Transcript 11 YEARS OF CLINICAL PROGRESS

11 YEARS OF CLINICAL
PROGRESS
RICHARD P ALLEN, PHD, DABSM, FAASM
JOHNS HOPKINS UNIV, NEUROLOGY
THE START
• 1945
Ekbom
– Identified the condition
– Gave it a name: Restless Legs Syndrome
– Emphasized listening to the patient and interest in
sensory phenomena particularly pain.
 In his monograph Preface starts out with a quote in French roughly
translated here by Dr. Arnulf:
 "Doctors ... call 'neurotics' or 'predisposed’ those people who have
the bad taste to suffer above their forces or to drag on pain against
their will. Every case exists. But I acquired the conviction that this
is here a major mistake from the contemporary medicine... I am
convinced that, almost always, those who suffer suffer exactly as
they describe it, and, paying to their pain an extreme attention,
they suffer more than one could imagine. There is only one pain
easy to bear, that's the pain of other than you.” René Leriche
The Restart: Diagnosis
• 1945
EKBOM: “disease in the legs characterized by
Peculiar Paresthesia.., Pain and Weakness…”
• 1997
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IRLSSG Art Walters
“Toward a better definition of the ….”
First effort at a consensus clinical criteria for RLS
Restored emphasis on urge to move
• 2 May 2002
IRLSSG/RLSF at NIH
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2003 “Restless Legs Syndrome: Diagnostic Criteria,.
–
Updated diagnosis,
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1st diagnostic criteria: children and augmentation
• 26 Oct 2008 IRLSSG and EU-RLSSG at JHU
–
Occurrence rate, differential dx, clinical significance, and
emphasis on appropriate use of objective tests
The Restart: Treatment/pathology
• 1982
Akpinar and Montplaisir
– Levo-dopa, dopamine hypothesis
• 1987
Walters and Hening
– Efficacy of opioids, and DA agonists
• 1994
O’Keeffe
– Iron treatment for iron deficiency
• 1992
Earley and Allen
– L-dopa compared to propoxyphene
– Iron, brain iron
RLS phenotypes
• Familial vs sporadic
– Walters 1990, Ondo 1996
• Early vs late age of onset
– Allen 2000, Winkelmann 2000
• Painful RLS
– Hening 2004
Progress: RLS Prevalence
Diagnosis
Paper
RLS prevalence
Limited questions
Lavignel 1994
15%
Full Dx criteria EU:
questions/interview
Berger 2004
10.6%
Högl 2005
Allen et al 2005
7.2%
Full dx EU:USA all
weekly
4.5%
2/wk + distress
MD Dx EU All
Clinically significant
Pediatric US/UK 12 - 17
8 - 11
Allen et al 2008
Picchietti et al 2007
(all/2/wk + distress)
2.7%
3.5%
2.1%
2.0% / 1.0%
1.9%/ 0.5%
Prevalence RLS 2/wk + distress : age and gender
general population US and Western Europe
Women>men over age 30
Increase with age to age
60
(Allen et al , 2005)
Prevalence of any RLS
- significant population factors
• WESTERN COUNTRIES -- 7 - 11%
• TURKEY -- 3%
• Korea ------- 4- 7%
• Japan/Singapore -- < 3 %
• (African Americans < ??)
Progress epidemiology of RLS: special
populations• Any condition that compromises iron status
– Pregnancy, End Stage Renal Disease, iron deficiency, gastric
surgery,etc.
• Some Neurological disorders
– Multiple Sclerosis, Neuropathies, etc.
• Medication use?
– SSRI, SNRI, Anti-histamines
• Possible decreased risk for women who have not been pregnant
– One Study only
Progress: Treatment
• US - Two FDA approved medications
– Ropinirole, pramipexole
• Newer treatment options
– Longer acting DA treatments
– Gabapentin /alpha 2 delta
– Opioids - longer acting forms
– Iron
Progress: Clinical Tools/Methods
• Validated diagnostic instruments
– 2 - 3 of these now available
– Recommended use in clinical trials and studies
• Validated severity and Quality of Life scales
– IRLS
– Two QoL scales
– MOS for sleep in RLS patients
• PSG studies: PLMS and PLMW,
• SIT - severity - maybe diagnosis
• Activity meters
• PLM recording methods
– Periodicity, nocturnal pattern
• Blood tests: serum ferritin
Clinical problems
• Augmentation
• Careless diagnosis
• Inadequate treatment – Most severe still poorly treated
– Symptomatic treatment may not address all of RLS
effects.
• Uncertain medical consequences
– Chronic RLS untreated (Why fewer very old RLS?)
– Long term (10-40 years of RLS treatments)