Restless Legs Syndrome RLS 38page PowerPoint presentation from RLS:UK a newly formed academic group

1
Restless Legs Syndrome (RLS) 38-page PowerPoint
presentation from RLSUK a newly formed academic
group and from The Ekbom Support Group a
multidisciplinary academic group run by Eileen
Gill in conjunction with RLSUK
Thomas Willis

• Wherefore to some, when being abed 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 a place of
  greatest torture"
• Thomas Willis-1672
• (Possibly the First Description by Willis)
• Slide show presentation of Restless Legs Syndrome
  (RLS) Teaching Kit
• To run the presentation, use the scroll wheel

2
Restless Legs Syndrome Classic Modern
Description by Ekbom

• Also known as Ekboms syndrome3
• Asthenia crurum paraesthetica
• sensory RLS
• Asthenia crurum dolorosa
• painful RLS
• Movement disorder of sleep and relaxed
  wakefulness associated with unpleasant sensory
  symptoms, usually of the lower limbs3

Karl-Axel Ekbom
3
Restless Legs SyndromeSome Basic Facts

• RLS can be reliably diagnosed by four clinical
  questions4
• Diagnosis can be established in primary care5
• Fidgety legs or night time cramps are not RLS6
• RLS can be effectively treated6

4
Restless Legs SyndromeSome Basic Facts

• Minimum Diagnostic Criteria4
• Irresistible urge to move limbs usually
  associated with paraesthesia/dysaesthesia in legs
• Symptoms worse or exclusively present at rest
  (lying sitting)
• Partial or complete relief with activity/movement
  
• Symptoms worse in the evening or at night

5
Restless Legs SyndromeSome Basic Facts

• Associated features4
• Chronic progressive course with
  periodic exacerbations
• Normal neurological examination (except
  neuropathy)
• Sleep disturbance (insomnia)

• Supportive clinical features4
• Dopaminergic drug
• responsiveness
• PLMS/PLMW
• Positive family history

6
Restless Legs SyndromeKey Features

• Relief of symptoms from movement2
• Persistence of relief as long as movement occurs2
• Circadian pattern2
• Usually no physical manifestations in the limbs2
• Severe sleep disturbance

7
Restless Legs SyndromeCommon Descriptions of RLS
Symptoms
8
Restless Legs SyndromeSome Basic Facts

• RLS

Secondary RLS
Primary (idiopathic) RLS
9
Restless Legs SyndromeNeurological Examination

• Diagnosis requires a basic neurological
  examination11
• Patients should have
• Normal power of lower limbs
• Normal reflexes of lower limb (knee and ankle
  jerks)
• A flexor plantar response
• No obvious sensory deficit to touch and vibration

10
Restless Legs Syndrome How Common is it?

• RLS of varying severity affects 5-10 of the
  general population8,9,12
• Approximately 15 of RLS sufferers (1-2 general
  population) are estimated to seek treatment13
• Age of onset is under 20 years in almost half of
  all cases14
• Prevalence increases with age8,12
• Women are more likely to be affected than men8,12
• Little prevalence data is available for ethnic
  groups13

11
Restless Legs Syndrome Possible Causes

• RLS may be due to dysfunction of
• Dopamine signalling in brain2
• Iron metabolism2
• Opioid system10
• A combination of above factors2
• Both CNS and spinal cord may be involved2
• Strong genetic basis2

12
Restless Legs Syndrome Genetic Basis

• More than 50 of idiopathic RLS cases may have a
  family history of RLS16
• 19.9 of first degree relatives may be affected17
• 1st and 2nd degree relatives have a significantly
  higher risk of RLS than controls18
• Transmission appears to be most likely to be
  autosomal dominant in young onset RLS (RLS onset
  

13
Restless Legs Syndrome UK Perspective (37.6
have family history)
37.6
40
35
30
25
21.4
20
RLS patients with family history ()
11.4
15
10
4.81
5
0
Yes unspecified
One member
Two or more members
Total
14
Restless Legs Syndrome Search for Genes

• No genes found for RLS yet
• Linkage reported to
• RLS 1 Chromosome 12q21
• RLS 2 Chromosome 14q1
• RLS 3 Chromosome 9p24-p2222

15
Restless Legs SyndromeThe Iron Theory

• Iron deficiency common2
• Iron levels have a circadian pattern7
• Iron supplementation useful2
• Iron is a co-factor in dopamine synthesis2
• D2 receptors correlate with iron deficiency2
• Ferritin levels correlate with disease severity2
• MRI of brain may confirm iron deficiency using a
  special programme
• Autopsy shows decreased iron in substantia nigra23

16
Restless Legs SyndromeThe Iron Theory

• RLS may be a functional disorder resulting from
  impaired iron acquisition by the neuromelanin
  cells in RLS23
• The underlying mechanism may be a defect in
  regulation of the transferrin receptors23

