Re: Good Site RLS/PLMD pertinent medical journal articles organzied!

[Guest guest]

Hi,

I found a neat site with 30 articles on RLS, PLMD and other sleep disorders

from presitigious medical journals. You can choose only those you wish to

read. Here is the link (if everyone has already been there and I have been in

the dark about this site forgive me!):

http://www.websciences.org/apss/1996/body/restless.html

Also, below is some of the articles I brought up to review (you can tell; the

first is on Ferritin Levels!). To newcomers, they call me the Ferritin lady as

this one thing helped my mother, a severe RLS patient, so much when the level

came up her symptoms improved by approximately 50%; anyone interested in

further info on Ferritin, feel free to post to me). Be sure to see the end of

the last article also!

The doctors at Hopkins and many others recommend that the Ferritin level

of an RLS patient be 50 to 100 (body's storage of iron and not tested for on a

regular panel; by the time you show up iron deficient on other tests, this is

down to zero and the body, when the savings account gets low on iron, starts

pinching pennies, you might say). Iron plays a part in helping the brain take

up dopamine is the way I understand it. Many RLS patients respond to

Parkinson's drugs and that indicates that subset that do, are.

Barbara

Periodic Limb Movement Disorder and iron deficiency

BARAN AS, GOLDBERG R, DIPHILLIPO MA, CURRAN K, FRY JM

Medical College Of Pennsylvania and Hahnemann University, Philadelphia, PA.

It is thought that patients with restless legs syndrome (RLS) are likely to

also have periodic limb movement disorder, although the converse is not

necessarily true. Iron deficiency states have been reported to be associated

with some cases of restless legs syndromel ,2, but an association between

periodic limb movement disorder (PLMD) and iron deficiency has not been

identified, to our knowledge. Because of the strong association between RLS

and PLMD, it was hypothesized that iron deficiency plays a role in the

etiology of PLMD. Serum ferritin levels were recommended as part of further

evaluation for patients with the diagnosis of PLMD, with or without RLS,

following polysomnography.

All patients recorded between December 1, 1992 and September 6, 1995 found to

have periodic limb movements greater than or equal to 10 per hour of sleep,

with or without symptoms of RLS were identified. Patients with a concurrent

diagnosis of significant obstructive sleep apnea requiring CPAP were excluded.

Serum ferritin is a sensitive measure of body iron stores. Abnormally low

serum ferritin levels were defined as less than 22 ng/ml, and low normal

levels were defined as falling within the range of 22-25 ng/ml.

Of the 156 patients in whom serum ferritin determination was recommended to

the referring physician and patient laboratory data were available in 37. The

data are presented in the table below.

Patients with PLMD & RLS number (%) Patients with PLMD only number (%) Total

Patients number (%)

Ferritin >25 ng/ml 12 (32.4) 17 (45.9) 29 (78.4)

Ferritin 22-25 ng/ml 2 (5.4) 1 (2.7) 3 (8.1)

Ferritin <22 ng/ml 3 (8.1) 2 (5.4) 5 (13.5)

Total Patients 17 (45.9) 20 (54.1) 37 (100)

We conclude that there may be an association between iron deficiency and PLMD

in the absence of RLS.

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1Ekbom, K.A. Restless legs syndrome. Neurology, 1960, 10: 868-873.

2O'Keefe, S.T. Restless legs syndrome in the elderly. Postgrad Med J, 1993,

69: 701-703.

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Reliability of a questionnaire for screening of restless legs syndrome in

uremic patients

MONDINI S, GERARDI R, SANTORO A, FERRARI G, BUZZI G, BORGHINI G, CIRIGNOTTA F

Unit of Sleep Medicine - Dpt. of Neurology Dpt of Nephrology - . S.Orsola-

Malpighi Hospital - University of Bologna - Italy.

Chronic renal insufficiency and dialysis are always listed among the causes of

sintomatic Restless Legs Syndrome (RLS). et al. found 40% of RLS in a

group of 55 patients undergoing haemodyalisis or peritoneal dialysis (1).

We evaluated the reliability of a subjective questionnaire on " legs

discomfort " as a screening tool for RLS in a population of chronically

dialysed patients.

