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An exhausting urge to move: sleep and leg disorders: careful questioning can pinpoint the cause of difficult-to-describe leg aches.

CASE STUDY

Ashley is a 49-year-old perimenopausal woman who presents to her physician, Dr Martin, with complaints of poor sleep related to discomfort in her legs. She explains the discomfort as a difficult-to-describe, deep aching in her muscles: "It's a very strange sensation; almost the way your muscle feels when you get a cramp, and then the cramp goes away." Ashley tells Dr Martin that this has been happening for years but has steadily worsened over time. It takes her 2 hours to fall asleep, and she gets no more than 4 hours of good, restful sleep at night. Ashley's husband complains about her repetitive kicking at different times during the night. Her symptoms are worse in the evening and are accompanied by pain. Activity provides at least temporary relief.

Further questioning reveals that the problem is especially stressful when Ashley is confined, such as in a car; as a passenger on long car trips, her legs begin to ache and she finds herself unable to sit and needing to move. She describes airplane rides as "horrible," stating that she avoids sitting in a middle or window seat at all costs.

Ashley has always been aware that her mother (now deceased) had the same problem, as does her sister; only her father has been "spared." She recalls her father needing to stop the car while her mother got out and walked around to alleviate the discomfort. Believing that humor is the best medicine, the family referred to the symptoms as "happy legs," but they were, in truth, quite frustrated that no one was able to tell them what was actually happening.

While in her 30s, Ashley underwent surgical repair of a herniated disk. She used that opportunity to describe the "weird feeling" in her legs to her neurosurgeon. The neurosurgeon seemed to dismiss her comments, at which point Ashley simply "gave up and just lived with it."

Ashley has no comorbid illnesses. She admits to being a heavy coffee drinker but takes no medications; she had been taking diphenhydramine for seasonal allergies but stopped a few weeks prior to this office visit.

Physical examination reveals no spinal cord or peripheral nerve lesions, no symptoms of vascular abnormalities, and normal tibial pulses. Dr Martin determines that Ashley is not pregnant, and findings from a previous polysomnographic study are normal. Laboratory testing shows low iron levels (serum ferritin, 37 ng/mL), serum glucose levels of 122 mg/dL, and serum creatinine levels of 0.9 mg/dL.

Differential Diagnosis

As described, Ashley's symptoms could suggest a number of disorders (TABLE): specifically, nocturnal leg cramps (NLC), akathisia, restless legs syndrome (RLS), peripheral polyneuropathy, hypnic jerks or sleep starts, and periodic limb movements in sleep (PLMs).

URGE criteria for RLS. Ashley's characterization of her leg discomfort suggests RLS. Her symptoms are painful and worsen in the evening and at night. Activity relieves her symptoms, at least temporarily. The most important clue is Ashley's self-described urge to move her legs, which points to one particular disorder.

There is no objective test for the diagnosis of RLS, but 4 major criteria, depicted by the URGE acronym,1-3 help to differentiate between RLS and other leg disorders, including NLC and PLMs.

* U=Urge to move limbs. The patient-described urge to move her legs is an extremely diagnostic sign. This urge is usually, but not always, accompanied by some uncomfortable and unpleasant sensations in the limbs.

* R=Rest. Rest or inactivity precipitates or exacerbates symptoms. The longer the patient is at rest or inactive, the greater the likelihood that she will experience symptoms.

* G=Getting up. Getting up or moving around relieves the sensation. This accounts for the sleep problems described by patients with RLS; they have trouble sleeping because they need to get up and walk around in an attempt to alleviate the sensation.

* E=Evening. Evening or nighttime appearance of symptoms is an important factor. RLS symptoms occur with circadian variation; they are worse in the evening and at night and much better in the morning.

Making the diagnosis. Ashley's family history of similar symptoms is revealing, since RLS can be hereditary. Unlike Ashley, some patients may not realize that their family history is positive for the disorder; the first time they are asked, patients may say that no member of their family has such symptoms or that they simply do not know. Often, patients will return to the office after speaking with family members who, only then, discuss the symptoms that they have experienced sometimes for years or even decades.

