Creating cartoons to represent habitual leg movements.

Many people have a habit of moving their legs and believe that this behavior is due to the restless legs syndrome (RLS), a highly prevalent neurological condition that greatly impairs the quality of life of affected individuals. This behavioral pattern, characterized by the habit of moving one's legs and feet, may be an important confounding factor in the diagnosis of RLS. OBJECTIVE: To describe the main movements associated with this benign behavioral state to characterize a possible clinical condition that can contribute to the differential diagnosis of RLS. METHODS: Experienced sleep specialists, who primarily see RLS patients listed the most frequent movements people without RLS report while describing their suspected RLS. We first compiled a list of the lower-limb movements described by the specialists. Then, one of the authors (KC) carried out all movements of the list on camera to obtain a video footage. This footage was sent to one of the authors, EPC, who, alongside a group of students, drew graphic representations (cartoons) of the recorded movements. RESULTS: The panel of sleep experts described 13 leg movements commonly reported by their patients. The experts reported 11 simple movements and two combined movements. CONCLUSION: In this study we developed an instrument that allows us to oppose and distinguish a pathological condition (RLS) from a behavioral phenomenon. This state of behavioral leg fidgeting needs to be better characterized and may eventually be recognized as a clinical entity per se.

Creating cartoons to represent habitual leg movements / Desenvolvimento de modelos iconográficos representativos de movimentos habituais de pernas

Abstract Many people have a habit of moving their legs and believe that this behavior is due to the restless legs syndrome (RLS), a highly prevalent neurological condition that greatly impairs the quality of life of affected individuals. This behavioral pattern, characterized by the habit of moving one's legs and feet, may be an important confounding factor in the diagnosis of RLS. Objective: To describe the main movements associated with this benign behavioral state to characterize a possible clinical condition that can contribute to the differential diagnosis of RLS. Methods: Experienced sleep specialists, who primarily see RLS patients listed the most frequent movements people without RLS report while describing their suspected RLS. We first compiled a list of the lower-limb movements described by the specialists. Then, one of the authors (KC) carried out all movements of the list on camera to obtain a video footage. This footage was sent to one of the authors, EPC, who, alongside a group of students, drew graphic representations (cartoons) of the recorded movements. Results: The panel of sleep experts described 13 leg movements commonly reported by their patients. The experts reported 11 simple movements and two combined movements. Conclusion: In this study we developed an instrument that allows us to oppose and distinguish a pathological condition (RLS) from a behavioral phenomenon. This state of behavioral leg fidgeting needs to be better characterized and may eventually be recognized as a clinical entity per se.

Resumo Muitas pessoas têm o hábito de movimentar as pernas e acreditam que esse comportamento decorre da Síndrome das Pernas Inquietas (SPI), uma condição neurológica altamente prevalente com grande impacto na qualidade de vida dos indivíduos acometidos. Esse padrão de comportamento, caracterizado pelo costume de mover as pernas e os pés, pode ser um importante fator confundidor no diagnóstico da SPI. Objetivo: Descrever os principais movimentos associados a esse estado comportamental benigno, com a finalidade de caracterizar uma eventual condição clínica que possa contribuir para o diagnóstico diferencial da SPI. Métodos: Especialistas em distúrbios do sono, que atendem principalmente pacientes com SPI, listaram os movimentos que as pessoas sem SPI reportam com maior frequência enquanto descrevem a sua suspeita de síndrome. Elaboramos uma lista de movimentos dos membros inferiores descritos pelos especialistas e um dos autores (KC) realizou esses movimentos para que fossem gravados em vídeo. Essa filmagem foi enviada ao autor EPC, que, em conjunto com um grupo de alunos, realizou a representação gráfica (cartoon) dos movimentos gravados. Resultados: Os especialistas reportaram 13 movimentos de pernas, sendo 11 movimentos simples e dois movimentos combinados. Conclusão: Neste estudo, elaboramos um instrumento que permite opor, com a finalidade de diferenciá-las, uma condição patológica (SPI) de um fenômeno comportamental. Esse estado de inquietude comportamental das pernas necessita ser mais bem caracterizado, podendo eventualmente vir a ser reconhecido como uma entidade clínica per se.

