[Sleep-related movement and behavioural disorders in adults]. / Trastornos del movimiento y de la conducta durante el sueño en el adulto.

Sleep-related movement and behaviour disorders may have an impact on sleep quality and lead to daytime symptoms. These groups of conditions include diseases such as restless legs syndrome, periodic leg movements, and REM and NREM parasomnias. The knowledge of their clinical features and management is of utmost importance for the neurologist and sleep specialist. Frequently, these patients are referred to such specialists and it is relevant to know that certain sleep disorders may be associated with other neurological conditions.

TITLE: Trastornos del movimiento y de la conducta durante el sueño en el adulto.Los trastornos del movimiento y de la conducta durante el sueño pueden tener un impacto en la calidad del sueño del paciente y dar lugar a síntomas diurnos. En estos grupos de enfermedades se incluyen entidades como el síndrome de piernas inquietas, los movimientos periódicos de las piernas y las parasomnias del sueño de movimientos oculares rápidos (REM) y no REM. El conocimiento de sus características clínicas y nociones sobre su manejo es de gran importancia para el neurólogo y especialista en sueño por su frecuencia e impacto en la calidad del sujeto. Con frecuencia, estos pacientes son referidos a dichos especialistas, y es relevante conocer que ciertos trastornos del sueño pueden asociarse a otras enfermedades neurológicas.

European guideline for the diagnosis and treatment of insomnia

This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).

World Association of Sleep Medicine (WASM) 2016 standards for recording and scoring leg movements in polysomnograms developed by a joint task force from the International and the European Restless Legs Syndrome Study Groups (IRLSSG and EURLSSG).

This report presents the results of the work by a joint task force of the International and European Restless Legs Syndrome Study Groups and World Association of Sleep Medicine that revised and updated the current standards for recording and scoring leg movements (LM) in polysomnographic recordings (PSG). First, the background of the decisions made and the explanations of the new rules are reported and then specific standard rules are presented for recording, detecting, scoring and reporting LM activity in PSG. Each standard rule has been classified with a level of evidence. At the end of the paper, Appendix 1 provides algorithms to aid implementation of these new standards in software tools. There are two main changes introduced by these new rules: 1) Candidate LM (CLM), are any monolateral LM 0.5-10 s long or bilateral LM 0.5-15 s long; 2) periodic LM (PLM) are now defined by runs of at least four consecutive CLM with an intermovement interval ≥10 and ≤ 90 s without any CLM preceded by an interval <10 s interrupting the PLM series. There are also new options defining CLM associated with respiratory events. The PLM rate may now first be determined for all CLM not excluding any related to respiration (providing a consistent number across studies regardless of the rules used to define association with respiration) and, subsequently, the PLM rate should also be calculated without considering the respiratory related events. Finally, special considerations for pediatric studies are provided. The expert visual scoringof LM has only been altered by the new standards to require accepting all LM > 0.5 s regardless of duration, otherwise the technician scores the LM as for the old standards. There is a new criterion for the morphology of LM that applies only to computerized LM detection to better match expert visual detection. Available automatic scoring programs will incorporate all the new rules so that the new standards should reduce technician burden for scoring PLMS.

Breakthrough symptoms during the daytime in patients with restless legs syndrome (Willis-Ekbom disease).

BACKGROUND: It is often assumed that most patients with restless legs syndrome (RLS) only experience symptoms at night. However, previous studies have estimated the prevalence of daytime symptoms to be 10-60%. This study sought to investigate the prevalence and pattern of daytime symptoms in patients with moderate-to-severe RLS. METHODS: Observational, cross-sectional investigation. A self-administered questionnaire was sent out, on a random basis, to 310 patients with RLS by the Spanish RLS patient support group. Only individuals with a confirmed diagnosis of RLS were included in the final survey. RESULTS: In total, 224 individuals were included in the survey (response rate 72%). Over 55% of patients reported daytime crises on most (>3) days of the week, and 41% suffered daytime symptoms on a daily basis. These breakthrough crises were characterized by unexpected and sudden symptoms and were frequently precipitated by a reduction in daytime activity. The mean severity of these crises on a visual analogue scale (range 0-10) was 6.8 (standard deviation 2.1), and they had a major impact on quality of life. The prevalence of breakthrough crises was related to duration of illness but not to duration of treatment. CONCLUSION: This study suggests that breakthrough crises are common in moderate-to-severe RLS and have a negative effect on quality of life. More studies are needed to investigate whether breakthrough crises reflect disease progression or, at least for those patients undergoing dopaminergic treatment, whether they represent an early indication of RLS augmentation.

