Thoughts

1. Challenge Start by clicking Here Thoughts Legacy Based on the Star.Legacy Model Perspectives & Resources Test your Mettle

2. Challenge About 10-15% of the general population suffer from a sleep disorder that is often unrecognized or misdiagnosed. Your challenge is to actively participating in this module in order to learn how to recognize and correctly diagnose this disorder. Next

3. Challenge Thoughts Legacy Based on the Star.Legacy Model Start Here Perspectives & Resources Test your Mettle

4. Thoughts First, think about some of your past experiences and your current beliefs about sleep and sleep disorders. Read the following question and then right-click anywhere in the white space on this screen and then select “Speaker Notes” to record your answers. When you are done close the Speaker Notes window and click on the NEXT button In your opinion, how serious is lost sleep as a medical condition? Next

5. INSTRUCTIONS: Read the following question right click in the white space on this screen and thenselect “Speaker Notes” to record your answers. When you are done close the Speaker Notes window and click on the NEXT button Think of the last patient who complained of insomnia, and for whom you prescribed a sleep aid, such as Ambien. How certain are you that the primary cause for this complaint was not another disorder, such as Restless Legs Syndrome or Obstructive Sleep Apnea? Next Back

6. INSTRUCTIONS: Read the following question and then right-click in the white space on this screen and then select “Speaker Notes” to record your answers. When you are done close the Speaker Notes window and click on the NEXT button What about ALL the patients you've treated for insomnia over the last three months? How do you know the primary cause of theircomplaints? Next Back

7. INSTRUCTIONS: Read the following question and then right-click in the white space on this screen and thenselect “Speaker Notes” to record your answers. When you are done close the Speaker Notes window and click on the NEXT button How serious would it be if you had difficulty getting the amount of sleep you need to remain competent as a physician? Next Back

8. Challenge Thoughts Legacy Based on the Star.Legacy Model Start Here Perspectives & Resources Test your Mettle

9. Opinions Case Studies Perspectives & Resources Information about a disorder that sometimes effects sleep, Restless Leg Syndrome, is becoming more and more available. Please click on the picture to read through each of the following areas and mark them as complete once you have finished. Symptoms & Diagnosis Done ____ Done ____ Done ____ **User note, the ability to check the areas as complete is not yet available. Next

10. Case Studies Case studies can give you a real life patient perspective. Familiarizing yourself with the symptoms as described by patients will allow you to more easily recognize how the common complaints associated with RLS sound like. 35 year old mother 53 year old man 24 year old woman Back

11. Case Study – 35 year old mother I am 35 years old and was diagnosed 6 months ago with RLS, even though I have had it all my life. I few years ago, I went to my doctor, and she said I was depressed and sent me to a psychologist. I told her I was not depressed, but I would be if I didn't get some sleep soon. I work full-time, go to school, and have a child with ADHD; I was falling asleep at the wheel driving to work in the morning! My husband thought I was lazy because I was falling asleep on the couch at 9 pm every night. I was really starting to get anxious. Finally, my doctor agreed to send me to a movement disorder specialist. By that time, I had started researching on my own, and figured out that I had RLS. After visiting this new doctor, I began taking medication and I finally had dreams again! It was wonderful! Next

12. Case Study – 53 year old man I am a 53-year-old man. It all started a few years ago with some symptoms that I thought "were in my mind" but then became severe and tormenting. My doctor was unfamiliar with my symptoms so I really felt like a Looney Tunes—a sleep-deprived, on-my-feet-all-the-time, suicidal Looney Tunes at that! Since I thought I had some mystery syndrome or was just nuts with my "legs driving me to distraction," it was only after much suffering that I finally went to a neurologist. He, thankfully, recognized my complaints and that was the start of some blessed relief! Next

13. Case Study – 24 year old woman I am 24 years old and have been married for 9 months. I was diagnosed with RLS a few month ago, but I’ve had these strange sensations since childhood. My doctor put me on Sinemet, but it is causing problems in the daytime now, and all my doctor does is tell me to increase the dose. I can't deal with it anymore. In order for my husband and me to get a decent night's sleep, we cannot sleep together. It is putting a strain on our marriage, but so far there is nothing else we can do. I’m up and down all night. At 4 am, I finally fall into a deep sleep, and the alarm goes off 2½ hours later. I can't sleep in on weekends; my body won't let me. I am going crazy. I don't know what to do anymore, but I don't want to go on living this way. I won't do anything drastic, but I am so tempted to just cut my legs off! I guess I'm looking for a miracle drug, but have my doubts that I will find it. Next