Ashley's husband's complaints about her repetitive kicking during the night support the diagnosis of RLS, rather than PLMs, which typically involves big toe extension, ankle dorsiflexion, and knee and hip flexion. Antihistamines, such as diphenhydramine, which Ashley recently stopped taking, have been shown to aggravate symptoms of RLS.

Ashley's personal and family history, along with an unremarkable physical exam, the normal findings of the sleep study, and laboratory test results are sufficient for Dr Martin to diagnose his patient with RLS, possibly related to iron deficiency. Typically, the condition is under- and/or misdiagnosed despite a reportedly high prevalence in the general population (up to 15% of the population). (1,4,5)

RLS or hypnic jerks? Many individuals experience brief jerking movements (hypnic jerks) at the onset of sleep. Hypnic jerks occur primarily in the legs or arms but can involve the whole body. Hypnic jerks are often associated with the sensation of falling asleep and at least one of the following: a falling sensation, a sensory flash, or a hypnagogic dream.6 Even though they are quite different, hypnic jerks can sometimes be confused with RLS or with PLMs, which is characterized by involuntary periodic movements in the lower extremities (usually the legs) during sleep (See "PLMs and PLMD" SIDEBAR).

Overview of RLS

The overall prevalence of RLS is 3% to 15%; nearly 25% of primary care patients have RLS symptoms. (1,4,5,7) The disorder is more common in western industrialized countries and less prevalent in Asian populations. (7,8)

RLS is a gradually progressive disorder. It is often diagnosed during the third decade and prevalence increases with age, as does disease progression. (1,5,8) Although an apparent drop-off in prevalence is seen at age 80 (FIGURE), this is likely due to the low numbers in the survey; in general, RLS tends to be more common in elderly individuals. (7)

Primary (idiopathic) RLS accounts for most cases of the disorder. Younger individuals are more likely to have primary RLS (onset before age 45); this form of the disorder progresses slowly and is likely to be hereditary. (9) Onset of primary RLS after age 45 is characterized by rapid disease progression and is less likely to be hereditary. (9)

Secondary RLS tends to correlate with late-onset disease and is therefore more common in older individuals. Secondary RLS also is more likely to be associated with pregnancy--approximately 20% of pregnant women experience RLS (9)--and is strongly associated with iron-deficiency anemia (10-13) and end-stage renal disease/dialysis. (9,13) Other RLS comorbidities include rheumatoid arthritis, peripheral neuropathies, and diabetes.9 Alcohol and medications, including certain antidepressants, lithium, antihistamines that cross the blood-brain barrier, and dopamine antagonists have also been linked to RLS. (14,15)

[FIGURE OMITTED]

RLS usually affects both legs simultaneously but can also be unilateral or alternating. (2) The arms may also be involved (2) and, in fact, RLS can actually affect the entire body.

RLS symptoms can be quite varied; along with an intense urge to move, patients often use terms such as "creepy," "crawly," and "tingly" to describe RLS sensations; others describe them as "crampy," "achy," or "painful." These symptoms can be felt in the muscles as well as the bones. They may feel like an intense pain, a burning sensation, or a lightning-shot type of pain. Patients may further describe RLS sensations as feeling like worms or bugs crawling deep in the muscle or water running under the skin. (2)

Many patients experience symptoms every night, but symptoms also vary enormously in frequency. Some patients have symptoms only intermittently and, rarely, others experience discomfort every waking moment of the day.

The RLS burden

In addition to pain and discomfort, RLS is a major cause of sleep disturbance (trouble falling asleep, decreased hours of sleep) which, in turn, may lead to daytime fatigue and sleepiness, poor functioning at work or at home, and impaired social interactions. (16) Patients often avoid long car trips or flying, social situations, and family activities. Most patients present to their physicians because of the associated sleep disturbance and may not mention their legs at all.