METHOD

Patients who were attending the Nephrology department at Malpighi Hospital for

hemodialysis were asked to fill in a self administered questionnaire on " legs

discomfort " . The first four questions included the minimal criteria for

clinical diagnosis of RLS:

1) Have you never experienced a disagreeable feeling in your legs with aching

and motor restlessness with urge to move the legs ?

2) Are these symptoms appearing mainly when sitting or lying down ?

3) Are the symptoms aggravated by nightfall ?

4) Is any relief obtained by legs movement or walking ?

Other questions concerned duration, frequency and severity of RLS and

secondary sleep disruption.

All patients were subsequently assessed clinically by two neurologists trained

in sleep disorders blinded to the questionnaire answers.

RESULTS

One hundred forteen patients receiving haemodyalisis were assessed: 70 were

males and 44 females, mean age was 61.8 yrs, mean duration of dialysis was 6.5

yrs.

Fifty seven patients (50 %) answered " yes " to first question and 31 patients

(27.2 %) answered " yes " to all four diagnostic questions.

Thirty eight patients were clinically found to have RLS (33.3 %); in 28 of

them (73.7 %) the disorder was present during last year and in 15 patients

(39.5%) disturbed sleep.

Considering the questionnaire positive for a diagnosis of RLS if the patient

answered " yes " to question one and negative if the answer was " no " , we

obtained a sensitivity of 71.1% and a specificity of 60.5%, with a positive

predictive value of 47.4% and a negative predictive value of 80.7%.

False positive patients (n=27) differed significantly from true negative

patients (n=46) in reporting more paresthesias, pain or itching (56.6% vs

23.9%, p=0.004). False negative patients (n=11) differed significantly from

true positive patients (n=30) in reporting less sleep disruption (16.7% vs

63.6%, p=0.006).

Considering the questionnaire positive for a diagnosis of RLS if the patient

answered " yes " to all four diagnostic questions, we obtained a sensitivity of

44.7% and a specificity of 81.6%, with a positive predictive value of 54.8%

and a negative predictive value of 74.7%.

False positive patients (n=14) differed significantly from true negative

patients (n=62) in reporting more paresthesias, pain or itching (71.4% vs 29%,

p=0.03) and nocturnal or diurnal cramps (64.3% vs 29%, p=0.02). Moreover they

presented a greater incidence of tendon hyporeflexia associated with one of

the following objective signs: hypopallesthesia, hypoesthesia, hypotrophy and

hyposthenia (64.3% vs 19.3%, p=0.01). False negative patients (n=21) did not

differ from true positive patients (n=17) in any aspect of the disease.

CONCLUSIONS

This questionnaire did not prove a reliable tool for screening RLS in uremic

patients undergoing dialysis. The poor reliability is probably due to the

following factors:

1) the presence of others legs symptoms and signs suggesting peripheral

neuropathy;

2) the moderate severity of legs discomfort and poor appraisal by the

patients.

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Reference

1. S.D., D.C.H., J.H.: Possible relation between restless

legs and anaemia in renal dialysis patients. Lancet 1991, 337: 1551

Restless Legs Syndrome and lumbosacral radiculopathy

WALTERS AS, HENING WA, WAGNER ML, CHOKROVERTY S

UMDNJ­ Wood Medical School Lyons Veterans Administration Medical

Center Rutgers University New York Medical School

OBJECTIVE: Restless Legs Syndrome (RLS) triggered by lumbosacral (LS)

radiculopathy is reported in the literature. However, no polysomnographic

studies are reported on these patients and it has not been determined whether

they have the same clinical features as patients with idiopathic RLS. The

purpose of this study is to determine if RLS triggered by L­S radiculopathy

occurs commonly in our patient population and to determine if patients with

this type of RLS have the same clinical features as those with idiopathic RLS.

METHODS: Neurological examinations were done, clinical case histories were

obtained, and polysomnography was performed on 33 patients with either

idiopathic or non­idiopathic RLS. RLS was presumed to be triggered by L­S

radiculopathy if the initial symptoms of RLS began shortly after the onset of

the radiculopathy.