14. Symptoms & Diagnosis Please read through the following paragraphs and their hyperlinked pages to learn more about symptoms and diagnosis of RLS. Understanding the patient’s descriptions of their symptoms is essential before the first steps in diagnosing evaluation of RLS starts with. Care givers should also be aware of the differential diagnosis. RLS is often confused with other disorders. Take a look at some of the common misdiagnosis. After diagnosis, management of RLS symptoms should consider the classifications of RLS Next

15. Symptoms as Described by Patients • Like an electric current • The heeby-jeebies • Crazy legs • Like Coca-Cola bubbling through my veins • The gotta-moves • Aching in my bones • Pulling • Elvis Legs • Tearing • Throbbing • Creepy Crawly • Pain • Like a tooth ache in the legs • Growing pains • Itching bones • Like maggots crawling through my veins Next www.restlesslegs.org.uk/diagnosis_rls.html

16. Diagnostic Steps • Recognize existence of RLS • Treat patients symptoms as serious • 4 Essential Diagnostic Criteria • Medical History • Laboratory Tests Next www.rlsstudygroup.org

17. The Toll RLS Takes Think back to the notes you took regarding sleep deprivation and its effect on productivity. If you would like to revisit those notes click HERE Think back to the case studies you read about people suffering from RLS. If you would like to review the case studies again click HERE Otherwise, please progress to the next screen. Next

18. RLS Diagnostic Evaluation URGE U: An urge to move the legs usually accompanied by Unpleasant or Uncomfortable Sensations in the Leg R: The urge to move or unpleasant sensations begin or worsen during periods of inactivity or Rest such as lying or sitting G:The urge to move or unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues (Get Up and Go) E:The urge to move or unpleasant sensations are worse in the Evening or night than during the day or only occur in the Evening or night. Next

19. Medical History Pay attention to: • Past medical problems • Family history • Current medications • Symptoms • frequency • duration • intensity • Sleeping patterns • Disturbance of sleep • Sleepiness • Daytime function Next

20. Laboratory tests can be used to rule out other conditions A negative test of any of the following: • Blood tests to exclude anemia, decreased iron stores, diabetes, and renal dysfunction • Electromyography and nerve conduction studies to measure electrical activity in muscles and nerves • Doppler sonography to evaluate muscle activity in the legs Next

21. Differential Diagnosis Next www.restlesslegs.org.uk/diagnosis_rls.html

22. Common Misdiagnosis PLMS – (Periodic Limb Movement in Sleep) though the two can be associated they are different, distinct disorders Insomnia – Sleep problems characterized by difficulty falling asleep, frequent waking during the night, or waking up earlier than desired. Insomnia can result in getting up in the morning feeling unrested and experiencing drowsiness during the day. Depression - mental state characterized by a pessimistic sense of inadequacy and a despondent lack of activity sad feelings of gloom and inadequacy Next

23. Classification of RLS Origin of Symptoms • Primary vs. Secondary Frequency of Symptoms • Intermittent vs. Daily Response to Treatment - Refractory Next

24. Symptom Origin • Primary or Idiopathic RLS • Insidious onset • Likely to have a large genetic component (more than 50% of sufferers have a family member with RLS) • Occurs at an early age (usually before 40 years) • Unrelated to comorbid disease or drug usage • Almost universally responsive to dopaminergic therapy • Secondary RLS • Faster onset • Occurs in relationship to other conditions, such as End-Stage Renal Disease, Iron-Deficiency and Pregnancy • Related to usage of certain prescribed drugs (SSRIs, dopamine and histamine-receptor antagonists) • Almost universally responsive to dopaminergic therapy Next

25. Frequency of Symptoms • Intermittent RLS • “RLS that is troublesome enough when present to require treatment but does not occur frequently enough to require daily therapy” • Daily RLS • “RLS that is frequent and troublesome enough to require daily therapy” Next Silber et al. An Algorithm for the Management of Restless Legs Syndrome. Mayo Clin Proc. 2004; 79(7): 916-922

26. Response to Treatment • Refractory RLS • “Daily RLS treated with a dopamine agonist with an inadequate treatment outcome, including: • Inadequate initial response • Inadequate response with time, even with increasing doses • Intolerable adverse effects • Augmentation that is not controllable with earlier doses of the drug” Next Silber et al. An Algorithm for the Management of Restless Legs Syndrome. Mayo Clin Proc. 2004; 79(7): 916-922

27. Intermittent RLS Next

28. Daily RLS Next

29. Refractory RLS Next

30. Opinions Please read through the following paragraphs and their hyperlinked pages There are no definitive causes that have yet been identified. You can explore some of the theories here: Sleep Disorders Guide(sleep disorder specialists)WeMove(non-profit specializing in movement disorders) Alternative treatments to medication are important both for identifying patients who have been managing their symptoms and to providing an alternative perspective for those who may not wish to use medication. Read what past participants of this learning model have posted about their subsequent interactions with RLS patients. http://rlsopinions.wikispaces.com/ Next