RLS patients may also experience feelings of frustration, anxiety, embarrassment, and depression (9,16) These feelings may be worsened by the attitudes of family members--and even some physicians--who may not accept RLS as a "real disease." Depression can become severe and has been anecdotally reported to be linked to suicide in some cases.

Cause and risk factors

Although the cause of RLS is unknown, at least 3 factors are likely involved: iron status, dopamine and opiate pathways, and various neurotransmitters. Brain-iron imaging has shown much lower relaxation rates in red nucleus and substantia nigra in RLS patients versus controls, indicating low stores of iron.

It is now recognized that most cases of RLS have a genetic basis, as evidenced by the findings of 2 recent studies. (19,20) In particular, in the Genome-Wide Association Study, investigators reported a very clear association between chromosomes 2, 6, and 15 and features of RLS (including the periodic jerking leg movements during sleep that are often associated with the disorder). (19,20)

Treatment: Increase Dopamine, Decrease Symptoms

RLS tends to be both underdiagnosed and undertreated. It is generally believed that approximately 2.7% of patients require treatment for RLS. (8)

Prior to initiating treatment, iron status--particularly serum ferritin--should be checked. Iron supplementation is required when serum ferritin is less than 50 ng/mL. (10,11) If the patient's symptoms do not respond, further treatment, usually with pharmacologic agents, may be needed.

Nonpharmacologic treatment

Nonpharmacologic treatment strategies for RLS include improved sleep hygiene (standardized bedtime and wake time), moderate daytime exercise, hot or warm baths, and anything that provides counterstimulation to the legs, such as leg vibration/massage. (14,15) Strenuous exercise before bed can worsen symptoms, and patients should be encouraged to avoid caffeine, alcohol, and nicotine, all of which worsen RLS symptoms. Antihistamines can also exacerbate symptoms, as do antidepressants (particularly lithium) and dopamine antagonists. (14,15)

Unfortunately, nonpharmacologic measures are generally not effective for most patients with significant RLS. The majority of such patients require pharmacologic treatment.

Pharmacologic treatment

Dopamine agonists. Dopamine agonists, considered first-line treatment for RLS (and periodic limb movement disorder [PLMD]; See "PLMs and PLMD" sidebar on page S18), (15) are generally highly effective for the treatment of moderate-to-severe disease. These agents, which can be taken on an as-needed basis, are proven for long-term use in RLS. Side effects, such as nausea and sleepiness, are rare when the dose is titrated slowly.

Pramipexole is a dopamine agonist that has been well studied and is approved by the US Food and Drug Administration (FDA) for moderate-tosevere primary RLS. (It is not approved for treatment of PLMD.) Pramipexole has been shown to significantly improve subjective RLS symptoms, as measured by the International Restless Leg Syndrome (IRLS) scale Not only does pramipexole reduce the pain and discomfort associated with RLS, it also improves the leg jerking activity typically seen in patients. In the Pramipexole for RLS: Efficacy and Tolerability of the Usage of Dopamine Agonists (PRELUDE) study, 50.0% to 77.3% of patients treated with the drug rated their conditions much better or very much better, versus 38.1% given placebo. (21) Clinicians' assessments of patients' responses revealed that the majority of patients (up to 86%) were much improved on pramipexole. The authors reported a significant reduction in IRLS scores (P [less than or equal to] .001) in all pramipexole groups, and a significant dose-independent decrease in Periodic Limb Movement Index (PLMI) scores with pramipexole (P < .001). (21) The medication was well tolerated, with no evidence of associated daytime somnolence. (21))

Ropinirole, another dopamine agonist that has been FDA approved for the treatment of moderate-to-severe primary RLS, has also been shown to help reduce the frequency of periodic leg movements, at night and during the daytime. (Some patients with RLS experience daytime leg-jerking activity.) (22-25) The drug is typically used in doses of up to 4 mg (0.254.0 mg), which are relatively low compared with those used for Parkinson's disease. Ropinirole is not FDA approved for treatment of PLMD.