Síndrome de piernas inquietas/Willis Ekbom desde la mirada del psiquiatra / Restless legs syndrome from the perspective of psychiatry

Restless Legs Syndrome (RLS) or Willis-Ekbom Disease is an under-diagnosed chronic and progressive primary sensory-motor disorder. It can lead to severe sleep disturbances, a usual cause of consultation. It is characterized by an urgent need to move the legs in resting situations, a cardinal symptom that is usually accompanied by an unpleasant sensation in legs. These symptoms appear or aggravate at the end of the day and in resting situations and are alleviated with movement. Based on these clinical characteristics, it has been defined as a quiescegenic focal akathisia. The diagnosis is essentially clinical. As a guide, there are five cardinal diagnostic criteria. The treatment consists of non-pharmacological measures and the use of medications such as dopamine agonists. Despite the treatment, the symptoms persist in 40% of patients. Psychiatrists should be aware of the syndrome since many drugs used by them such as antipsychotics, antidepressants and anxiolytics can worsen the symptoms. Moreover, the syndrome may be associated with depressive and anxiety diseases.

[Restless legs syndrome from the perspective of psychiatry]. / Síndrome de piernas inquietas/Willis Ekbom desde la mirada del psiquiatra.

Restless Legs Syndrome (RLS) or Willis-Ekbom Disease is an under-diagnosed chronic and progressive primary sensory-motor disorder. It can lead to severe sleep disturbances, a usual cause of consultation. It is characterized by an urgent need to move the legs in resting situations, a cardinal symptom that is usually accompanied by an unpleasant sensation in legs. These symptoms appear or aggravate at the end of the day and in resting situations and are alleviated with movement. Based on these clinical characteristics, it has been defined as a quiescegenic focal akathisia. The diagnosis is essentially clinical. As a guide, there are five cardinal diagnostic criteria. The treatment consists of non-pharmacological measures and the use of medications such as dopamine agonists. Despite the treatment, the symptoms persist in 40% of patients. Psychiatrists should be aware of the syndrome since many drugs used by them such as antipsychotics, antidepressants and anxiolytics can worsen the symptoms. Moreover, the syndrome may be associated with depressive and anxiety diseases.

Prevalence and quality of life and sleep in children and adolescents with restless legs syndrome/Willis-Ekbom disease.

OBJECTIVE: To estimate the prevalence of restless legs syndrome/Willis-Ekbom disease (RLS/WED) and its impact on sleep and quality of life in children and adolescents. METHODS: This was a cross-sectional study conducted in the Municipality of Cássia dos Coqueiros, Brazil. Participants included 383 children and adolescents 5-17 years of age. A comparison group was randomly matched by gender and age with the RLS/WED-affected individuals, pairing one by one. RESULTS: Interviews were conducted for 383 individuals by a neurologist experienced in sleep medicine. RLS/WED was diagnosed using the essential clinical criteria for definitive RLS/WED in children recommended by the International Restless Legs Syndrome Study Group. Sleep and quality of life were evaluated using the Sleep Behavior Questionnaire (SBQ) and the Health-related Quality of Life Questionnaire─Pediatric Quality of Life Inventory (PedsQL). Comparisons were established with a group of randomly selected individuals without RLS/WED, matched by age and gender (control group). The prevalence of RLS/WED symptoms that manifested at least twice a week was 1.9%. The average age of children with RLS/WED was higher compared to the general population (11.5 ± 2.3 vs 9.9 ± 2.5, p < 0.005). A family history of RLS/WED was detected in 90.9% of the patients. The scores obtained by SBQ were higher (53.9 ± 9.4 vs 47.6 ± 10.9, p < 0.047), whereas the scores achieved by PedsQL were lower (69.8 ± 14.8 vs 81.9 ± 10.4, p < 0.003) in children with RLS/WED compared to controls. CONCLUSION: The prevalence of RLS/WED symptoms manifested at least twice in the preceding week was 1.9% in children and adolescents. Worsened sleep and quality of life were observed in the study.

Willis-Ekbom Disease or Restless Legs Syndrome?