31. Alternative Treatments Patients may report that certain behaviors that have temporarily relieved their symptoms. Some of these are: • Refraining from alcohol consumption and tobacco. • Avoiding anti-nausea medications, neuroleptic, and antidepressants. • A regular sleep routine • Regular, moderate exercise • Leg massage may work to calm restless legs. • A warm bath • Over-the-counter pain reliever such as ibuprofen before bed Back

32. Challenge Thoughts Legacy Based on the Star.Legacy Model Start Here Perspectives & Resources Test your Mettle

33. Test your Mettle Having read some information, try actually applying what you know to some sample patients. Next

34. Mr. Smith has come into your office with the following symptoms. • trouble or difficulty falling asleep • waking up often during the night • difficulty returning to sleep • waking up too early in the morning • sleep that does not leave you refreshed • worrying about sleep problems • excessive napping in the afternoon or evening How would you diagnose him? Insomnia Restless Leg Syndrome Depression

35. Not Exactly.Take a look at this case thinking more about depression. Next

36. Not Exactly.Take a look at this case thinking more about Insomnia. Next

37. Not Exactly.Take a look again at the diagnostic resources which explain more about RLS. Resources

38. During a routine visit, John Doe is complaining of the following issues: • poor sleep, early-morning awakening, or oversleeping • decreased energy, fatigue, being "slowed down" • persistent sad, anxious or "empty" mood • feeling hopeless, pessimistic, guilty, worthless, helpless • loss of interest or pleasure in hobbies and activities, including sex • difficulty concentrating, remembering, making decisions • restlessness, irritability How would you diagnose him? Restless Leg Syndrome Depression Insomnia

39. Ms. Jones is seeing you today because she is bothered by: • exhaustion/fatigue • daytime sleepiness • inability to get comfortable • uncomfortable/abnormal feelings in the legs • pain • inability to stay still/urge to move the limbs • twitching/jerks of legs How would you diagnose her? Insomnia Restless Leg Syndrome Periodic Limb Movement in Sleep

40. Correct. Next

41. Correct. Next

42. Correct. Next

43. Which of the following are the 4 diagnostic criteria used for RLS? Next

44. That’s Correct! It is one of the Four Next

45. Sorry, try again. That is NOT one of the 4 listed! Next

46. Read the following two case studies and think about the possibility of RLS. Which of these two (if either) would you diagnose with RLS? Explain your rationale for why? What would your advice to these two patients be? Go to Case Studies

47. A 74-year-old man reported a 2-year history of leg "cramping . . . pain, and an urge to move" that improved if he walked around. He believes that both legs were equally involved. The onset of symptoms was subacute over a few weeks, and has been stable since. Every night at 9:30 pm, the symptoms start. They interfere with his sleep and result in awakenings until about 4:00 am. He then sleeps until 7:00 am. He reports that the symptoms worsened if he drank alcohol in the evening, and he has since stopped. AA is a 30-year-old nurse with difficulty initiating and maintaining sleep because of cramping and a crawling sensation within her legs every night since she was 14. She was able to walk the feelings off until last year when the symptoms and resulting daytime sleepiness progressed to require medical therapy with levodopa-carbidopa. She was doing well initially with medication but has recently begun to experience symptoms earlier in the evening. She has no trouble at work and symptoms recur only with rest. Her mother, who died at age 55 from breast cancer, was suffering from leg cramps at night as well. Social history and physical exam are unremarkable. Respond to Case Studies http://rlsopinions.wikispaces.com/Course+Responses Next

48. Challenge Thoughts Legacy Based on the Star.Legacy Model Start Here Perspectives & Resources Test your Mettle

49. Leaving a Legacy As physicians, your dual role as student and possible content expert can be overlapping. Now that you have completed the course, we invite you to please add your reflections and experiences on RLS in the Opinions section. If you know of research that is currently being done, please suggest how participants can obtain that information. Or if you would like to simply recount some of your experiences with successful or unsuccessful treatment of patients experiencing RLS symptoms, please do so back at the wiki. You can return at any time. Thank you for participating in this course. In order to make this course module more effective for other participants, please take the time to complete our evaluation form. Survey

50. After completing this challenge, you should be able to: • Identify four diagnostic criteria for restless leg syndrome • Outline conditions commonly associated with RLS. • Compare the benefits and risks of pharmacologic treatments for RLS. • Compare the benefits and risks of alternative treatments for RLS. • Describe factors that worsen or exacerbate symptoms of RLS. • Identify additional resources for information on RLS. Adapted from http://www.rls.org/NetCommunity/Page.aspx?&pid=437&srcid=437