Relationship of periodic leg movements and severity of restless legs syndrome: a study in unmedicated and medicated patients.

OBJECTIVE: To evaluate the relationship of the severity of restless legs syndrome (RLS) as assessed by a subjective, patient-rated scale (International RLS Study Group Rating Scale, IRLS), and of periodic leg movements in sleep (PLMS) as an objective parameter, in two different patient populations. METHODS: Data of 200 unmedicated patients with idiopathic RLS were evaluated. Group 1 (n=100) consisted of selected patients participating in the Pergolide European Australian RLS (PEARLS) study. Group 2 (n=100) represented an outpatient RLS population investigated in a Sleep Disorders Center. Additionally, Group 1 was also evaluated after a 6 week double-blind treatment period, where 47 patients received pergolide and 53 patients placebo. RESULTS: In unmedicated patients, IRLS scores correlated with the PLMS-arousal index (r=0.22, p=0.033) but not with the PLMS index in Group 1 while no correlation was found in Group 2. The change of the IRLS score under treatment in Group 1 correlated significantly both with the change of the PLMS index (r=0.42, p<0.001) and the change of the PLMS-arousal index (r=0.38, p<0.001). CONCLUSIONS: The IRLS adequately reflects treatment changes of PLMS indices. In unmedicated patients, the IRLS correlates with PLMS indices probably only in selected RLS populations with predefined PSG criteria and high PLM activity. SIGNIFICANCE: The IRLS is an appropriate subjective rating scale for measuring treatment effects in RLS.     

The effect of hyperbaric oxygen treatment on postural stability and gait of a brain injured patient: single case study

Hyperbaric oxygen (HBO) therapy has been found to reduce intracranial and cerebrospinal fluid pressures, and increase grey matter metabolic activity in patients with brain injuries. To date, few studies have quantitatively assessed the changes in the patient's functional outcomes following this expensive therapeutic intervention. The purpose of this case study was to examine the immediate and longer term changes in postural stability and gait in a 17 year old patient who sustained a traumatic brain injury, following administration of hyperbaric oxygen (HBO) therapy combined with physical and occupational therapy. The patient underwent assessments of postural stability and gait 1 week prior to HBO therapy, immediately following, and 6 weeks after completion of HBO therapy. Some improvements in postural stability were observed immediately following HBO, although these improvements were not evident 6 weeks later. Only slight improvements were noted in his walking abilities immediately following the intervention, with essentially little change evident 6 weeks later. The results of this do not support anecdotal evidence that there were substantial improvements in the subject's postural stability and gait following HBO therapy.     

Flexion contracture after total knee arthroplasty in a patient with Parkinson's disease: successful treatment with botulinum toxin type A

The few reports in the orthopedic literature that discuss outcomes after total knee arthroplasty in patients with Parkinson's disease cite mixed results. These patients are at increased risk for the development of flexion contracture, which has been shown to significantly worsen functional scores. The present report describes the development of a flexion contracture in a patient with Parkinson's disease after total knee arthroplasty. This contracture was successfully treated with manipulation under anesthesia and injections of botulinum toxin type A into the hamstring and gastrocnemius muscles, in conjunction with a static progressive extension orthosis and rigorous physical therapy.     

Validation of the Augmentation Severity Rating Scale (ASRS): a multicentric, prospective study with levodopa on restless legs syndrome