BACKGROUND: Restless Legs Syndrome (RLS) or Willis-Ekbom Disease (WED) is highly prevalent, but patients and healthcare providers alike know little about it. Furthermore, controversy persists as to the best way of diagnosing this nosological entity. OBJECTIVE: To verify whether the term used to refer to this disease entity (Restless Legs Syndrome or Willis-Ekbom Disease) affects the prevalence of self-diagnosed RLS/WED in a sample of newly graduated physicians. METHODS: Newly graduated physicians were asked to self-evaluate for the presence of RLS/WED. Briefly, participants were allocated randomly across two groups. One was asked to self-assess for RLS, while the other was asked to self-assess for WED. The evaluation form given to one group asked 'Do you have Restless Legs Syndrome?' whereas the form given to participants in the other group asked 'Do you have Willis-Ekbom Disease?'. Both forms also contained the four criteria for diagnosing RLS proposed by the International Restless Legs Syndrome Study Group (IRLSSG) and instructions for self-diagnosis according to these criteria. RESULTS: The study sample comprised 1413 newly graduated physicians. Of the 708 participants who were given the form that used the term RLS, 87 (12.28%) diagnosed themselves with the condition. Conversely, of 705 physicians given the form with the term WED, 13 (1.84%) diagnosed themselves with the condition (p <0.0001). CONCLUSION: A greater proportion of newly graduated physicians diagnosed themselves with RLS/WED when presented with the term Restless Legs Syndrome than when presented with the term Willis-Ekbom Disease. This suggests that the term Restless Legs Syndrome may not be the most appropriate term to denote this nosological entity.

Psychological distress in patients with restless legs syndrome (Willis-Ekbom disease): a population-based door-to-door survey in rural Ecuador.

BACKGROUND: Reported prevalence of restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED), varies from country to country, and methodologic inconsistencies limit comparison of data. Impact of RLS on quality of life and health has been studied primarily in industrialized countries, particularly Europe and the United States. Many studies have relied exclusively on self-report of symptoms or have assessed only medical populations. Recently, interest has emerged on the impact of WED in rural, underserved populations globally. METHODS: In a population-based survey conducted in rural Ecuador, we assessed the relationship of psychological distress to WED, evaluated with the Depression Anxiety Stress Scales-21. WED was diagnosed through a 2-phase method in which all residents were screened with the International Restless Legs Syndrome Study Group (IRLSSG) questionnaire and all suspected cases were subsequently confirmed through expert medical examination. WED severity was assessed with the IRLSSG rating scale. RESULTS: Of 665 persons (mean [SD] age, 59.5 [12.6] years; women, 386 [58%]), 76 had depression, 93 had anxiety, and 60 reported stress. Forty persons (6%) had WED, with 15 (38%) having severe disease. In a regression model adjusted for age and sex, the prevalence of depression, anxiety, and stress was about 3 times greater among persons with WED than the general population. CONCLUSIONS: Although cross-sectional data cannot establish causation, this study shows the large behavioral health burden associated with WED in an untreated, rural population.

Cancer patients under maintenance hemodialysis: relationship between quality of life, depression, sleep quality and malnutrition-inflammation score.

BACKGROUND: The kidney is one major organ affected by cancer and its associated therapies. The aim of this study was to compare the levels of depression, quality of life and sleep quality in hemodialysis patients with or without cancer, and to analyze the associations with the malnutrition-inflammation score (MIS). PATIENTS AND METHODS: In this cross-sectional study, 40 cancer patients under hemodialysis and 44 patients under hemodialysis without cancer who served as the control group were included. Participants underwent structured interviews to investigate depression, quality of life, sleep quality and restless legs syndrome. RESULTS: Hemodialysis patients with cancer had a greater depression score (16.5 ± 4.8 vs. 10.8 ± 5.2, p < 0.001). Patients had similar physical and mental composite quality of life scores. Patients under hemodialysis with cancer had poor quality of sleep (mean score 8.8 ± 3.5 vs. 6.4 ± 4.1, p = 0.011) and a higher prevalence of restless leg syndrome (55.9 vs. 25.7%, p = 0.011). These features were associated with MIS in patients without cancer but not in patients with cancer. CONCLUSION: Cancer patients undergoing hemodialysis present a higher prevalence of depression, poor quality of life, sleep disorders; however, associations of these features with MIS are different in hemodialysis patients with or without cancer. These findings can change the clinical approach to these patients.