17
Secondary RLSPossible Causes

• Iron deficiency state
• Renal failure/end-stage renal disease
• Haemodialysis
• Pregnancy (usually 3rd trimester)
• Axonal neuropathy
• Others (rare)
• Parkinsons disease
• Spinocerebellar ataxia types 2 3
• Rheumatoid arthritis
• Diabetes mellitus

18
Restless Legs SyndromeVariations in Clinical
Presentation

• Early onset
• Often familial
• Progressive
• Late onset
• 45 yrs
• Low ferritin
• Secondary RLS
• Pain dominant/sensory dominant
• RLS with dominant periodic leg movements

19
Restless Legs SyndromePeriodic Leg Movements
(PLM)

• Periodic flexion of ankle, knee and thighs with
  fanning of toes7
• Pathological PLMS occur 5 times per hour/sleep4
• Polysomnography is required to quantify PLMS4
• 80 of RLS patients have a PLMS index 54
• PLMS also occur in a variety of sleep and
  neurological disorders4

20
Restless Legs SyndromeDiagnosis can be
ascertained by

• Clinical history (use the IRLSSG criteria)4
• Basic neurological examination7
• Blood test for ferritin level, glucose7
• In selected cases referral to secondary care
  for10
• Sleep studies
• Exclusion of other secondary causes

21
Restless Legs SyndromeDifferential Diagnosis

• Nocturnal leg cramps
• Akathisia (restlessness)
• Insomnia
• Positional discomfort

22
Restless Legs SyndromeWhy Treat RLS?

• RLS patients have a significantly impaired QoL27
• Untreated, RLS can
• Impact on sleep8,9
• Impact on mood27
• Impact on work30
• Impact on relationships30

23
Restless Legs SyndromeTreatment Issues

• Not all patients with RLS require pharmacological
  treatment6
• Oral iron supplementation should be tried to iron
  deficient patients as judged by low ferritin
  levels with monitoring of iron level after
  treatment6
• Approximately 15 of RLS patients may need
  specific treatment13
• Indications for treatment are7
• Severe chronic sleep loss/insomnia
• Severe daytime fatigue/tiredness
• Forced lifestyle changes (unable to travel)
• Severe PLMS
• Severe sensory symptoms

24
Restless Legs SyndromeDrugs to be Avoided

• Antidepressants (amitryptine/prozac)
• Antihypertensives (Calcium channel blockers)
• Antiemetics (metoclopramide)
• Caffeine at night time
• Alcohol at night time

25
Treatment of RLSDopaminergic Drugs are the
Mainstay
Pramipexole Ropinirole Rotigotine Cabergoline
Sinemet Madopar Stalevo
26
Treatment of RLSDopaminergic Drugs

• Levodopa
• Small evidence base6,32
• Augmentation and rebound in over 80 of
  patients33
• Dopamine agonists (DA)
• Large evidence base of double-blind
  placebo-controlled studies6,32
• Over 300 patients assessed34
• Low augmentation/rebound rates6,32
• DA vs. levodopa
• One trial Pergolide versus levodopa35
• Pergolide significantly more effective on PLMS
  (79 vs. 45)35

27
Treatment of RLSAugmentation and Rebound

• Augmentation
• Increasing requirement of drug
• Daytime/evening symptoms
• Symptoms become refractory to high doses
• Spread of symptoms to upper limbs and face
• Up to 80 rate with levodopa treatment
• Rebound
• Related to half-life of drug
• Early morning symptoms
• Low rates of augmentation and rebound with
  dopamine agonists

28
Treatment of RLSNon-dopaminergic Therapy

• Other Drugs
• Dose Range Specific Issues
• Oxycodon 2.5-25 mg Painful RLS
• Propoxyphene 100-260 mg Painful RLS
• Tramadol 50-100 mg Painful RLS
• Clonazepam 0.5-2 mg evening dose Drowsiness
• Triazolam 0.125/0.25 mg Insomnia
• Nitrazepam 2.5 10 mg Insomnia
• Carbamazepine 100 600 mg Resistant RLS
• Gabapentin 300-2400 mg Resistant and painful
  RLS
• For Iron deficiency
• Iron sulphate 200 mg tid Oral

29
Treatment of RLSTreatment Algorithm
Diagnosis of RLS
Exclude other secondary causes
Exclude iron deficiency
Avoid drugs worsening RLS
Severity assessment
Neuroleptics Antiemetics Antidepressants
Antihistamines
Iron deficiency (Serum ferritin Moderate- severe RLS needing treatment
Non-severe RLS
Add oral iron
Non-ergot dopamine agonist Evening dosing
Treat underlying disease
Little impact on Qol/lifestyle
Titrate up according to response
If augmentation or rebound use dopamine agonist
bid/tid regime
Sleep hygiene Non-pharmacological measures
QoL review
If low response use an alternative dopamine
agonist
Painful RLS
Associated insomnia
Add or substitute opiates, gabapentin
Add clonazepam
30
Treatment of RLSProblems in the UK In some
cases referral may be delayed between 10-40 yrs!!
Delayed Referral for Treatment
3
4
2
11
36
5-9
10-19
20-29
30-39
40-49
50-59
24
20
Duration of RLS (Years)
31
Management of RLS What treatments are currently
offered to patients?
Drug treatment received by patients with RLS38
25
20
20
18
15
13
13
RLS sufferers ()
10
6
5
4
5
0
Anti- depressants
Anti- convulsants
Quinine
Non-narcotic analgesia
Hypnotics
Dopamine agonists
Levodopa
32
Support for RLS Patients Ekbom Support Group run
by Eileen Gill and RLSUK

