathy. Recently, an atypical RLS phenotype without PLM and l-DOPA resistant has been characterized. RLS can occur in childhood and should be distinguished from attention deficit/hyperactivity disorder, growing pains and sleep complaints in childhood. RLS should be included in the diagnosis of all patients consulting for sleep complaints or discomfort in the lower limbs. It should be differentiated from akathisia, that is, an urge to move the whole body without uncomfortable sensations. Polysomnographic studies and the suggested immobilization test can detect PLM. Furthermore, an l-DOPA challenge has recently been validated to support the diagnosis of RLS. RLS may cause severe-sleep disturbances, poor quality of life, depressive and anxious symptoms and may be a risk factor for cardiovascular disease. In most cases, RLS is idiopathic. It may also be secondary to iron deficiency, end-stage renal disease, pregnancy, peripheral neuropathy and drugs, such as antipsychotics and antidepressants. The small-fiber neuropathy can mimic RLS or even trigger it. RLS is associated with many neurological and sleep disorders including Parkinson's disease, but does not predispose to these diseases. The pathophysiology of RLS includes an altered brain-iron metabolism, a dopaminergic dysfunction, a probable role of pain control systems and a genetic susceptibility with nine loci and three polymorphisms in genes serving developmental functions. RLS treatment begins with the elimination of triggering factors and iron supplementation when deficient. Mild or intermittent RLS is usually treated with low doses of l-DOPA or codeine; the first-line treatment for moderate to severe RLS is dopaminergic agonists (pramipexole, ropinirole, rotigotine). In severe, refractory or neuropathy-associated RLS, antiepileptic (gabapentin, pregabalin) or opioid (oxycodone, tramadol) drugs can be used.

Clinical significance of RLS

While the restless legs syndrome (RLS) may have been known in antiquity, it has only recently come to medical attention. Individuals with RLS fall along a spectrum from mild, infrequent symptoms to those with severe daily life-impairing discomforts and sleep disruption. These problems can cause impaired mood, daytime fatigue, cognitive difficulties, and inability to participate in a variety of quiet activities. This leads to a general reduction in quality of life similar to other significant psychiatric and medical disorders. Recent studies suggest that RLS may be a risk factor for developing both psychiatric disorders (such as major depression and anxiety) and somatic diseases (such as hypertension and cardiovascular disease). In dialysis patients, RLS has been found to be a risk factor for mortality. Therefore, those with RLS who have clinically significant symptoms suffer increased morbidity and are at risk for impaired long-term medical outcomes.