Demographic and motor features associated with the occurrence of neuropsychiatric and sleep complications of Parkinson's disease.

OBJECTIVE: To determine whether four key neuropsychiatric and sleep related features associated with Parkinson's disease (PD) are associated with the motor handicap and demographic data. BACKGROUND: The growing number of recognised non-motor features of PD makes routine screening of all these symptoms impractical. Here, we investigated the hypothesis that standard demographic data and the routine assessment of motor signs is associated with the presence of dementia, psychosis, clinically probable rapid eye movement (REM) sleep behavior disorder (cpRBD) and restless legs syndrome (RLS). METHODS: 775 patients with PD underwent standardised assessment of motor features and the presence of dementia, psychosis, cpRBD and RLS. A stepwise feature elimination procedure with fitted logistic regression models was applied to identify which/if any combination of demographic and motor factors is associated with each of the four studied non-motor features. A within-study out-of-sample estimate of the power of the predicted values of the models was calculated using standard evaluation procedures. RESULTS: Age and Hoehn&Yahr (H&Y) stage were strongly associated with the presence of dementia (p value<0.001 for both factors in the final selected model) while a combination of age, disease duration, H&Y stage, dopamine agonists and catechol-O-methyltransferase (COMT) inhibitors was associated with the presence of psychosis. Disease duration and H&Y stage were the significant indicators of cpRBD, and the lack of significant motor asymmetry was the only significant feature associated with RLS-type symptoms but the evidence of association was weak. CONCLUSIONS: Demographic and motor features routinely collected in patients with PD can estimate the occurrence of neuropsychiatric and sleep-related features of PD.

Comorbidities, medications and depressive symptoms in patients with restless legs syndrome and migraine / Comorbidades, medicações e sintomas depressivos em pacientes com síndrome das pernas inquietas e enxaqueca

OBJECTIVE: The pathophysiology of migraine and restless legs syndrome (RLS) seems to involve inherited mechanism and dysfunction of the dopaminergic system. Previous articles have shown that the frequency of RLS is higher in migraine patients than in controls. We conducted a study to evaluate comorbidities, medication used and depressive symptoms that can explain the relation between migraine and RLS. METHODS: A case-control study was performed in which patients with migraine (n=72) and a control group without migraine (n=72) were interviewed. Data including RLS diagnosis, depressive symptoms, comorbidities and drugs used were evaluated. RESULTS: There was a significant association between migraine and RLS (p=0.01), but comorbidities such as diabetes, hypertension, anemia and drugs used did not explain this association. Depression scores, as measured by the Beck Depression Inventory, were higher in migraine patients with RLS (p =0.04). CONCLUSION: No specific factors explaining the association between migraine and RLS were found. Symptoms of depression were more frequent in patients with migraine and RLS.

OBJETIVO: A fisiopatologia da enxaqueca e da síndrome das pernas inquietas (SPI) parece envolver mecanismos genéticos e disfunção do sistema dopaminérgico. Artigos anteriores mostraram que a frequência de SPI em pacientes com enxaqueca é maior do que nos controles. Desenvolvemos um estudo para avaliar comorbidades, medicamentos utilizados e sintomas depressivos em pacientes com migrânea e SPI. MÉTODOS: Foi desenvolvido um estudo de caso-controle. Foram entrevistados pacientes com enxaqueca (n=72) e sujeitos de um grupo controle (n=72). Foram avaliados dados incluindo diagnóstico de SPI, sintomas depressivos, comorbidades e medicamentos usados. RESULTADOS: Houve associação significativa entre enxaqueca e SPI (p=0,01). Comorbidades como diabetes, hipertensão, anemia ou drogas utilizadas não explicam esta associação. Escores de depressão, medidos pelo Inventário de Beck, foram mais altos em pacientes com enxaqueca e SPI (p=0,04). CONCLUSÃO: Não foram encontrados fatores específicos que explicam a associação entre enxaqueca e SPI. Sintomas de depressão foram mais frequentes em pacientes com enxaqueca e SPI.

Comorbidities, medications and depressive symptoms in patients with restless legs syndrome and migraine.