Ropinirole has been shown to improve subjective measures of RLS symptoms (improved IRLS scores), sleep (disturbance, quality, and adequacy), quality of life, and anxiety, and also improves the overall clinical condition, as assessed by the Clinical Global Impression and IRLS scales. (22-25) The drug is well tolerated, with an adverse event profile very similar to that of other dopamine agonists. In one study, many fewer ropinirole-treated patients relapsed compared with patients who were switched to placebo after 24 weeks of treatment. Specifically, at all time points (even from day 3), there was a significant difference between ropinirole and placebo, despite a placebo response. (22-25)

Alternative pharmacologic therapies. In patients who do not respond to treatment with pramipexole and ropinirole, other medications are sometimes used, none of which are FDA approved for either RLS or PLMD. These include iron supplements (if the patient is iron deficient), benzodiazepines (clonazepam), anticonvulsants (gabapentin), skeletal muscle relaxants (baclofen), opiates (codeine), and tiagabine (gamma-aminobutyric acid [GABA] reuptake inhibitor).

For severe iron deficiency, iron supplementation given as a high-dose iron dextran infusion has been shown to provide significant transient reduction in symptoms. (26) Gabapentin is reported to improve sensorimotor symptoms, sleep architecture, and PLMI scores. (27) A rotigotine patch enables continuous delivery, making the drug effective both day and night. (28) Cabergoline improves sensorimotor symptoms and sleep disturbances. (29) Neither rotigotine nor cabergoline is FDA approved for RLS or PLMD.

Summary

RLS is a common condition with a clear genetic association, occurring in up to 15% of the population. (1-3,7) For some of those affected, RLS can be intensely disabling; the disorder not only causes pain and discomfort but interferes with sleep which, in turn, can affect a patient's ability to function normally in their everyday lives.

Patients who present with complaints about sleep should be questioned about any leg discomfort or movements. Diagnosis is aided by differentiation between RLS and hypnic jerks and between RLS and PLMs.

Despite its prevalence, RLS tends to be both underdiagnosed and undertreated. It is now believed that approximately 3% of affected patients require treatment; (30) iron supplementation is indicated if serum ferritin levels are low, but a dopamine agonist is usually needed as well and is considered first-line treatment for the disorder. (15)

Periodic Limb Movements in Sleep and Periodic Limb Movement Disorder

Restless legs syndrome (RLS) is a symptomatic disorder that can be associated with kicking of the legs. In the accompanying case study, the patient's husband complains that she kicks during the night.

Periodic limb movements in sleep (PLMs) are involuntary periodic movements in the lower extremities (usually the legs) during sleep, affecting up to 85% of patients with RLS. (1-3) Periodic limb movement disorder (PLMD) is the disorder associated with PLMs when the PLMs is not associated with any other disorder, including RLS. Although patients may be unaware of such movements, they can cause significant sleep disturbances and arousals.

PLMs

The periodic movements of PLMs usually involve big toe extension, ankle dorsiflexion, and knee and hip flexion. (1,2) Limb movements last for 0.5 to 5 seconds and occur every 4 to 90 seconds; typical movements occur for 20 to 40 seconds. (1-3)

PLMs occur with sleep disorders other than RLS and can also occur in individuals without sleep disorders. Prevalence is estimated to be 4% to 11% in adults and increases with age. (3) Risk factors and secondary causes of PLMs include narcolepsy, attention-deficit hyperactivity disorder, spinal cord injury, diabetes, sleep apnea syndrome, rheumatoid arthritis, pregnancy, iron-deficiency syndrome, and drug dependency. Precipitating medications include uremia medication, benzodiazepines, neuroleptic medication, and dopaminergic agents; barbiturate withdrawal can also cause PLMD. (2,3)

PLMs are typically diagnosed with polysomnography (with sensors placed over the calf muscles to record leg movements during sleep) and the periodic limb movement index (PLMI; number of leg movements during each hour of sleep). (3) Clinical disturbance and fatigue are also used to diagnose the condition.