BACKGROUND: Augmentation is the main complication during long-term dopaminergic treatment of restless legs syndrome (RLS) and reflects an overall increase in RLS severity. Its severity varies considerably from a minor problem to a devastating exacerbation of disease. Despite its clinical relevance, systematic evaluations have rarely been undertaken and there has been no development of methods to assess the severity of augmentation. To fill this gap, the European RLS Study Group (EURLSSG) has developed the Augmentation Severity Rating Scale (ASRS), using three items that assess the degree of change in three specific dimensions of augmentation. The changes in each dimension are summed to give an ASRS total score. METHODS: The ASRS was developed to cover the basic dimensions defining RLS augmentation. The items were developed by an interactive process involving professional and patient input. The ASRS that was evaluated included four major items and two alternative forms of one item. The validation was conducted using 63 (85%) mostly untreated RLS patients from six centers, who were treated for six months with levodopa (L-Dopa) (up to 500 mg/day, as clinically needed). Two consecutive assessments before and at baseline measured test-retest reliability. Consecutive ASRS ratings by two independent raters on a subsample of patients evaluated inter-rater reliability. Comparison with clinical severity ratings of two independent experts provided external validation of the ASRS. Comparison of patients with and without augmentation with regard to the items and the total score of the ASRS added discriminant validity. RESULTS: Sixty patients (63% females, mean age: 53 years, baseline International RLS Severity Rating (IRLS) score 24.7+/-5.2) were treated with a median daily dose of 300 mg L-Dopa (range: 50-500 mg). Thirty-six patients (60%) experienced augmentation. Item analyses indicated that one item could be removed as it did not contribute significantly to the test score and only one form of the duplicated item needed to be used. The final ASRS then included three items. Test-retest reliability for the total score was rho=0.72, and inter-rater reliability was rcc=0.94. Cronbach's alpha was 0.62. Validity as assessed by the correlation between the worst ASRS total score during the trial and the expert rating was rho=0.72. ASRS total score differed between patients without versus with augmentation (mean: 7.4 (standard deviation (SD)=4.0) vs. 2.0 (2.7) (P<0.0001). CONCLUSIONS: The ASRS is a reliable and valid scale to measure the severity of augmentation. Due to the need to systematically quantify augmentation for both long-term efficacy and tolerability, the ASRS may become a useful tool to monitor augmentation in future clinical trials.     

Hypertrophic olivary degeneration after surgical removal of cavernous malformations of the brain stem: report of four cases and review of the literature

Summary Background. Hypertrophic olivary degeneration (HOD) is a pathological phenomenon that occurs after injury to the dentato-olivary pathway. Its hallmarks include hypertrophy of the olive with increased T2 signal intensity on magnetic resonance imaging, and it often manifests with palatal tremor and oscillopsia clinically. Method. We report the cases of four patients who developed delayed HOD after surgical resection of pontine lesions. Findings. We discuss the anatomical and pathological details of this disease and review the few other reported cases of HOD after resection of lesions within the brainstem. Conclusions. HOD should be recognized as a possible complication of surgery within the brainstem and must be diagnosed promptly so that patients can be appropriately counseled and symptoms can be treated. Correspondence: William T. Couldwell, MD, Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA.     

Do periodic leg movements influence patients' perception of sleep quality?

BACKGROUND AND PURPOSE: Periodic leg movements in sleep (PLMS) are a common finding in various sleep disorders. Whether PLMS are an epiphenomenon or are causally related to the presence of sleep-wake disturbances is still being debated. We investigated the relationship of the occurrence of PLMS to patients' perception of sleep quality during a night of polysomnography in various sleep disorders. METHODS: The retrospective evaluation included PLMS recordings over two nights of 78 consecutive patients diagnosed with a restless legs syndrome, primary insomnia or insomnia associated with a psychiatric disorder. The subjects' perception of sleep during the polysomnography night was assessed by the subscale 'sleep quality' of the validated self-rating sleep questionnaire SFA (SFA-SQ). RESULTS: SFA-SQ scores correlated with the PLMS index (number of PLMS per hour of sleep) only in patients with restless legs syndrome during the first of the two nights investigated (r=-0.464, P<0.01). PLMS appear to have a low impact on the subjects' perception of sleep quality. The correlation of subjective sleep quality to PLMS index in the first of the two investigated nights in RLS patients may reflect an adaptation effect. CONCLUSION: The results of our study favor the hypothesis that PLMS most likely are not the primary cause of sleep disturbances in these patient groups.