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Sleep Modules

Restless Leg Syndrome
Case Study

James A. Rowley, MD
for the Sleep Education for Pulmonary Fellows and Practitioners,
SRN ATS Committee
May 2015

Part 1: Case Presentation

AF is a 35 year old female who comes to your office with complaints of difficulty falling asleep at night for the last year.

Questions

  • What are important components of a good history focused on insomnia?
  • What is the differential diagnosis of insomnia?

Case Presentation

  • Upon further questioning, AF states:
    • Bedtime is at 11p and generally takes her 30-45 minutes to fall asleep
    • Wake time is 7a weekdays, 8a on weekends
    • When cannot fall asleep, generally stays in bed watching the clock
    • While trying to fall asleep, feels restless and is constantly moving her legs
    • Does not watch TV or read in bed
    • Only drinks juices or herbal tea after dinner
    • Does not smoke or consume alcohol
    • Is generally sleepy when gets into bed at night
    • Does not worry about her sleep during the day
    • Feels fatigued during the day

Questions

  • What additional questions should be asked to confirm the diagnosis of restless leg syndrome?
  • Are there any questionnaires for RLS?

Case Presentation

  • Upon further questioning, AF states that:
    • The restlessness in her legs often feels like something is crawling up them
    • The restlessness generally improves if she moves her legs around
    • She occasionally notices the creepy-crawly feeling when watching TV in her living room if lying on couch
    • Symptoms bother her at least 4 nights per week
    • Had similar symptoms about 5 years ago during her pregnancy
    • Her father and brother have similar symptoms

Part II: Diagnostic Testing

  • Given the diagnosis of RLS:
    • Which medications need to be checked for?
    • What diagnostic testing is indicated?

Case Presentation

  • Upon further questioning:
    • AF only medication is omeprazole for GERD
  • Ferritin level is 80

Questions

  • What treatment options are available for RLS and what would you recommend for this patient?
  • Is RLS associated with other medical conditions and long term health outcomes?

Part III: Treatment

You prescribe AF pramipexole 0.25 mg one hour before bedtime.

AF returns after 2 months with marked improvement in:

  • Symptoms of restlessness: now only bother her about 1x/month
  • Sleep latency most nights ~10 minutes

Question

  • What is the relationship between RLS and periodic limb movements during wakefulness (Figure 1) and sleep (Figure 2) as observed on a sleep study?

Figure 1:

Tracing of PLMs during Sleep

RLS Figure 1

Figure 2:

Tracing of PLMs during Wakefulness

RLS Figure 2

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Last Reviewed: July 2015