• Patients can find support for their condition
  through contact with other sufferers and
  healthcare professionals with a specialist
  interest in RLS
• The Ekbom Support Group is a multidisciplinary
  academic group run by Eileen Gill in conjunction
  with RLSUK
• RLSUK is an academic group dedicated to
  improvinng awareness and research in RLS in the
  UK.
• RLSUK has booklets in relation to RLS for
  distribution to medical practitioners.
• (www.restlesslegs.org.uk)

33
References

• Bonati MT, Ferini-Strambi L, Aridon P et al.
  Autosomal dominant restless legs syndrome maps on
  chromosome 14q. Brain 20031261485-1492.
• Allen RP, Earley CJ. Restless legs syndrome a
  review of clinical and pathophysiologic features.
  J Clin Neurophysiol 200118128-147.
• Ekbom KA. Restless legs a clinical study. Acta
  Med Scand 1945158(Suppl)1-122.
• Allen RP, Picchietti D, Hening WA International
  Restless Legs Syndrome Study Group. Restless legs
  syndrome diagnostic criteria, special
  considerations, and epidemiology A report from
  the restless legs syndrome diagnosis and
  epidemiology workshop at the National Institutes
  of Health. Sleep Med 20034101-119.
• Wellbery CE. Getting the facts on Restless legs.
  Am Fam Physician 20006251-52.
• Byrne R, Sinha S, Chaudhuri KR. Restless legs
  syndrome diagnosis and review of management
  options. Neuropsychiatric Disease and Treatment
  200621-10.
• Schapira AHV. Restless legs syndrome An update
  on treatment options. Drugs
  200464149-158.

34
References

• Hening W, Walters AS, Allen RP et al. Impact,
  diagnosis and treatment of restless legs syndrome
  (RLS) in a primary care population the REST
  (RLS epidemiology, symptoms, and treatment)
  primary care study. Sleep Med 20045237-246.
• Allen RP, Walters AS, Montplaisir J et al.
  Restless legs syndrome prevalence and impact
  REST General Population Study. Arch Intern Med
  20051651286-1292.
• Chaudhuri KR, Forbes A, Grosset D et al.
  Diagnosing restless legs syndrome (RLS) in
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  2004201785-1795.
• Tse W, Koller W, Olanow CW. Restless legs
  syndrome differential diagnosis and treatment.
  In Chaudhuri KR, Odin R, Olanow CW, eds.
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• Tison F, Crochard A, Léger D et al. Epidemiology
  of restless legs syndrome in French adults. A
  nationwide survey The INSTANT study. Neurology
  200565239-246 .
• Zucconi M, Ferini-Strambi L. Epidemiology and
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  Sleep Medicine 20045293-299.

35
References

• Walters AS, Hickey K, Maltzman J. A questionnaire
  study of 138 patients with restless legs
  syndrome the night walkers survey. Neurology
  19964692-95.
• Appiah-Kubi LS, Pal S, Chaudhuri KR. Restless
  legs syndrome (RLS), Parkinsons disease, and
  sustained dopaminergic therapy for RLS. Sleep Med
  20023S51-S55.
• Winkelmann J, Wetter TC, Collado-Seidel V.
  Clinical characteristics and frequency of the
  hereditary restless legs syndrome in a population
  of 300 patients. Sleep 200023597-602.
• TO BE CONFIRMED
• Allen RP, La Buda MC, Becker P et al. Family
  history study of the restless legs syndrome.
  Sleep Med 20023S3-S7.
• Winkelmann J. The genetics of restless legs
  syndrome. Sleep Med 20023S9-S12.
• UK Ekbom Support Group Survey, 2004.
• Desautels A, Turecki G, Montplaisir J.
  Identification of a major susceptibility locus
  for restless legs syndrome on chromosome 12q. Am
  J. Hum. Genet. 2001691266-1270.

36
References

• Chen S, Ondo WG, Rao S et al. Genomewide linkage
  scan identifies a novel susceptibility locus for
  restless legs syndrome on chromosome 9p. Am J Hum
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• Connor JR, Wang XS, Patton SM et al. Decreased
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  cells in restless legs syndrome. Neurology
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• Ondo W. Secondary restless legs syndrome. In
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• Silber MH, Ehrenberg BL, Allen RP et al for the
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References

• Chaudhuri KR, Meilak C. What is restless legs
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• Allen 2003
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38
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• Oertel W, Stiasny-Kolster K. Pramipexole is
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• www.ekbom.org.uk