PLMD

A patient with clinically significant sleep disturbance associated with PLMs that cannot be accounted for by RLS or any other sleep disorder is considered to have PLMD. The diagnosis is made when the PLMI is 5 or higher. (3) Affected patients may complain of fatigue or daytime somnolence. As with PLMs, the prevalence of PLMD increases with age. (1,3)

When needed, medications to treat PLMD are essentially the same as those used to treat RLS. Dopaminergic agents, which modify activity of the subcortical motor system, serve as first-line treatment, and sedatives may enable uninterrupted sleep in mild cases. Although dopaminergic agents are approved by the US Food and Drug Administration to treat RLS, they are not currently approved for treating PLMD.

Michael J. Thorpy, MD

References

(1.) Ohayon MM, Roth T. Prevalence of restless legs syndrome and periodic limb movement disorder in the general population. J Psychosom Res. 2002;53:547-554.

(2.) Kushida CA. Clinical presentation, diagnosis, and quality of life issues in restless legs syndrome. Am J Med. 2007;120 (suppl 1):S4-S12.

(3.) Vetrugno R, D'Angelo R, Montagna P. Periodic limb movements in sleep and periodic limb movement disorder. Neurol Sci. 2007;28 (suppl 1):S9-S14.

Restless Legs Syndrome: The ObGyn Perspective

A number of leg disorders have a potential neurologic etiology. Such conditions include restless legs syndrome (RLS), periodic limb movement disorder (PLMD), and peripheral neuropathy. RLS is a common condition that most frequently affects individuals of European descent, women, older individuals, and persons with a family history of the disorder. (1-3) Although the exact pathophysiology of RLS has not been fully determined, it appears that both iron and dopamine pathology may be important. (4,5) An underlying genetic predisposition may also play an important role. (8,7)

RLS may be idiopathic, without any associated medical conditions, or secondary in nature due to iron deficiency, renal disease, or pregnancy. (3) In fact, up to 20% of pregnant women will develop RLS. (3) Although secondary RLS will usually resolve with treatment of the underlying condition, idiopathic RLS is often a chronic disorder. RLS and PLMD have some similarities but usually can be differentiated through a detailed history. The hallmark of RLS is painful leg sensations that can be relieved by voluntary leg movement. Such sensations may be intermittent and tend to worsen in the evening or at night. In contrast, PLMD is associated with periodic involuntary movement of the legs usually while sleeping. (3,8)

Physical examination and testing are focused on identifying comorbid conditions that may exacerbate RLS. There are no specific clinical or laboratory findings viewed as pathognomonic of the condition. The case scenario provides a fairly typical presentation of a woman with RLS and a careful history should readily lead to the correct diagnosis.

Ronald T. Burkman, MD

References

(1.) Sevim S, Dogu O, Camdeviren H, et al. Unexpectedly low prevalence and unusual characteristics of RLS in Mersin, Turkey. Neurology. 2003;61:1562-1569.

(2.) Allen RP, Walters AS, Montplaisir J, et al. Restless legs syndrome prevalence and impact: REST general population study. Arch Intern Med. 2005;165:1286-1292.

(3.) Kushida CA. Clinical presentation, diagnosis, and quality of life issues in restless legs syndrome. Am J Med. 2007;120:S4-S12.

(4.) Walters AS. Review of receptor agonist and antagonist studies relevant to the opiate system in restless legs syndrome. Sleep Med. 2002;3:301-304.

(5.) Allen RP, Barker PB, Wehrl F, et al. MRI measurement of brain iron in patients with restless legs syndrome. Neurology. 2001;56:263265.

(6.) Stefansson H, Rye DB, Hicks A, et al. A genetic risk factor for periodic limb movements in sleep. N Engl J Med. 2007;357:639-647.