RESULTS: Four of 33 patients had RLS initially triggered by lumbosacral

radiculopathy. All 4 of these patients had the 4 obligatory clinical features

found in idiopathic RLS, namely, a) leg discomfort, motor restlessness, and

worsening of symptoms at c) rest and d) night. All 4 patients had periodic

limb movements (PLM) while asleep, awake or both. None of these 4 patients had

a definite family history of RLS. An additional number of patients had

symptoms of RLS exacerbated by a later onset radiculopathy .

CONCLUSIONS: These 4 patients have the same clinical features as those with

idiopathic RLS. The appearance of PLM in these patients may be a non­specific

age related phenomenon, but this seems less likely because of their prominent

appearance in wakefulness as well as sleep. Lumbosacral radiculopathy may

either a) cause a syndrome clinically identical to that of idiopathic RLS or,

alternatively, it could be the initial trigger for symptoms of idiopathic

RLS in predisposed individuals.

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Research supported by a VA Merit Review research grant.

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Autosomal dominant restless legs syndrome in a young girl with symptom onset

at 12 months

WISE M, GILLESPIE S

The Children's Hospital of Alabama and The University of Alabama at

Birmingham, Birmingham, AL

Restless leg syndrome (RLS) typically begins during adult life, but several

reports describe onset in the first decade. This report documents the clinical

course in a young girl with a four generation history of RLS. The patient

presented at four years of age with a history of dramatic episodes of

continuous leg movements and unpleasant sensations in the legs which lasted

for hours beginning at bedtime. The episodes began at 12 months of age and

were documented carefully in the mother's journal. The parents captured

several examples of these episodes on videotape, and findings were felt by the

authors to represent RLS. The episodes occurred on average every 6 to 8 weeks,

but increased to every 10 to 14 days by 4 years of age. The day following

these episodes the child was almost nonfunctional at preschool due to fatigue,

sleepiness, and irritability. Episodes are precipitated by fatigue. The child

is otherwise healthy, with no history of exposure to medications which might

cause involuntary movements, anemia, or chronic disease. The family history

reveals that the child's mother, maternal grandmother, three maternal aunts,

and a maternal greatgrandfather are afflicted with the same problem. Although

family members had never sought medical attention for RLS, they described the

problem colorfully as the " grandmother fidgets " .

This report documents onset of RLS during infancy. Long term follow­up will be

informative in tracking the evolution of symptoms. RLS should be considered as

a diagnostic possibility in young children with hyperkinetic movements

occurring at bedtime.

Parkinson's disease patients have impaired sleep quality and frequent sleep

complaints

HENING W, ROLLERI M, CHOKROVERTY S

Wood Medical School, New Brunswick, NJ; and St. 's

Hospital Center, NYC, NY

OBJECTIVE: To determine how Parkinson's disease patients (PDPs) rate their

sleep and their primary complaints about sleep.

BACKGROUND Sleep is an important consideration in treating patients with

Parkinson's disease 1. It has been shown in prior studies that PDPs complain

about the qualities of their sleep 2, 3; although one study found that they

differed primarily on complaints of daytime napping, hallucinations, and

nocturnal vocalizations from age matched controls4 . Patients with Parkinson's

disease have also been reported to have a variety of specific sleep disorders

such as REM behavior disorder (RBD) 5, which may be an initial manifestation

of Parkinson's disease 6 or Restless Legs Syndrome (RLS) 7, which may function

like a dyskinesia related to inadequate dopamine availability. Because of

these possible associations and the controversy concerning the degree of

increased sleep difficulties in PDPs, we to reexamine how PDPs evaluate their

sleep and what their major complaints might be.

METHODOLOGY We initiated a study of sleep in PD by administering a sleep

questionnaire with simultaneous live instructions to 71 PDPs (mean age: 67.3

years) and 17 accompanying persons (Controls, mean age 58.8 years). The

questionnaire aimed to get at quality and quantity of sleep as well as

satisfaction with sleep and daytime function. Significance of different

proportions in the PDPs and controls were assessed by the chi square test.