Treatment of restless legs syndrome with pregabalin: a double-blind, placebo-controlled study.

OBJECTIVES: To assess the therapeutic efficacy, required dose, and tolerability of pregabalin in patients with idiopathic restless legs syndrome (RLS). METHODS: This was a double-blind, placebo-controlled trial with polysomnographic control, providing Class II evidence. Ninety-eight patients underwent a 2-week single-blind period with placebo; 58 were randomized to receive pregabalin or placebo for 12 weeks under a flexible-dose schedule. Endpoints were mean change from baseline in the International Restless Legs Scale (IRLS) total score, Clinical Global Impression (CGI), and RLS-6 scales, as well as changes in periodic limb movements (PLMs) and sleep architecture. RESULTS: Patients under treatment with pregabalin had a greater improvement in IRLS score than under placebo (63% vs 38.2%; p < 0.05). The mean effective dose of pregabalin at the end of treatment was 322.50 mg/day (+/-98.77), although therapeutic effects were already seen at a mean dose of 139 mg/day. Similarly, improvements were observed on the CGI, RLS-6 scale, and the Medical Outcomes Study sleep scale (all p < 0.01) when compared to placebo. Treatment with pregabalin also resulted in a reduction of the mean (+/-SD) PLM index (p < 0.001). Furthermore, there was a marked improvement in sleep architecture with an increase in slow wave sleep (p < 0.01), and decreases in wake after sleep onset and stages 1 and 2 (p < 0.05). Pregabalin was generally well-tolerated. Adverse events were mild but common, and included unsteadiness, daytime sleepiness, and headache. CONCLUSIONS: This study shows significant therapeutic effects of pregabalin on both sensorial and motor symptoms in restless legs syndrome. Treatment with pregabalin was associated with an improvement of sleep architecture and periodic limb movements. Adverse events included unsteadiness and sleepiness and should be screened carefully in the working population, particularly when pregabalin is administered in the afternoon. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that pregabalin is effective for the treatment of restless legs syndrome and improves sleep architecture and periodic limb movements in placebo-unresponsive patients.

Traducción validada al español de cuestionarios de evaluación de pacientes con síndrome de piernas inquietas / Validated translation to Spanish of the evaluation questionnaire of patients with restless legs syndrome

Introducción. El síndrome de piernas inquietas (SPI) es un trastorno sensitivo y motor frecuente, caracterizado por una necesidad imperiosa de mover las piernas cuando el sujeto se encuentra sentado o tumbado, generalmente al final de la tarde o por la noche. Objetivo. Describir el proceso de adaptación al español de tres herramientas diferentes de estudio del SPI: los criterios para el diagnóstico, un cuestionario de detección de SPI por el clínico en atención primaria (Practitioner Screening Questionnaire, PSQ) y un conjunto básico de preguntas para estudios epidemiológicos (Basic Set of Questions for Epidemiological Studies, CBPEP). Se propone un procedimiento que puede ser adoptado para generar las herramientas en otros idiomas. Métodos. Se utilizó el método de traducción-retrotraducción. Participaron cinco traductores: dos para traducciones directas y dos para las inversas, y un quinto cuando se introdujeron cambios, trabajando de forma independiente en su lengua materna. Dos evaluadores expertos determinaron la equivalencia entre el instrumento original y la versión traducida. La comprensión de los cuestionarios adaptados fue evaluada mediante administración autoaplicada a una muestra de estudiantes y a otra administración heteroaplicada a pacientes con SPI. Resultados. El procedimiento seguido varió ligeramente según el uso previsto de cada instrumento: por profesionales de la salud (criterios de diagnóstico de una enfermedad) o para administración a pacientes (cuestionarios heteroaplicados o autoaplicados). El PSQ y CBPEP no presentaron importantes diferencias, tras su adaptación, con la versión original. Se ha buscado mantener la equivalencia conceptual para garantizar que el instrumento adaptado conservara la función y validez originales. Se utilizó una misma terminología en los diferentes instrumentos para proporcionarles coherencia si se usan conjuntamente. La versión española del PSQ ha ampliado el primer ítem con ejemplos de sensaciones para facilitar su comprensión por pacientes de diferentes partes de España. Conclusiones. Se han obtenido versiones españolas de tres cuestionarios como base para futuras validaciones psicométricas que permitan su uso en España. El instrumento adaptado en último lugar es el que mostró el mejor resultado, en cuanto a equivalencia, obtenido durante el proceso (AU)

