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Unhappy Feet Restless Leg Syndrome - USAFP Home Page

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									Unhappy Feet: Restless Leg
       Syndrome
   Bob Marshall, MD MPH MISM
          CAPT MC USN
   Director of Clinical Informatics
  US Navy Bureau of Medicine and
     Surgery, Washington, DC
          Objectives for Today
•   Define the syndrome
•   Review prevalence and diagnostic criteria
•   Review impact on QoL
•   Discuss how to make the diagnosis
•   Review treatment
•   Review prognosis
•   Summarize and provide take-home message
                Definition
• Restless legs syndrome (RLS) is a
  sensorimotor disorder typically
  characterized by an uncomfortable feeling
  in the legs that leads to an urge to move
• A clinical diagnosis made in the office, not
  in the sleep laboratory
• Diagnosis is based on a careful history

                                       Kushida, CA. 2007.
              Prevalence
• Numerous survey and epidemiological
  studies done
• Prevalence ranges from 7-10 % with
  symptoms at least once per week
• Ethnic and geographic variations
• Women more affected than men: approx 2:1
• Iron deficiency, pregnancy, family hx and
  renal dz increase risk
                              Gamaldo, CE and Earley, CJ. 2006.
            Interesting Facts
• Two types: idiopathic and secondary
  – Idiopathic, more prevalent, found in younger
    patients and felt to be familial
  – Secondary due to Fe deficiency, pregnancy,
    renal failure, poor gut Fe absorption (surgery)
• Seen at any age, but young children
  uncommon
• Once have symptoms, they persist
Prevalence increases with age




                          Allen, RP. 2007.
           Diagnostic Criteria
• An urge to move the legs, usually accompanied or
  caused by uncomfortable and unpleasant
  sensations in the legs
• The urge to move or unpleasant sensations begin
  or worsen during periods of rest or inactivity such
  as lying or sitting
• The urge to move or unpleasant sensations are
  partially or totally relieved by movement
• The urge to move or unpleasant sensations are
  worse in the evening or night than during the day
  or only occur in the evening or night
                                             Allen, RA. 2003.
            Impact on QoL
• In large population study, moderate or
  severely distressing symptoms at least twice
  a week were experienced 2.7%.
• All eight domains of the SF-36 QoL
  questionnaire had significantly lower scores
  than age and sex adjusted US population
• Actual values very similar to those with
  type 2 diabetes or osteoarthritis
                             Reese, JP, et al. 2007; Allen, RP, et al. 2005.
Effects on Work/Daily Activities
          Economic Burden
• Almost all costs outpatient and lost work
• RLS patients had 1.5-2.0x costs versus age
  and sex matched controls
• Using IRLS criteria, a 1.728 increase on
  IRLS scale equaled 1% increase in work
  dysfunction
• Studies indicate RLS costs similar to other
  chronic diseases
                           Curtice, TG, et al. 2006.; Douzinas, N, et al. 2005.
   Making the Diagnosis            1 of 2

• Need to ask the questions, especially of
  patients presenting with sleep problems
• Only 25% of patients with RLS are
  accurately diagnosed
• Diagnosis more difficult in children and
  cognitively impaired elderly patients
• Medical, physical and neurological exams
  in primary RLS are all normal
   Making the Diagnosis                    2 of 2

• Secondary causes of RLS can be detected
  – Iron studies for Fe deficiency (ferritin & iron
    saturation levels)
  – Renal studies for ESRD
  – Pregnancy test (only if possible missed
    pregnancy)
• Polysomnography and Suggested
  Immobilization Test (SIT) not diagnostic

                                            Kushida, CA. 2007.
         Differential Diagnosis
•   Neuropathic pain syndromes
•   Peripheral neuropathy
•   Arthritis
•   Nocturnal leg cramps
•   Restless insomnia
•   Painful legs and moving toes
•   Vascular insufficiencies
•   Drug-induced akathisia
              Comorbidities
•   Back pain
•   Depression/depressed mood
•   Hypertension
•   Insomnia
•   Anxiety
•   Arthritis
•   Nocturnal cramps
 Non-Pharmacologic Treatment
• Find and treat underlying disorders
• Avoid RLS precipitants (medications)
  – SSRI’s, TCA’s, dopamine-blocking agents
• Good sleep hygiene
• Lifestyle modifications: walk before bed,
  hot bath/cold shower, limb massage
• Moderate exercise
• Weight management
                                       Hening, WA. 2007.
Pharmacologic Treatment                              1 of 3

• Intermittent RLS symptoms
  – Medications that can be taken as needed
  – Levodopa with decarboxylase inhibitor
    (carbidopa or benserazide)
  – Mild- to moderate-strength opioid (codeine,
    propoxyphene, tramadol, hydrocodone,
    oxycodone)
  – Sedative-hypnotics
  – Dopamine agonist: low dose, if tolerated
                                   Hering, WA. 2007. ; RLS Foundation
Pharmacologic Treatment                  2 of 3

• Daily RLS symptoms
  – Dopamine agonists: ropinirole, pramipexole
  – Anticonvulsants: gabapentin
  – Opioids: tramadol, oxycodone, hydrocodone,
    extended-release forms
  – Benzodiazepines: clonazepam
  – Iron supplementation
Pharmacologic Treatment                     3 of 3

• Refractory RLS symptoms
  – Change to a different dopamine agonist
  – Switch to an opioid or anticonvulsant
  – Add second medication, possibly with reduced
    agonist dose (e.g., add drug from another class)
  – Consider “drug holiday”: covered by opioid or
    different agonist
  – High-potency opioids for severe, resistant cases
    (e.g., methadone 5–40 mg/day)
         Special Populations
• Pregnant patients (up to 20%)
  – Usually subsides after delivery; supplement
    with Fe and folic acid
• Children
  – Sleep hygiene and caffeine avoidance first
  – Dopaminergic agents after; good response
  – Can help with ADHD sx
• Secondary RLS – treat the problem
   Determining Response to Tx
• Augmentation
  – Occurs with DA agents, especially with
    levodopa (~82%); 20-30% with others
  – Recognize and remove DA agent; treat with
    other agent
• Best to use consistent rating scale (at each
  visit)
  – Two available…IRLSSG and Johns Hopkins
    RLS rating Scale
IRLSSG Rating Scale
               Prognosis
• In some patients, RLS sx may abate and
  disappear for years
• In most patients, RLS sx never disappear
• In many patients, RLS sx progress slowly
  over time (i.e. become more severe)
• No long term studies of therapy (beyond
  one year)
  EB-Based Recommendations
• RLS common (~10%) and underdiagnosed
  (~25%) – need to screen patients for sleep
  complaints and primary symptoms
• Diagnosis is clinical based on 4 criteria
• Secondary causes: Fe deficiency, pregnancy
  and ESRD – all treatable or self-limited
• Treat based on frequency and severity of
  symptoms
                         LOE – Tx - 2c; Dx - 2b; Prognosis - 2c; DDx - 2b
   EB-Based Recommendations
• Dopamine agonists currently best agents for
  moderate to severe symptoms*
• Intermittent or mild symptoms – lifestyle
  modifications +/- levodopa/carbidopa
• Use rating scales to gauge response to
  therapy and symptom severity
• Symptoms generally progressive

                           *no long term studies; ropinirole, L-Dopa and
                           pergolide best studied…from Bandolier
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