RESULTS PDPs rated their sleep as significantly worse than controls (PDPs:

23.9% good or excellent, 29.6% poor or terrible; Controls: 52.9% good or

excellent, 11.8% poor or terrible). While bed times and rise times were

comparable, PDPs had to get out of bed more often at night (PDPs, mean 2.84;

controls, 2.15 ) and had more sleepiness during the daytime (PDPs, 90.1%;

controls, 64.7%). Snoring was equally reported in both groups while PDPs had

more disturbing dreams (PDPs, 54.3%; controls, 23.6%). Motor abnormalities of

sleep were particularly striking in PDPs: they had more disturbing movements

during sleep (PDPs, 40.0%; controls, 7.1%), difficulty turning over in bed

(PDPs, 67.1%; controls, 5.9%), falls or jumps out of bed (PDPs, 27.5%;

controls, 5.9%), and vocalizations during sleep (PDPs, 42.2%; controls, 5.9%).

PDPs also had more complaints suggestive of RLS: more leg discomforts in

repose (PDPs, 45.1%; controls, 11.8%) and more frequent urges to get up when

lying down (PDPs, 32.8%; controls, 0%).

CONCLUSIONS control group and have significantly more complaints about

multiple aspects of sleep, especially those relating to motor function. Among

their complaints are those which suggest RLS, RBD, or similar sleep­related

movement disorders. In treating PDPs, physicians should be aware of these

frequent and typical sleep disturbances and be prepared to diagnose and treat

them.

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1. Aldrich, M. S. Parkinsonism. In: Kryger MH, Roth T, Dement WC, eds. 1994.

Philadelphia: W.S. Saunders Company, 1994:783­789.

2. Lees, A. J., Blackburn, N. A., , V. L. The nighttime problems of

Parkinson's disease. Clin Neuropharm, 1988, 11: 512­519.

3. Rubio, P., Burgeura, J. A., Sobrino, R., et al. Trastornos del sueno y

enfermedad de Parkinson: estudio de una casuista. Rev Neurol (Barc), 1995, 23:

265­268.

4. Factor, S. A., McAlarney, T., ­Ramos, J. R., et al. Sleep disorders

and sleep effect in Parkinson's disease. Movement Disorders, 1990, 5: 280­285.

5. Comella, C. L., Tanner, C. M., Ristanovic, R. K. Polysomnographic sleep

measures in Parkinson's disease patients with treatment­induced

hallucinations. Ann. Neurol., 1993, 34: 710­714.

6. Schenck, C. H., Bundlie, S. R., Mahowald, M. W. Delayed emergence of

Parkinson's disease in 38% of 29 older males initially diagnosed with

idiopathic REM sleep behavior disorder (RBD). Sleep Res., 1995, 24: In Press.

7. Fazzini, E., , R., Fahn, S. Restless leg in Parkinson's

disease­­clinical evidence for underactivity of catecholamine

neurotransmission. Ann. Neurol., 1989, 26: 142.

Drs. Hening and Mrs. Rolleri were supported by the Department of Veterans

Affairs Medical Research Service.

Sleep disturbances in cervical radicullary syndrome

MASCOV-IONESCU C, TIU C, IONESCU CD, DANESCU I

Clinic of Neurology, Universitary Hospital of Bucharest

Our study consists in observation and. investigation a group of 38 (20 males

and 18 females)among 50 and 62 years old. These persons had cervical

radicullary syndrome and sleep disturbances (a restless sleep with nightmares,

interruptions in the first part of the night, followed by asthenia, memory

troubles headache, vertiges, cervical aches during the daytime). We performed

the electroencephalogram in wakefulness and during the sleep, the Doppler

study for the carotidian and vertebral and basilar circulation, catecholamines

measurement study, cerebral CT­scan.

In all the cases the cervical sympathetical irritation syndrome was due to

cervical discopathy.

Regarding to multiple functional implications of cervical sympathetical

irritation due to vagal­sympathetical and somatic connections located in the

cranial pole of sympathetical chain and characteristics of sympathetical-

adrenergic reactivity is possible to show the role of superior cervical

sympathetic node in the modulation of epinephrine and norepinephrine action

concerning the reticulate substance at the level of brain stem and implicit

concerning the sleep through the facility but and inhibition that the

catecholamines exerts at this 1 level.