Introduction. Restless legs syndrome (RLS) is a common sensory- motor condition, characterised by the irresistible need to move the legs while sitting or lying down, usually presenting late in the day, from the end of the afternoon into the night. Objective. To describe the translation process to Spanish of three different research RLS tools: the diagnosis criteria, the Practitioner Screening Questionnaire and the Basic Set of Questions for Epidemiological Studies. A procedure is proposed for the translation of these tools into other languages. Methods. The back translation method was employed. Five translators took part: two translated into their mother tongue and two into their foreign tongue, and once the translations were completed, a fifth independent translator introduced the changes using his mother tongue. Two expert analysts determined the equivalence between the original questionnaire and the translation. The clarity of the translated questionnaires was evaluated in a sample of students, who completed these themselves, and in RLS patients, for whom the doctor(s) or another authorised person filled them out. Results. The procedure undertaken varied according as to how each instrument were to be used either by health care professionals (diagnosis criteria) or to obtain information from patients (the questionnaire being directly completed by the patient directly or indirectly by a health care professional). No significant differences between the original and the translation of the practitioner screening questionnaire and the basic set of questions for epidemiological studies were found. The translators aimed to maintain concept equivalence function and validity of the original instrument were preserved in the trans lation. The same terminology was employed in the di fferent translations to make sure they were all consistent should they be used together. The Spanish version of the practitioner screening questionnaire has added terms to the first item by providing examples of sensations to ensure its understanding by patients from different parts of Spain. Conclusions. Spanish translated versions of three different questionnaires have been obtained to be used for RLS assessment in Spain, following appropriate psychometric validation. The instrument translated in the third place showed the closest equivalence with original (AU)

[Validated translation to Spanish of the evaluation questionnaire of patients with restless legs syndrome.]. / Traducción validada al español de cuestionarios de evaluación de pacientes con síndrome de piernas inquietas.

Introduction. Restless legs syndrome (RLS) is a common sensory- motor condition, characterised by the irresistible need to move the legs while sitting or lying down, usually presenting late in the day, from the end of the afternoon into the night. Objective. To describe the translation process to Spanish of three different research RLS tools: the diagnosis criteria, the Practitioner Screening Questionnaire and the Basic Set of Questions for Epidemiological Studies. A procedure is proposed for the translation of these tools into other languages. Methods. The back translation method was employed. Five translators took part: two translated into their mother tongue and two into their foreign tongue, and once the translations were completed, a fifth independent translator introduced the changes using his mother tongue. Two expert analysts determined the equivalence between the original questionnaire and the translation. The clarity of the translated questionnaires was evaluated in a sample of students, who completed these themselves, and in RLS patients, for whom the doctor(s) or another authorised person filled them out. Results. The procedure undertaken varied according as to how each instrument were to be used either by health care professionals (diagnosis criteria) or to obtain information from patients (the questionnaire being directly completed by the patient directly or indirectly by a health care professional). No significant differences between the original and the translation of the practitioner screening questionnaire and the basic set of questions for epidemiological studies were found. The translators aimed to maintain concept equivalence function and validity of the original instrument were preserved in the trans lation. The same terminology was employed in the di fferent translations to make sure they were all consistent should they be used together. The Spanish version of the practitioner screening questionnaire has added terms to the first item by providing examples of sensations to ensure its understanding by patients from different parts of Spain. Conclusions. Spanish translated versions of three different questionnaires have been obtained to be used for RLS assessment in Spain, following appropriate psychometric validation. The instrument translated in the third place showed the closest equivalence with original.

A biphasic daily pattern of slow wave activity during a two-day 90-minute sleep wake schedule.

