Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health.

In summary, although actigraphy is not as accurate as PSG for determining some sleep measurements, studies are in general agreement that actigraphy, with its ability to record continuously for long time periods, is more reliable than sleep logs which rely on the patients' recall of how many times they woke up or how long they slept during the night and is more reliable than observations which only capture short time periods Actigraphy can provide information obtainable in no other practical way It can also have a role in the medical care of patients with sleep disorders However, it should not be held to the same expectations as polysomnography Actigraphy is one-dimensional, whereas polysomnography comprises at least 3 distinct types of data (EEG, EOG, EMG), which jointly determine whether a person is asleep or awake It is therefore doubtful whether actigraphic data will ever be informationally equivalent to the PSG, although progress on hardware and data processing software is continuously being made Although the 1995 practice parameters paper determined that actigraphy was not appropriate for the diagnosis of sleep disorders, more recent studies suggest that for some disorders, actigraphy may be more practical than PSG While actigraphy is still not appropriate for the diagnosis of sleep disordered breathing or of periodic limb movements in sleep, it is highly appropriate for examining the sleep variability (ie, night-to-night variability) in patients with insomnia Actigraphy is also appropriate for the assessment of and stability of treatment effects of anything from hypnotic drugs to light treatment to CPAP, particularly if assessments are done before and after the start of treatment A recent independent review of the actigraphy literature by Sadeh and Acebo reached many of these same conclusions Some of the research studies failed to find relationships between sleep measures and health-related symptoms The interpretation of these data is also not clear-cut Is it that the actigraph is not reliable enough to the access the relationship between sleep changes and quality of life measures, or, is it that, in fact, there is no relationship between sleep in that population and quality of life measures? Other studies of sleep disordered breathing, where actigraphy was not used and was not an outcome measure also failed to find any relationship with quality of life Is it then the actigraph that is not reliable or that the associations just do not exist? The one area where actigraphy can be used for clinical diagnosis is in the evaluation of circadian rhythm disorders Actigraphy has been shown to be very good for identifying rhythms Results of actigraphic recordings correlate well with measurements of melatonin and of core body temperature rhythms Activity records also show sleep disturbance when sleep is attempted at an unfavorable phase of the circadian cycle Actigraphy therefore would be particularly good for aiding in the diagnosis of delayed or advanced sleep phase syndrome, non-24-hour-sleep syndrome and in the evaluation of sleep disturbances in shift workers It must be remembered, however, that overt rest-activity rhythms are susceptible to various masking effects, so they may not always show the underlying rhythm of the endogenous circadian pacemaker In conclusion, the latest set of research articles suggest that in the clinical setting, actigraphy is reliable for evaluating sleep patterns in patients with insomnia, for studying the effect of treatments designed to improve sleep, in the diagnosis of circadian rhythm disorders (including shift work), and in evaluating sleep in individuals who are less likely to tolerate PSG, such as infants and demented elderly While actigraphy has been used in research studies for many years, up to now, methodological issues had not been systematically addressed in clinical research and practice Those issues have now been addressed and actigraphy may now be reaching the maturity needed for application in the clinical arena

The role of actigraphy in the study of sleep and circadian rhythms.

1.0 BACKGROUND ACTIGRAPHY HAS BEEN USED TO STUDY SLEEP/WAKE PATTERNS FOR OVER 20 YEARS. The advantage of actigraphy over traditional polysomnography (PSG) is that actigraphy can conveniently record continuously for 24-hours a day for days, weeks or even longer. In 1995, Sadeh et al.,1 under the auspices of the American Sleep Disorders Association (now called the American Academy of Sleep Medicine, AASM), reviewed the current knowledge about the role of actigraphy in the evaluation of sleep disorders. They concluded that actigraphy does provide useful information and that it may be a “cost-effective method for assessing specific sleep disorders...[but that] methodological issues have not been systematically addressed in clinical research and practice.” Based on that task force’s report, the AASM Standards of Practice Committee concluded that actigraphy was not indicated for routine diagnosis or for assessment of severity or management of sleep disorders, but might be a useful adjunct for diagnosing insomnia, circadian rhythm disorders or excessive sleepiness.2 Since that time, actigraph technology has improved, and many more studies have been conducted. Several review papers have concluded that wrist actigraphy can usefully approximate sleep versus wake state during 24 hours and have noted that actigraphy has been used for monitoring insomnia, circadian sleep/wake disturbances, and periodic limb movement disorder.3,4 This paper begins where the 1995 paper left off. Under the auspices of the AASM, a new task force was established to review the current state of the art of this technology.

