A 45-year-old female patient was accurately diagnosed with PLMD associated with arousals and RLS through the skills of a dedicated sleep technician and interpreting physician team.

It is difficult for sleep technologists to observe patients with restless legs syndrome (RLS), also known as Ekbom syndrome. These patients are completely aware of the severity of their disorder. They are also made miserable by the constant movement and increasing irritation of RLS, coupled with sleep deprivation. Depending on the type of movements that the patient makes to obtain relief from leg discomfort, the technologist may spend a large portion of the night reapplying limb leads and adjusting the camera to capture this phenomenon. In the years prior to digital data acquisition, the technologist would also be refilling the plotter’s ink supply to compensate for the tremendous number of movements being recorded.

The single most important factor in acquiring a high-quality polysomnogram in RLS is technologist preparation. It is the technologist’s responsibility to read all the information pertaining to a patient prior to his or her arrival at the sleep center. If they are available, the complete history and physical examination notes, all sleep-related questionnaires (including an Epworth Sleepiness Scale and a Beck Inventory for depression screening), the sleep diary, and the bed partner’s notes should be thoroughly reviewed. This information will give the technologist insight into why the study has been ordered, which symptoms are most prevalent, how the technologist can best educate the patient, which parameters need to be monitored, and how the referring physician can be provided with the most accurate examples of the patient’s sleep. The proper attachment of the limb leads and careful attention to videotaping the suspected movements are also crucial.

Features of RLS
The essential features of RLS include the desire to move the limbs that is usually associated with paresthesias or dysesthesias, motor restlessness, symptoms that are worse or exclusively present at rest (with at least partial and temporary relief given by activity), and symptoms that are worse in the evening or during the night. Often, the most frequent complaint is the overwhelming urge to move the legs that prevents the patient from going to sleep. The pins-and-needles or creeping- and-crawling sensations of RLS are often described in detail. The severity of RLS can vary greatly from night to night or throughout a lifetime. Prolonged exposure to a cold or very warm environment, fatigue, and pregnancy can greatly increase or aggravate symptoms of RLS.

Several problems may ensue as a direct result of this disorder; these include daytime somnolence, depression, marital problems, and, in severe cases, suicidal tendencies. In approximately one third of the RLS population, the would-be bed partner sleeps separately due to the patient’s annoying leg movements.1 A strong family history of RLS seems to link this disorder to a genetic predisposition. In approximately 30% of the population with RLS, there is at least one family member with the disorder.1 There is a tendency for the symptoms to be present at an earlier age in each generation. RLS is not linked to any psychological disorders or emotional problems. This is important to note because so many RLS patients will report that depression and exhaustion have become prevalent since the onset of the syndrome.

The most recent research1 indicates that 5% to 10% of the population experiences RLS at some time. RLS occurs more commonly in older individuals, but can occur at any age in females or males. The American Academy of Sleep Medicine (AASM) reports1 that RLS goes without formal diagnosis in far too many cases. It is the goal of many sleep professionals to educate the public, primary care physicians, and health care providers concerning RLS. A better understanding of signs and symptoms, coupled with readily available treatment, will reduce sleep deprivation’s toll on the patient and society.

Relieving Symptoms
Relief of RLS symptoms may not come as quickly as desired. Usually, patients will try multiple home remedies prior to seeking medical advice. Some home remedies that patients have reported to be beneficial are hot baths, leg massages, heat or ice packs, and regular exercise. After self-treatment efforts have been exhausted or are no longer effective, a physician may be consulted to determine the origin of the problem. Conditions associated with RLS include iron deficiency anemia, poor blood circulation in the legs, nerve problems, muscle disorders, and kidney disease. The physician will need to complete a medical history and review all necessary blood analyses to rule out these related conditions. The first line of treatment will be correcting these problems. RLS may be relieved once the related conditions have been adequately treated. If the symptoms of RLS continue despite the treatment of the other conditions, or if RLS is present without any related conditions, then pharmacological treatment begins. Drugs used to treat RLS include dopamine antagonists, benzodiazepines, anticonvulsants, and opioids. The effectiveness of these drugs may vary from patient to patient. The physician will closely track improvement; patients may need to try several different medications until one proves beneficial. The severity of the RLS and the interaction of any other medications that the patient may be taking play a large role in the effectiveness of the RLS medication.