OBJECTIVE: The pathophysiology of migraine and restless legs syndrome (RLS) seems to involve inherited mechanism and dysfunction of the dopaminergic system. Previous articles have shown that the frequency of RLS is higher in migraine patients than in controls. We conducted a study to evaluate comorbidities, medication used and depressive symptoms that can explain the relation between migraine and RLS. METHODS: A case-control study was performed in which patients with migraine (n=72) and a control group without migraine (n=72) were interviewed. Data including RLS diagnosis, depressive symptoms, comorbidities and drugs used were evaluated. RESULTS: There was a significant association between migraine and RLS (p=0.01), but comorbidities such as diabetes, hypertension, anemia and drugs used did not explain this association. Depression scores, as measured by the Beck Depression Inventory, were higher in migraine patients with RLS (p =0.04). CONCLUSION: No specific factors explaining the association between migraine and RLS were found. Symptoms of depression were more frequent in patients with migraine and RLS.

Restless legs syndrome: a qualitative analysis of psychosocial suffering and interdisciplinary attention.

The aim of this study is to investigate psychosocial factors related to the diagnosis and treatment of patients with restless legs syndrome. Fifteen patients were interviewed at the Neuro-Sono Outpatient Clinic, Universidade Federal de São Paulo. The results were submitted to a qualitative analysis. We identified four content categories: illness description, illness history, illness experience, and relationships. Lack of control over the body and lack of recognition by professionals produce stigma and lead patients to suffering. The research underscores the relevance of psychosocial factors to the diagnosis and treatment of patients with restless legs syndrome and the importance of having interdisciplinary teams when attending patients with restless legs syndrome.

Effect of therapeutic massage on insomnia and climacteric symptoms in postmenopausal women.

INTRODUCTION: Physiological and psychological alterations in the climacteric period frequently influence women's quality of life. Hot flushes, nocturia, mood alterations, respiratory disturbances, insomnia and restless leg syndrome all affect sleep, and the altered hormonal state in this period impacts the aging process. As hormonal therapy is not indicated in some cases, the search for complementary therapies, such as massage therapy, to improve insomnia in the climacteric period is increasing. OBJECTIVE: To evaluate the effect of therapeutic massage on insomnia and climacteric symptoms in postmenopausal women. METHODS: Forty-four volunteers were randomly distributed into three groups: therapeutic massage (TM), passive movement (PM) and control (CTL). The women received 32 therapeutic massage sessions and passive movement twice a week. Questionnaires were given in the pre-trial and the 16th and 32nd sessions. The Insomnia Severity Index (ISI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Menopause Quality of Life questionnaire (MENQOL), Kupperman Menopausal Index and Lipp Symptoms of Stress Inventory were assessed. In addition, the women underwent polysomnography at baseline and post-treatment. Statistical analyses were calculated using Friedman and Wilcoxon non-parametric tests. The level of significance was fixed at p ≤ 0.05. RESULTS: There was an improvement in ISI in the TM group (p = 0.000) and in the PM group (p = 0.001). A decrease in the BDI occurred in the TM group (p = 0.004), and the MENQOL improved in the TM group (p = 0.015). Furthermore, there were no significant differences in polysomnography parameters in the TM group, with only an increase in minimal saturation (p = 0.053). CONCLUSION: The TM group exhibited improved subjective data considering the changes in symptoms according to the ISI and the MENQOL and a decrease in symptoms according to the BDI.

[Restless legs syndrome is highly underdiagnosed in a neurologic-psychiatric outpatient clinic]. / Alto subdiagnóstico del síndrome de piernas inquietas en la consulta ambulatoria neurológica y psiquiátrica.

BACKGROUND: Restless legs syndrome (RLS) is a neurological condition that is characterized by the irresistible urge to move the legs and is very common. In the last decade, much attention has been focused on RLS, given its high occurrence, underdiagnosis, and impact on quality of life. AIM: To determine the frequency of RLS in a neurologic-psychiatric outpatient clinic. PATIENTS AND METHODS: We interviewed patients attending a private neurological outpatient clinic, using a standardized validated questionnaire, and an additional phone interview to confirm diagnosis. RESULTS: Of approximately 800 people attending the clinic, the questionnaire was answered by 238 subjects (168 females). Fifteen percent of respondents were affected by RLS and none had been diagnosed before. Most patients had a severe form that probably required treatment. CONCLUSIONS: A low awareness of RLS exists in Chile, even among specialized physicians.