(7.) Winkleman J, Schormair B, Lichtner P, et al. Genome-wide association study of restless legs syndrome identifies common variants in three genomic regions. Nat Genet. 2007;39:1000-1006.

(8.) Vetrugno R, D'Angelo R, Montagna P. Periodic limb movements in sleep and periodic limb movement disorder. Neurol Sci. 2007;28 (suppl 1):S9-S14.

References

(1.) Nichols DA, Allen RP, Grauke JH, et al. Restless legs syndrome symptoms in primary care: a prevalence study. Arch Intern Med. 2003;163:2323-2329.

(2.) Allen R, Walter A, Hening W, et al. Factors affecting the quality of life (QoL) of adults with restless legs syndrome (RLS): a population-based survey. Eur J Neurol 2003;10(suppl 1):138-139.

(3.) Walters AS, Aldrich MS, Allen R, et al; for International Restless Legs Syndrome Study Group. Toward a better definition of the restless legs syndrome. Mov Disord. 1995;10:634-642.

(4.) Allen RP, Hening WA, Montplaisir J, et al. Restless legs syndrome (RLS) is a common disorder rarely diagnosed in Europe or USA: the REST (RLS Epidemiology, Symptoms and Treatment) study in primary care. Mov Disord. 2002;17(suppl 5):S240-S241.

(5.) Ohayon MM, Roth T. Prevalence of restless legs syndrome and periodic limb movement disorder in the general population. J Psychosore Res. 2002;53:547-554.

(6.) Oswald l. Sudden bodily jerks on falling asleep. Brain. 1959;82:92-103.

(7.) Sevim S, Dogu O, Camdeviren H, et al. Unexpectedly low prevalence and unusual characteristics of RLS in Mersin, Turkey. Neurology. 2003;61 : 1562-1569.

(8.) Allen RP, Walters AS, Montplaisir J, et al. Restless legs syndrome prevalence and impact: REST general population study. Arch Intern Med. 2005;165:1286-1292.

(9.) Kushida CA. Clinical presentation, diagnosis, and quality of life issues in restless legs syndrome. Am J Med. 2007;120 (suppl 1): S4-S12.

(10.) Earley CJ, Allen RP, Beard JL, et al. Insight into the pathophysiology of restless legs syndrome. J Neurosci Res. 2000;62:623628.

(11.) Lee KA, Zaffke ME, Baratte-Beebe K. Restless legs syndrome and sleep disturbance during pregnancy: the role of folate and iron. J Womens Health Gend Based Med. 2001;10:335-341.

(12.) Akyol A, Kiyloglu N, Kadikoylu G, et al. Iron deficiency anemia and restless legs syndrome: is there an electrophysiological abnormality? Clin Neurol Neurosurg. 2003;106:23-27.

(13.) Hui DS, Wong TY, Ko FW, et al. Prevalence of sleep disturbances in Chinese patients with end-stage renal failure on continuous ambulatory peritoneal dialysis. Am J Kidney Dis. 2000;36:783-788.

(14.) Parker KP, Rye DB. Restless legs syndrome and periodic limb movement disorder. Nurs Clin North Am. 2002;37:655-673.

(15.) Stiasny K, Oertel WH, Trenkwalder C. Clinical symptomatology and treatment of restless legs syndrome and periodic limb movement disorder. Sleep Med Rev. 2002;6:253-265.

(16.) Fehnel S, et al. 7th Congress of the European Federation of Neurological Societies: August 30-September 2, 2003; Helsinki, Finland. Abstract 677.

(17.) Wakers AS. Review of receptor agonist and antagonist studies relevant to the opiate system in restless legs syndrome. Sleep Med. 2002;3:301-304.

(18.) Allen RP, Barker PB, Wehrl F, et al. MRI measurement of brain iron in patients with restless legs syndrome. Neurology. 2001;56:263-265.