Physicians may be able to diagnose RLS based on symptoms alone; however, an overnight polysomnogram may be ordered to rule out any other sleep disturbances that might also require treatment. Although successful management of RLS is possible, it may take several weeks to find the right medication and dosage. The patient should closely track improvement and inform the physician of any continued problems.

Case Study
A typical RLS patient was seen at Jennie Edmundson Memorial Hospital, Council Bluffs, Iowa, on June 8, 1999. She was 45 years old, was 165 cm tall, and weighed 62 kg. Her chief complaint was having a hard time getting to sleep and waking up during the night. Her presleep questionnaire offered many clues; her answers indicated that she frequently disturbed her bed partner through persistent twitching or jerking of her arms or legs and that she almost always experienced crawling or aching sensations in her legs and the inability to keep her legs still upon retiring for the night. She also had other RLS symptoms, including increased irritability, daytime somnolence, and frequent trouble staying asleep.

A family history of RLS was noted following review of the questionnaire and the physician’s history and physical examination record. The patient’s father had been diagnosed and treated for RLS. The patient’s Epworth Sleepiness Scale did not indicate daytime somnolence. The total score was 1. Specific questions about daytime functioning offered insight into her decreased daytime ability, however. She did not report any alcohol consumption. She reported excellent sleep hygiene and consistent bedtimes and waking times. The patient’s only medications were sertraline (50 mg per day) and carbamazepine (100 mg, three times per day). Armed with this information, the technologist was able to educate the patient about any related blood work, explain that medication is often recommended therapy, and assure her that the test, although it may be difficult, will offer the physician the best possibility of accurately diagnosing and treating the problem.

The overnight polysomnogram confirmed the physician’s suspected diagnosis of RLS. The patient had a sleep latency of 42.5 minutes. The prolonged sleep latency was directly related to twitching and jerking of the legs. Excellent documentation and polysomnographic data confirmed these movements. The technologist noted that the patient was complaining of achy legs and needed to get out of bed prior to sleep onset in order to stretch. Once the patient did obtain sleep, its efficiency was markedly decreased. The overall sleep efficiency was 49.1%.

This patient also had periodic limb movement disorder (PLMD) in conjunction with RLS. The total number of limb movements in sleep was 43, with an arousal index of 13.9 per hour. It has been reported1 that almost all patients with RLS will have some component of PLMD. The patient did not have any abnormal respiratory events, apnea, or snoring while being monitored polysomnographically. Her baseline oxygen saturation was 97%; this decreased, during rapid–eye-movement (REM) sleep, to 91%. REM latency was 153 minutes, which is not completely abnormal in the presence of RLS, prolonged sleep latency, and the first-night effect. All other parameters were within normal ranges. The patient maintained a normal sinus cardiac rhythm throughout the recording.

Once the interpreting physician had reviewed the data and the accompanying video documentation, a diagnosis was made: PLMD associated with arousals and RLS. The physician recommended a trial of medications and medication combinations to improve the patient’s sleep quality; recommended drugs were consistent with the AASM literature2 pertaining to RLS/PLMD.

The patient has now been using clonazepam for the treatment of RLS for 3 years. She does not report any recurring symptoms, and her bed partner no longer complains of being disturbed by her movements.

Discussion
This patient represents the best-case scenario for RLS treatment. A trained sleep physician was sought, a detailed sleep history was obtained, and a polysomnogram was ordered to rule out any other significant sleep problems. The technologist was skilled, ensuring a high-quality study. The interpreting physician made therapeutic recommendations and followed through on those recommendations with the primary care physician. The patient’s RLS symptoms were relieved by the prescribed medications.

This case shows that it takes an entire team of dedicated professionals to ensure the best possible outcome for every patient seen in a sleep laboratory.

Jennifer D. James, RPSGT, is a clinical specialist at somniTech Inc, Overland Park, Kan.

Acknowledgement
The author wishes to thank Kathleen Wilson, RPSGT, for her assistance in choosing the case presented.

References
1. American Academy of Sleep Medicine. RLS and PLMD: A Wellness Booklet. Rochester, Minn: AASM; 2000.
2. Kryger M, Roth T, Dement WC. Principles and Practice of Sleep Medicine. 3rd ed. Philadelphia: WB Saunders; 2000.