Twenty-four hour sleep patterns were measured in six healthy male volunteers during a 90-minute short sleep-wake (SW 30:60) cycle protocol for 48 hours. Sleep pressure estimates (amount of Slow Wave Sleep [SWS], SWA, and Rate of Synchronization [RoS: the rate of SWA build-up at the beginning of the NREM period]) were compared with the 24-hour patterns of body temperature (Tb24) and sleep propensity. A moderate sleep debt was incurred over the 48 hour study as indicated by decreased levels of 24 hour sleep. On day 1, ultradian patterns of REM and SWS sleep were prominent; on day 2, more prominent were circadian patterns of REM sleep, SWS, Sleep Latency, TST and Tb24. Also on Day 2, biphasic patterns of SWA and RoS were expressed, with peaks occurring during the falling and rising limbs of Tb24. The biphasic peaks in SWA and RoS may be associated with phase-specific interactions of the circadian pacemaker with the sleep homeostat during conditions of moderate sleep pressure. Further research is needed to replicate the finding and to identify biological factors that may underlie the twelve hour pattern in SWA.

EFNS guidelines on management of restless legs syndrome and periodic limb movement disorder in sleep.

In 2003, the EFNS Task Force was set up for putting forth guidelines for the management of the Restless Legs Syndrome (RLS) and the Periodic Limb Movement Disorder (PLMD). After determining the objectives for management and the search strategy for primary and secondary RLS and for PLMD, a review of the scientific literature up to 2004 was performed for the drug classes and interventions employed in treatment (drugs acting on the adrenoreceptor, antiepileptic drugs, benzodiazepines/hypnotics, dopaminergic agents, opioids, other treatments). Previous guidelines were consulted. All trials were analysed according to class of evidence, and recommendations formed according to the 2004 EFNS criteria for rating. Dopaminergic agents came out as having the best evidence for efficacy in primary RLS. Reported adverse events were usually mild and reversible; augmentation was a feature with dopaminergic agents. No controlled trials were available for RLS in children and for RLS during pregnancy. The following level A recommendations can be offered: for primary RLS, cabergoline, gabapentin, pergolide, ropinirole, levodopa and rotigotine by transdermal delivery (the latter two for short-term use) are effective in relieving the symptoms. Transdermal oestradiol is ineffective for PLMD.

En torno a la fisiopatología del síndrome de piernas inquietas / No disponible

El síndrome de piernas inquietas es un trastorno del sueño y del movimiento, que hasta hace poco tiempo ha recibido una escasa atención. No obstante, los estudios epidemiológicos muestran tasas de prevalencia, en los países occidentales, entre el 5 y el 10%. Su causa es desconocida, pero los estudios neurofarmacológicos, deneuroimagen y neurofisiológicos apuntan a una posible disfunción del sistema dopaminérgico, al menos para los casos idiopáticos. No obstante, las alteraciones encontradas son débiles e inconsistentes, y su localización en el Sistema Nervioso Central es puramente especulativa. Por otro lado, en los últimos años se han realizado avances que sugieren una posible implicación del metabolismo del hierro, así como en el campo de la genética. Se revisan los fundamentos sobre la fisiopatología de este cuadro

Restless Legs Syndrome (RLS) is a sleep and a movement disorder that until recently has obtained little attention. However, epidemiological studies have estimated the prevalence rates in western countries ataround 5-10%. The cause of RLS remains still unknown, although neuropharmacological, neurophysiological, and brain imaging studies suggest a dysfunction of the dopaminergic system is involved at least in idiopathic RLS. Nevertheless, these findings are weak and inconsistent, and at this point, even the question of whether the central nervous system is involved remains speculative. On the other hand, over the last few years a number of studies have suggested the involvement ofabnormalities in iron metabolism. Simultanously, interesting developments are taking place in genetic research. The present article reviews the major findings in the pathophysiology of this condition (AU)

Restless legs syndrome: an overview of the current understanding and management.

Over the last few years, major progress in research has improved our understanding of the restless legs syndrome (RLS). Although frequently under-diagnosed, several epidemiological studies have estimated its prevalence in western countries at 4-10% of the general population. Its diagnosis is usually made on a clinical basis, according to the criteria established by the International RLS Study Group (Mov Disord 1995; 10:634). Furthermore, major advances have also been achieved regarding our understanding of the pathophysiology of the disorder. Thus, several brain imaging studies, as well as pharmacological challenges, suggest the presence of a dopaminergic dysfunction playing a major role in its causation. In addition, a strong association has been discovered between brain iron deficiency and RLS. Eventually, dopaminergic drugs have shown therapeutic efficacy in various large-scale therapeutic trials, and, today, dopaminergic agonists represent the first line of treatment. In conclusion, these and other recent findings shed light on our understanding and management of one of the most common movement disorders.