Alto subdiagnóstico del síndrome de piernas inquietas en la consulta ambulatoria neurológica y psiquiátrica / Restless legs syndrome is highly underdiagnosed in a neurologic-psychiatric outpatient clinic

Background: Restless legs syndrome (RLS) is a neurological condition that is characterized by the irresistible urge to move the legs and is very common. In the last decade, much attention has been focused on RLS, given its high occurrence, underdiagnosis, and impact on quality of Ufe. Aim: To determine the frequency of RLS in a neurologic-psychiatric outpatient clinic. Patients and Methods: We interviewed patients attending a prívate neurological outpatient clinic, using a standardized validated questionnaire, and an additional phone interview to confirm diagnosis. Results: Of approximately 800 people attending the clinic, the questionnaire was answered by 238 subjects (168 females). Fifteen percent of respondents were affected by RLS and none had been diagnosed before. Most patients had a severe form that probably required treatment. Conclusions: A low awareness of RLS exists in Chile, even among specialized physicians.

Levodopa for idiopathic restless legs syndrome: evidence-based review.

Restless legs syndrome (RLS) is a sensory motor disorder characterized by a distressing urge to move the legs and sometimes also other parts of the body usually accompanied by a marked sense of discomfort or pain in the leg or other affected body part. The prevalence of RLS is estimated at 2.7 to 5% of adults and it is more common in women. The treatment of RLS with levodopa has been reported thus a systematic synthesis of evidence is necessary to evaluate the effectiveness and safety of levodopa for RLS. Systematic review of randomized or quasi-randomized, double blind trials on levodopa. Relief of restless legs symptoms marked on a validated scale, subjective sleep quality, sleep quality measured by night polysomnography and actigraphy, quality of life measured by subjective measures, adverse events associated with the treatments. Nine eligible clinical trials were included. The subjective analyses of these studies showed contradictory results, although the objective analyses showed that treatment group had a statistically significant improvement of periodic leg movement (PLM) index, favoring the treatment group. The most commonly adverse event seen was gastrointestinal symptoms. The short-term treatment with levodopa was demonstrated effective and safety for PLM, but there was only few trials assessing long-term treatment and the augmentation phenomenon in RLS. Further long-term randomized controlled trials using standard follow-up measurements as the International RLS Study Group Rating Scale are necessary.

Síndrome de Ekbom acompanhada de automutilação / Ekbom's syndrome followed by self-mutilation

O delírio parasitário (ou síndrome de Ekbom) é uma condição rara, onde o paciente apresenta uma forte convicção de que está infestado por pequenos parasitas ou organismos. Muitas vezes, os delírios são tão intensos que levam esses pacientes à automutilação. Relatamos aqui um caso de um senhor de 67 anos, isolado socialmente, solteiro, apresentando delírio parasitário em região perineal, culminando em lesões por automutilação.

Delusional parasitosis (or Ekbom's syndrome) is a rare condition, in which the patient has a strong conviction that he or she is infested by small parasites or organisms. These delusions are often so intense that they lead the patient to self-mutilation. We report a case of a 67-year-old man, socially isolated, single, with delusional parasitosis in the perineal area, culminating in self-mutilation lesions.

Síndrome de Ekbom e torcicolo espasmódico: Relato de caso / Ekbom's sydrome and spasmodic torticollis: case report

A síndrome de Ekbom, conhecida também como delírio de infestaçäo parasitária, acarofobia, "delusional parasitosis", parasitose psicogênica, é doença de rara ocorrência. Caracteriza-se pela firme convicçäo dos pacientes de que estäo infectados por vermes que saem pela pele, em geral do couro cabeludo ou até mesmo da boca, dos olhos e da regiäo genital. A maioria dos pacientes é idosa e do sexo feminino, freqüentemente com isolamento social. Alguns casos estäo associados a doenças orgânicas como hipertireoidismo, diabetes, lesöes corticais, intoxicaçöes medicamentosas. A comorbidade com torcicolo espasmódico, até onde vai nosso conhecimento, é um achado inédito na literatura. Relatamos caso de uma senhora de 72 anos de idade que se apresentou com torcicolo espasmódico associado ao quadro psiquiátrico