The recordings of electroencephalograms during the sleep show the diminuation

of the duration of the paradoxical sleep and the alteration of the ratio

between the sleep's phases. These confirm the appearance of some troubles of

the metabolically and functional balance who exists between cathecholamines

and with implications in the induction and maintain of the sleep.

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Schmidt,P.;Bthews,G.­Human Physiology,Berlin­Gottingen Heidelberg,

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Improvement in nocturnal myoclonus and restless legs syndrome after treatment

of iron-deficiency anemia: case report

POCETA JS, LOUBE DI, HAYDUK R, ERMAN MK

Scripps Clinic and Research Foundation, La Jolla, California, U.S.A .

Restless legs syndrome (RLS), (Ekbom's syndrome) is a condition with

unpleasant leg sensations, often leading to restlessness and sleep disruption.

Nocturnal myoclonus, also called periodic limb movements of sleep (PLMS), is a

movement disorder of repetitive, rhythmic, jerky movements of the legs during

sleep which often accompanies RLS. The pathophysiology of these conditions is

unknown, but there may be an alteration in central dopamine systems. For

example treatment with dopaminergic agents is usually effective, and RLS has

certain similarities to neuroleptic­induced akathisia. Their appears to be a

genetic component as well. Certain medical conditions appear to predispose to

RLS and nocturnal myoclonus such as neuropathies, uremia, and anemias, but

identifiable causative conditions are not present in the majority of cases.

Ekbom described a series of patients with partial gastrectomy and

iron­deficiency anemia who developed RLS O'Keeffe compared measures of iron

status in a group of elderly patients with RLS to a matched control group and

found that serum ferritin levels were lower in the patient group, even without

anemia. Improvement in RLS symptoms occurred with oral iron repletion.

However, no studies have assessed nocturnal myoclonus in relationship to

iron­deficiency anemia or ill treatment. We report a case of both nocturnal

myoclonus and RLS in which improvement occurred after treatment with

intravenously administered iron.

Case Report. A 47 year­old male complained of 18 months of sleep onset and

sleep maintenance insomnia; associated with a feeling of an inner energy boom.

He had bilateral restlessness of the legs when trying to sleep, punctuated by

jerky movements and a feeling of electrical impulses in the legs. During

sleep, his wife noted repetitive motions of the legs, and sometimes of the

arms. Seven years previously he had undergone a gastric stapling procedure for

treatment of obesity. His weight initially decreased from about 250 pounds to

200 pounds, but he had gained most of this back. He was taking B­1 injections

prophylactically. The sleep study showed 649 periodic leg movements, which

were of high amplitude with myoclonic onset. He was treated with temazepam and

propoxyphene with fair success. He was found to be anemic and iron deficient,

as described in the Table. Evaluation found no cause of blood loss, but

treatment with oral iron administration was not effective. He was therefore

placed on intravenous iron infusions which corrected the anemia and normalized

serum iron studies. His symptoms of RLS disappeared, as well as the movements

during sleep. Repeat sleep study showed only 101 periodic leg movements, and a

marked decrease in amplitude of these remaining jerks. He was able to sleep

adequately with no medication.

[Guest guest]

Barbara,

These are good articles to print off and present to our doctors. It's

sort of Greek to me, but my neurologist tends to play down anecdotal

accounts, while respecting documented research such as this. Both she

and my primary doctor almost laugh in my face when I mention the ferritin

thing, and lecture me about taking iron supplements. They both have had

the nerve to tell me, (in a sort of joking way) that I shouldn't spend so

much time on the net, receiving non-medical accounts about possibilities

for causes and treatments.. Needless to say, I don't take their advice

on this one! So far I have followed their advice not to try the iron

supplement, because I also remember Dr. Levin warning about the harmful

effects of too much iron. I did take iron supplements on the advice of

my doctor when I was anemic due to severe menstrual bleeding. Come to

think of it, that was when the rls really started kicking in big time. I

don't remember if the rls improved while I was taking the iron. So many

questions, so few answers.

Thanks for the site info and articles.

ne, 58, Lawrenceville, NJ

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