Supresión del sueño REM y efecto antidepresivo / Suppression of REM sleep and antidepressant effect

La necesidad de establecer marcadores biológicos que permitan anticipar los efectos terapéuticos de los fármacos antidepresivos ha llevado a centrar los esfuerzos en estudiar la fiabilidad de estos fármacos para suprimir el sueño REM y su posible valor predictivo de la respuesta terapéutica. El análisis de la bibliografía sobre los efectos supresores de los antidepresivos sobre el sueño REM, en voluntarios sanos, muestra una supresión media del 34%, cuando se administran en dosis única, y del 29%, cuando se hace en dosis múltiple. No obstante, en ambos tipos de diseño el grado de variabilidad en la respuesta es grande, aun cuando se normalizan los resultados en función de las dosis terapéuticas. No se aprecia relación entre el perfil neuroquímico del fármaco y sus efectos sobre el REM, aunque éstos son mayores cuando el mecanismo de acción es predominantemente monoaminérgico. Con la excepción de la trazodona, los efectos supresores sobre el sueño REM disminuyen con el tiempo. Los estudios que se realicen en el futuro sobre esta cuestión deberán utilizar modelos que permitan contemplar las oscilaciones propias del sueño REM durante la noche, en función de las variaciones farmacocinéticas de cada sustancia (AU)

No disponible

Ropinirole in the treatment of restless legs syndrome: results from the TREAT RLS 1 study, a 12 week, randomised, placebo controlled study in 10 European countries.

OBJECTIVE: To assess the efficacy, safety, and tolerability of ropinirole in the treatment of patients with restless legs syndrome. METHODS: A 12 week, prospective, double blind, randomised comparison involving 284 patients from 10 European countries. All participants had a score of > or =15 on the international restless legs scale (IRLS). Patients were randomised (1:1) to receive either ropinirole 0.25-4.0 mg once daily or placebo. The primary efficacy end point was mean change from baseline to week 12 in total IRLS score. Global improvements (clinical global impression (CGI) scale) and improvements in sleep, health related quality of life (QoL; using generic and disease specific measures), work, and other activities were also assessed. RESULTS: 112/146 patients (76.7%) taking ropinirole and 109/138 (79.0%) taking placebo completed the study. Improvement in IRLS at week 12 with ropinirole (mean (SD) dose, 1.90 (1.13) mg/day) was greater than with placebo (mean (SE): -11.04 (0.719) v -8.03 (0.738) points; adjusted difference = -3.01 (95% confidence interval (CI), -5.03 to -0.99); p = 0.0036). More patients in the ropinirole group (53.4%) showed improvement on the CGI scale at week 12 than in the placebo group (40.9%; adjusted odds ratio = 1.7 (1.02 to 2.69); p = 0.0416). Significant differences on both IRLS and CGI scales favouring ropinirole were apparent by week 1. Ropinirole was also associated with significantly greater improvements in sleep and QoL end points. The most common adverse events were nausea and headache. CONCLUSIONS: Ropinirole improves restless legs syndrome compared with placebo, with benefits apparent by week 1. It is generally well tolerated.

L-DOPA-induced excessive daytime sleepiness in PD: a placebo-controlled case with MSLT assessment.

A 74-year-old patient with idiopathic Parkinson's disease was evaluated for unintended sleep episodes that occurred after long-term treatment with 400 mg/day of L-dopa. Overnight sleep studies and multiple sleep latency testing were carried out under double-blind administration of either L-dopa or placebo. Mean sleep latency with L-dopa was 7 minutes, in contrast to a normal value of 19 minutes, 25 seconds with placebo. The authors' results suggest that L-dopa may cause daytime somnolence in some patients with Parkinson's disease.

Consensus on drug treatment, definition and diagnosis for insomnia.

