Transcript National Institutes of Neurological Disorders and Stroke

Restless Legs
Syndrome
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National Institutes of
Neurological Disorders
and Stroke – NINDS.
National Institutes of
Health.
May 15,2009
Newman
Restless Legs Syndrome
• RLS, Wittmaack-Ekbom's syndrome, or
Nocturnal myoclonus, often misdiagnosed, may
be described as uncontrollable urges to move
the limbs in order to stop uncomfortable
sensations in the body, most commonly in the
legs, but can also be in the arms.
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History
• Studies were done by Thomas Willis (1622-1675) and by
Theodor Wittmaack. Another description of the disease
and its symptoms were made by George Miller Beard
(1839-1883).
• In a 1945 publication titled 'Restless Legs', Karl-Axel
Ekbom, described the disease and presented eight
cases used for his studies.
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Symptoms
• Start at any age
• The sensations uncommon, and there is a
difficult to describ them.
• Spontaneous improvement over a period of
weeks or months can occur.
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Symptoms
• Usually occur deep inside the leg, between the
knee and ankle; more rarely, in the arms and
hands.
• Movement bring immediate relief however,
often temporary and partial.
• Any type of inactivity involving sitting or lying,
can trigger the sensations.
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Symptoms
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Periodic Limb moviment Disorder
• 80-90% of people with RLS also have Periodic
Limb Moviment Disorder, which causes slow
"jerks" or flexions of the affected body part.
Typically occur every 10 to 60 seconds,
sometimes throughout the night. The symptoms
cause repeated awakening.
• These movements are involuntary.People have
no control over them.
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Incidence/Prevalence
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About 10% of adults in North America and Europe.
Underdiagnosed.
• Some physicians wrongly attribute the symptoms to
insomnia, stress, arthritis, muscle cramps, or aging.
• Symptoms can be difficult for a child to describe.
Sometimes is misdiagnosed as "growing pains" or
attention deficit disorder.
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types
• The cause is unknown.
• A family history in most of 40% of cases. (genetic form).
(CR12q)
• People with familial RLS tend to be younger when
symptoms start and have a slower progression
• Secondary – Often has a sudden onset and occurs after
the age of 40.
• Iron deficiency, accounts for just over 20% of all cases.
• “Sublacta causa, tollitur effectus”
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types
• Primary –
• Secondary –
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Early onset.
Familial over 40%.
Idiopathic.
Diagnostic is hard in
pediatrics.
• Slower progression.
Sudden onset.
After 40.
Iron deficiency over 20%.
Treatment of underlying
conditions.
• Fast progression
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Causes
Spinal cord tumors,
peripheral nerve
lesions.
Sleep apnea* or
narcolepsy.
Varicose veins.
Thyroid problems.
Iron deficiency
Gen “MEIS1”
Neurology,july 2009.
• Researchers also have found that
caffeine, alcohol, and tobacco
may aggravate or trigger
symptoms in patients who are
predisposed
• Some pregnant women
experience RLS, especially in
their last trimester. Symptoms
usually disappear within 4 weeks
after delivery.
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Causes
• An underlying medical • Particular medications
problem :
• tricyclic
• anti-nausea and antiseizure drugs,
• diabetes mellitus,
(SSRIs),
• kidney disease,
• Parkinson’s Disease, • lithium,
• some cold
• rheumatoid arthritis.
• allergy drugs
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International Restless Legs Syndrome
Study Group 1995
• A desire to move the limbs, often associated with
paresthesias or dysesthesias.
• Symptoms that are worse or present only during rest and
are partially or temporarily relieved by activity.
• Motor restlessness,
• Nocturnal worsening of symptoms.
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Diagnostic
• In 2003, a National Institutes of Health (NIH)
consensus panel modified their criteria:
• (1) an urge to move the limbs with or without sensations.
• (2) worsening at rest.
• (3) improvement with activity.
• (4) worsening in the evening or night.
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Diagnostic
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• Sleep pattern of a Restless Legs Syndrome
patient (red) vs. a healthy sleep pattern (blue).
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Diagnostic
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medical history,
family history,
current medications,
sleepiness,
disturbance of sleep,
daytime function.
• Blood tests to exclude
anemia,
• decreased iron stores
(ferritin level),
• diabetes,
• thyroid and
• renal dysfunctions
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Treatment
• An algorithm for treating Primary RLS was
created by leading RLS researchers at the
Mayo Clinic and is endorsed by the Restless
Legs Syndrome Foundation.
• This document provides guidance to both the
treating physician and the patient, and includes
both nonpharmacological and pharmacological
treatments.
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Lifestyle changes and other nonmedicinal approaches
• For those with mild to moderate symptoms, decreased
use of caffeine, alcohol, and tobacco may provide some
relief.
• Supplements to correct deficiencies in iron, folate, and
magnesium.
• A program of regular moderate exercise.
• Taking a hot bath, massaging the legs.
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Treatment
The Mayo Clinic Algorithim includes, medication from
four categories:
1 - Dopaminergics such as ropinirole, pramipexole,
carbidopa/levodopa or pergolide:
A recent study indicated that the used in restless leg
patients can lead to an increase in compulsive
gambling.
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Treatment
• 2 - Opioids such as propoxyphene, oxycodone, codein.
• 3 - Benzodiazepines (clonazepam and diazepam) - May
induce or aggravate sleep apnea*.
• 4 - Anticonvulsants - sensations as painful, such as
gabapentin.
• Medications taken regularly may lose their effect, making
it necessary to change medications periodically.
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Treatment
• In treatment with levodopa/carbidopa, most
patients eventually will develop augmentation,
meaning that symptoms are reduced at night but
begin to develop earlier in the day than usual.
Dopamine agonists such as pramipexole, and
ropinirole may be effective in some patients and
are less likely to cause augmentation.
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Treatment
• Ropinirole - Approved In 2005 by the Food and Drug
Administration to treat moderate to severe Restless Legs
Syndrome. The drug was first approved for Parkinson's
disease in 1997.
• Pramipexole - (Mirapex, Sifrol, Mirapexen in the EU).In
February 2006, the EU Scientific Committee issued a
positive recommendation for approving for the treatment
of RLS in the EU. US FDA approved in 2006.
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Treatment
• Rotigotine - Currently in process for US FDA
and EU approval for RLS.
Delivered via a transdermal patch.
• Pergolide - In March 2007 was withdrawn from
the U.S. Market.
Withdrawn due to implication in valvular heart
disease, that was shown in two independent
studies.
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Prognosis
• Is generally a lifelong condition and there is no cure.
Symptoms may gradually worsen with age, more slowly
for those with the idiopathic form than for patients who
have an associated medical condition. Current therapies
can control the disorder, minimizing symptoms and
increasing periods of restful sleep. Some patients have
remissions, for days, weeks, or months. A diagnosis of
RLS does not indicate the onset of another neurological
disease.
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Key points
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Often misdiagnosed.
Pediatrics – Attention deficits disorder
Treatment of underlying condition.
There is no cure to the idiopathic form.
NIH criteria.
Iron deficiency, 20% of all cases.
Family History, 40% of cases.
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Newman
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