(19.) Stefansson H, Rye DB, Hicks A, et al. A genetic risk factor for periodic limb movements in sleep. N Engl J Med. 2007;357:639647.

(20.) Winkleman J, Schormair B, Lichmer P, et al. Genome-Wide Association Study of restless legs syndrome identifies common variants in three genomic regions. Nat Genet. 2007;39:1000-1006.

(21.) Partinen M, Hirvonen K, Jama L, et al. Efficacy and safety of pramipexole in idiopathic restless legs syndrome: a polysomnographic dose-finding study--the PRELUDE study. Sleep Med. 2006;7:407-417.

(22.) Allen R, Becker PM, Bogan R, et al. Ropinirole decreases periodic leg movements and improves sleep parameters in patients with restless legs syndrome. Sleep. 2004;27:907914.

(23.) Bliwise DL, Freeman A, Ingram CD, et al. Randomized, double-blind, placebocontrolled, short-term trial of ropinirole in restless legs syndrome. Sleep Med. 2005;6:141-147.

(24.) Bogan RK, Fry JM, Schmidt MH, et al; for TREAT RLS US (Therapy with Ropinirole Efficacy and Tolerability in RLS US) Study Group. Ropinirole in the treatment of patients with restless legs syndrome: a USbased randomized, double-blind, placebocontrolled clinical trial. Mayo Clin Proc. 2006;81:17-27.

(25.) Montplaisir J, Karrasch J, Haan J, et al. Ropinirole is effective in the long-term management of restless legs syndrome: a randomized controlled trial. Mov Disord. 2006;21:1627-1635.

(26.) Sloand JA, Shelly MA, Feigin A, et al. A double-blind, placebo-controlled trial of intravenous iron dextran therapy in patients with ESRD and restless legs syndrome. Am J Kidney Dis. 2004;43:663-670.

(27.) Happe S, Sauter C, Klosch G, et al. Gabapentin versus ropinirole in the treatment of idiopathic restless legs syndrome. Neuropsychobiology. 2003;48:82-86.

(28.) Stiansy-Kolster K, Kohnen R, Schollmayer E, et al; for Rotigotine Sp 666 Study Group. Patch application of the dopamine agonist rotigotine to patients with moderate to advanced stages of restless legs syndrome: a double-blind, placebo-controlled pilot study. Mov Disord. 2004;19:1432-1438.

(29.) Oertel WH, Benes H, Bodenschatz R, et al. Efficacy of cabergoline in restless legs syndrome: a placebo-controlled study with polysomnography (CATOR). Neurology. 2006 ;67:1040-1046.

(30.) Chaudhuri KR, Forbes A, Grosset D, et al. Diagnosing restless legs syndrome (RLS) in primary care. Curr Med Res Opin. 2004;20:1785-1795.

Michael J. Thorpy, MD Professor of Neurology Albert Einstein College of Medicine Director, Sleep-Wake Disorders Center Montefiore Medical Center Bronx, New York
TABLE

Differential Diagnosis of Leg Discomfort

Disorder             Characteristic features

Nocturnal leg        Pain in the leg or foot associated with sudden
cramps               muscle hardness or tightness, often occurring
                     at night

Akathisia            General restlessness often associated with prior
                     use of neuroleptic medications

Restless legs        An irresistible urge to move the legs and abnormal
syndrome             leg sensations (eg, creepy, crawly, tingly,
                     painful, burning, achy, shock-like)

Peripheral           Symmetrical loss of sensation (eg, pain, numbness)
polyneuropathy       in the legs, which can be accompanied by muscle
                     weakness or autonomic symptoms

Hypnic jerks or      Sudden brief jerks at sleep onset, typically in
sleep starts         the whole body; often associated with the
                     sensation of falling

Periodic limb        Involuntary periodic movements (usually in the
movements in sleep   legs) lasting 0.5 to 5 seconds during sleep
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Publication:OBG Management
Article Type:Case study
Geographic Code:1USA
Date:Apr 1, 2008
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