Thirty-four experts and a literature supervisor got together in order to reach a 'consensus' regarding the definition, diagnosis and pharmacological treatment of insomnia. Insomnia is a subjective perception of dissatisfaction with the amount and/or quality of sleep. It includes difficulty in initiating or maintaining sleep or early awakening with inability to fall asleep again. It is associated with complaints of non-restorative sleep and dysfunction of diurnal alertness, energy, cognitive function, behaviour or emotional state, with a decrease in quality of life. The diagnosis is based on clinical and sleep history, physical examination and additional tests, although polysomnography is not routinely indicated. Therapy should include treatment of the underlying causes, cognitive and behavioural measures and drug treatment. Hypnotic therapy can be prescribed from the onset of insomnia and non-benzodiazepine selective agonists of the GABA-A receptor complex are the drugs of first choice. It is recommended that hypnotic treatment be maintained in cases where withdrawal impairs the patient's quality of life and when all other therapeutic measures have failed. Experience suggests that intermittent treatment is better than continuous therapy. The available data do not confirm safety of hypnotics in pregnancy, lactation and childhood insomnia. Benzodiazepines are not indicated in decompensated chronic pulmonary disease but no significant adverse effects on respiratory function have been reported with zolpidem and zopiclone in stable mild to moderate chronic obstructive pulmonary disease and in treated obstructive sleep apnoea syndrome. Data for zaleplon are inconclusive. If the patient recovers subjective control over the sleep process, gradual discontinuation of hypnotic treatment can be considered.

Treatment of restless legs syndrome with gabapentin: a double-blind, cross-over study.

OBJECTIVE: To assess the effects of gabapentin on sensory and motor symptoms in patients with restless legs syndrome (RLS). METHODS: Patients with RLS (22 idiopathic, 2 secondary to iron deficiency) were randomized and treated for 6 weeks with either gabapentin or placebo. After a 1-week washout they crossed over to the alternative treatment for 6 weeks. Patients were rated at baseline and at scheduled intervals by the RLS Rating Scale, Clinical Global Impression, pain analogue scale, and Pittsburgh Sleep Quality Index. At the end of each treatment period, all-night polysomnography was performed. RESULTS: Compared to placebo, gabapentin was associated with reduced symptoms on all rating scales. In addition, sleep studies showed a significantly reduced periodic leg movements during sleep (PLMS) index and improved sleep architecture (increased total sleep time, sleep efficiency, and slow wave sleep, and decreased stage 1 sleep). Patients whose symptoms included pain benefited most from gabapentin. The mean effective dosage at the end of the 6-week treatment period was 1,855 mg, although therapeutic effects were already observed at the end of week 4 (1,391 mg). CONCLUSIONS: Gabapentin improves sensory and motor symptoms in RLS and also improves sleep architecture and PLMS.

Circadian aspects in the pathophysiology of the restless legs syndrome.

Several pieces of evidence suggest that a dopaminergic dysfunction might play a key role in the pathophysiology of restless legs syndrome (RLS), including the therapeutic effects of dopaminergic drugs and the results of several positron emission tomography and single photon emission computed tomography studies. However, RLS symptoms display a distinct circadian pattern, with an increase of both sensorial and motor symptoms in the evening and at night. Although the latter could also be caused by homeostatic mechanisms such as a linkage to the previous amount of wakefulness, several studies performed over the last few years under semiconstant, routine conditions have suggested the existence of a 'true' circadian mechanism modulating the severity of RLS symptoms across the day-night cycle. Thus, both periodic leg movements of sleep and restlessness show a maximal severity in timely coincidence with the falling phase of the core temperature circadian cycle. The present article reviews the evidence showing circadian oscillation of dopaminergic function and postulates that the amplitude of circadian rhythm of dopaminergic function is increased in RLS, with a hypofunction at night.

Tratamiento no-dopaminérgico del síndrome de piernas inquietas / Non-dopaminergic treatment of restless legs syndrome

El tratamiento del síndrome de piernas inquietas ha sufrido importantes cambios a lo largo de los últimos años. Junto a los fármacos dopaminérgicos, cuya eficacia terapéutica es indudable, se han estudiado y desarrollado nuevos tratamientos cuyo mecanismo de acción es diferente y que pueden ofrecer ventajas comparativas a muchos pacientes con dificultades para tolerar los primeros. Básicamente se distinguen cuatro grandes grupos: opiáceos, benzodiacepinas y anticonvulsivantes, así como un cuarto grupo de sustancias heterogéneas. En conjunto ofrecen un arsenal terapéutico que permite acercarnos en mayor medida a las características particulares de cada paciente. En este trabajo, se describen las diferentes alternativas farmacológicas existentes hoy en día, discutiéndose algunos aspectos a tener de cara a la selección del tratamiento, así como las perspectivas futuras que se plantean para mejorar nuestras opciones terapéuticas (AU)