The Role of Actigraphy in the Study of Sleep and Circadian Rhythms AMERICAN ACADEMY OF SLEEP MEDICINE REVIEW PAPER

Psychometric evaluation of the pittsburgh sleep quality index

The role of actigraphy in sleep medicine

We report the effects of a single bedtime dose of L-dopa 100-200 mg on sleep quality, frequency of periodic leg movements (PLM) and daily living in patients with idiopathic and uremic restless legs syndrome (RLS) Seventeen patients with idiopathic and 11 with uremic (on continuous hemodialysis) RLS were evaluated comparatively by polysomnography, actigraphy and subjective ratings in a randomized, controlled and double-blind crossover trial with L-dopa and placebo for 4 weeks each Neurophysiologic assessments showed significant reduction of the number of periodic leg movements (p = 0003) and the PLM-index (p = 0005) most pronounced during the first 4 hours of bedtime after L-dopa (p = 0001) Subjective evaluation confirmed improvement of sleep quality (p = 0002) and showed significantly higher quality of life during daytime (p = 0030) while the patients received L-dopa therapy We conclude that L-dopa 100-200 mg proved to be effective in idiopathic RLS and for the first time under controlled conditions in uremic RLS without any severe side effects

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L-Dopa Therapy of Uremic and Idiopathic Restless Legs Syndrome: A Double-Blind, Crossover Trial

Objective: To investigate whether a combination treatment of regular-release levodopa (rr-l-dopa) and sustained-release levodopa (sr-l-dopa) compared with monotherapy of rr-l-dopa improves sleep quality and reduces periodic limb movements (PLM) in patients with restless legs syndrome (RLS) and problems with maintaining sleep. Background: Reappearance of RLS symptoms during the second half of the night while being treated with rr-l-dopa is a common problem in the treatment of sleep disturbances caused by RLS. Methods: A randomized, controlled, double-blind crossover trial was undertaken. Eligible patients fulfilled the diagnostic criteria of the International RLS Study Group, and met an actigraphically confirmed higher number of PLM per hour time in bed (PLM index) during the second half compared with the first half of the night under treatment with rr-l-dopa. During the crossover periods the patients received 100 to 200 mg rr-l-dopa plus either placebo or 100 to 200 mg sr-l-dopa at bedtime for 4 weeks each period. Results: Thirty patients with RLS (11 men and 19 women) were assessed by actigraphy and subjective sleep quality, and showed a significant improvement in PLM index ( p p p Conclusions: A combination therapy of rr-l-dopa and sr-l-dopa is better than monotherapy with rr-l-dopa in reducing the frequency of PLM and problems maintaining sleep, even in patients who are severely affected.

A controlled study of additional sr-l-dopa in l-dopa–responsive restless legs syndrome with late-night symptoms

A new actigraphic method by which periodic leg movements (PLM) can be measured is presented. Data acquistion and analysis were brought into line to distinguish short-lasting repetive leg movements from random motor restlessness. The definition of PLM follows the generally accepted criteria for PLM scoring. Thirty restless legs patients, all also suffering from PLM, were investigated three times by polysomnography, including tibialis anterior surface electromyography and actigraphy. A high correlation (reliability) was found for the number of PLM per hour spent in bed between the two methods. Furthermore, the actigraph records PLM specifically. An index of random motor restlessness is not sufficient for a reliable PLM according. In addition, periodic movements in sleep (PMS) and PLM show comparable variability in general. The actigraphic assessment of PLM, however, gives a better measure because PMS recordings may result in a substantial underestimation of PLM when sleep efficiency is reduced. This method is an ambulatory assessment tool that can also be used for screening purposes.

New actigraphic assessment method for periodic leg movements (PLM)

In a randomized, controlled and double-blind cross-over trial with L-Dopa and placebo we evaluated the effects of a single bedtime dose of L-Dopa 100 to 200 mg on sleep quality and frequency of periodic leg movements (PLM) in 17 patients with idiopathic and in 11 patients with uremic restless legs syndrome (RLS) by polysomnography, actigraphy, and subjective ratings. Treatment with L-Dopa showed significant reduction of the number of periodic leg movements and the PLM-index most pronounced during the first 4 hours of bedtime. Subjective evaluation confirmed improvement of sleep quality. L-Dopa proved to be effective in idiopathic and uremic RLS without any severe side effects.

Behandlung des idiopathischen und urämischen Restless-legs-Syndrom mit L-Dopa. Eine doppelblinde cross-over Studie

3-50-03 Treatment of the restless legs syndrome with a combination of standard and sustained-release levodopa/benserazide (Madopar Depot®): A double-blind controlled study

J. Kazenwadel

Papers

L-Dopa Therapy of Uremic and Idiopathic Restless Legs Syndrome: A Double-Blind, Crossover Trial

A controlled study of additional sr-l-dopa in l-dopa–responsive restless legs syndrome with late-night symptoms

New actigraphic assessment method for periodic leg movements (PLM)

Behandlung des idiopathischen und urämischen Restless-legs-Syndrom mit L-Dopa. Eine doppelblinde cross-over Studie

3-50-03 Treatment of the restless legs syndrome with a combination of standard and sustained-release levodopa/benserazide (Madopar Depot®): A double-blind controlled study