Neuro chapter 11 Restless leg syndrome Flashcards
Restless legs syndrome
- chronic neurologic disorder characterized by an irresistible urge to move the legs.
- accompanied by uncomfortable, unpleasant sensations in the legs.
Symptoms of RLS cannot be attributed to…
- other medical conditions
- behavioral conditions
- the effects of drug abuse or medication.
Primary causes of RLS
- idiopathic in most cases; possible dopaminergic system involvement, iron deficiencies, or genetics
early onset
age < 45 years; family clusters, slow progression
- tends to be more severe
late onset
age > 45 years, no family clusters
- more rapid progression of disease
often associated with
- radiculopathy
- neuropathy
- myelopathy
secondary causes of RLS
may be associated with:
end stage renal disease/uremia
- pregnancy
- iron deficiency anemia
- diabetic neuropathy
- Parkinson’s disease
secondary causes of RLS
Pharmacologic
- SSRI’s
- SNRIs
- diphenhydramine
- dopamine antagonists
Patients with severe RLS generally have first symptoms…
before age 20, but are not diagnosed.
Women are affected…..
twice as often as men.
white patients affected ______ often than black patients
more
Incidence in children and adolescents is unknown, but consider….
in children who can express all diagnostic criteria in their own words.
Risk factors
family history
iron deficiency anemia
pregnancy
assessment findings
- irresistible urge to move legs
- urge worsens with periods of rest/inactivity
- urge is partially or completely relieved by movement
- urge worsens in the evening or night versus daytime OR occurs only in the evening/at night
- symptoms occur at least 3 times/week OR have persisted > or equal to 3 months
- use quiestionnaires to support diagnosis
- physical examination evaluates for potential secondary causes such as neuropathy, radiculopathy, or Parkinsonian features
- a normal neurologic exam rules out secondadry causes and supports RLS diagnosis
differential diagnosis
Adult
Periodic limb movement disorder (PLMD) Volitional limb movements or physiologic movements during sleep Akathisia neuropathy nocturnal leg cramps pain in legs and when moving toes: involuntary flexion/extension of toes; associated with spinal cord injury - vascular disease - radiculopathy
differential diagnosis
pediatric
- growing pains
- motor tics
- ADHD
- Muscle pain
- leg cramps
- Osgood-Schlatter disease
- chondromalacia patella
- arthalgias
- sleep-disordered breathing and periodic limb movements
- akathisia
Diagnostic studies
serum iron levels
serum ferritin
transferrin saturation
TIBC
Diagnostics
if secondary causes suspected:
CBC BUN Cr FBG Mag TSH Vit B12 Folate
Diagnostics
if polyneuropathy or radiculopathy suspected
needle electromyography and nerve conduction studies
Diagnostics
Polysomnography
consider if periodic leg movement syndrome suspected or if significant sleep disturbance occurs despite treatment
Decline may be more rapid with…
presence of associated comorbid conditions such as neuropathy, radiculopathy, or parkinsonian features
Prevention
none known
healthy lifestyle practices may assist with treatment (smoking cessation, regular exercise, moderate alcohol use, stress management)
Nonpharmacologic management
Hot or cold bath limb massage compression stockings counterpulsation devices CBT exercise sleep hygiene measures avoidance of caffeine, alcohol, and nicotine relaxis vibrating pad (requires prescription)
Pharmacologic management
Intermittent or daily, depending on nature of the symptoms
- discontinue medications causing symptoms when possible: SSRIs, SNRIs, diphenhydramine, and dopamine antagonists
- opioids and sedative hypnotics are not approved for RLS
iron replacement should be guided by lab results and not empirically prescribed
Dopaminergic agents
- dopamine agonists are considered first-line, reducing RLS symptoms and improving quality of life and sleep
- extended-release forms are not approved for RLS
- Pramipexole is not metabolized by the liver
- half-lives for all drugs range 5-7 hours
- short-term adverse effects include nausea, vomiting, somnolence, and fatigue
- augmentation is common with this class
