Rachel Marie E. Salas, MD, on a New Era of Restless Legs Syndrome Management

Rachel Marie E. Salas, MD, FAAN presented research at the 32nd Annual Meeting of the Associated Professional Sleep Societies (SLEEP 2018) in June. Here, Dr Salas answers our questions about restless legs syndrome (RLS) and other limb movement disorders. She is a sleep neurologist who is an associate professor of neurology and nursing; director of Interprofessional Education and Interprofessional Collaborative Practice; and director of the Neurology Clerkship and the PreDoc Program at Johns Hopkins Medicine in Baltimore, Maryland.

Neurology Consultant: Can you briefly describe your research into the underlying mechanisms of sleep and chronic sleep disorders—restless legs syndrome (RLS) and other limb movement disorders—and how it came about?

Rachel Salas: My independent research focus is on the neurobiological mechanisms underlying sleep disorders, particularly RLS and insomnia, which remain poorly understood. I was trained in an ACGME [Accreditation Council for Graduate Medical Education] sleep medicine fellowship at Johns Hopkins, where I had the mentorship from Drs Christopher Earley and Richard Allen from an RLS (clinical and research) perspective. Recently, I collaborated with Dr Allen on a National Institutes of Health grant study, “Glutamate, Hyperarousal and Restless Legs Syndrome,”1 where I spearheaded the transcranial magnetic stimulation (TMS) arm of the study assessing cortical excitability, with results in press in the journal Sleep Medicine.

Neurology Consultant: At the recent SLEEP 2018 meeting, you moderated a discussion titled, “The New Era of Restless Legs Syndrome Management,” Explain why there is a “new era,” and how our understanding of RLS management has evolved.

RS: Our patients are looking for new therapies for RLS. While opioids are a treatment option for complex RLS, and patients often do well with low doses, the current opioid crisis has resulted in some constraints, for sure. Iron therapy is another therapy that clinicians may not be familiar with in terms of RLS. With current standard practice recommendations, patients are routinely placed on dopamine agonists, and clinicians may not be aware of augmentation and/or how to manage it in affected patients. Thus, this symposium intended to give insight on treating with opioids and iron, identifying and managing augmentation, which are topics that even sleep specialists want the latest updated information on as we learn more on the research front.

Neurology Consultant: Clinicians are quite familiar with the role of dopamine agonists and gabapentin/pregabalin, as well as nonpharmacologic therapies (massage, lifestyle changes, iron supplementation, etc) in the treatment of patients with RLS. Can you offer insight about the current and potential future therapies for RLS?

RS: I presented at SLEEP 2018 on my work using TMS to better understand the neurobiology of RLS in hopes to potentially offer other treatment strategies for our RLS patients (eg, TMS as therapy) in the near future.2 TMS allows us to noninvasively measure motor responses to stimulation in certain parts of the brain. We used a neuronavigation system and magnetic resonance imaging to target the motor cortex using a handheld to illicit a stimulation that can either result in an excitatory or inhibitory response in the brain. Then we can measure the motor response to this stimulation, which allows us to understand mechanisms in the brain in RLS patients compared with good sleep controls. I also brought up how we as sleep specialists need to help other clinicians to properly diagnose RLS and look for common exacerbators. Many times, patients are misdiagnosed and started on medications for RLS even though they do not meet the diagnostic criteria. Furthermore, sometimes patients’ RLS gets worse because of iron issues or another exacerbator, yet these patients are often told to increase their RLS medication, which can cause adverse effects. So I wanted to recommend that education—not only for patients, but also for clinicians—is key.

Neurology Consultant: Speaking of education, can you tell us about the app you are working on?

RS: We are developing a clinical and educational app, MySleepScript, to hopefully help with this in the future, but it is still in a research phase.3 The educational app, MySleep101, is an engaging and animated educational experience that was developed by an interdisciplinary team of sleep experts (Charlene Gamaldo, MD; Luis Buenaver, PhD; and me) at The Johns Hopkins University School of Medicine. The key concepts related to basic sleep physiology and common sleep disorders are presented by the experts in brief and high-yield mini module formats. This app also allows an opportunity for health care provider–learners to gain a better understanding of sleep issues and disorders that they will likely encounter in their patients. We also have a free version of the app for patients, called SleepMatters, available on iTunes. We use this app at the Johns Hopkins Center for Sleep by referring patients whom we have diagnosed with a common sleep disorder to view it. MySleepScript is the clinical tool that we hope to release soon in effort to help clinicians identify patients who should be referred to a sleep center and to help educate patients on the sleep disorder of concern.

Patients also are interested in nonpharmacologic therapies, and I support RLS patients working with the sleep behavioral psychologist to best treat their condition.

Neurology Consultant: How best can neurologists and other health care providers integrate this information into clinical practice?

RS: Education is key. Make the diagnosis first. RLS is a clinical diagnosis. Rule out mimics. Look for exacerbators. Many times, patients may be getting information online and doing more harm than good. Ask your patients what they are doing on their own for RLS. Refer to a sleep psychologist for optimal care. There are always things patients can do in terms of their sleep behaviors and practices that can help their RLS. Attend conferences such as SLEEP and the American Academy of Neurology Annual Meeting where you can learn the latest and be updated with new options to better identify and treat patients with RLS.

Neurology Consultant: What else should neurologists know about the approach to management of RLS and other chronic sleep disorders?

RS: Identifying and treating other sleep disorders in RLS patients is key to improvement, better quality of life, and better RLS management. If your patients have untreated apnea or insomnia, studies show that RLS patients will experience more RLS as a result.

References:

1. Glutamate, hyperarousal and restless legs syndrome. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT01675323. Accessed August 14, 2018.
2. Hone-Blanchet A, Salas RE, Celnik P, et al. Co-registration of magnetic resonance spectroscopy and transcranial magnetic stimulation. J Neurosci Methods. 2015;242:52-57.
3. Doshi A, Gamaldo CE, Dziedzic P, et al. Finding time for sleep: identifying sleep concerns in non-sleep specialty clinics using the MySleepScript app. J Mob Technol Med. 2017;6(2):19-27.

For Further Reading:

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• Allen RP, Salas RE, Gamaldo C. Movement disorders in sleep. In: Kryger MH, Avidan AY, Berry RB, eds. Atlas of Clinical Sleep Medicine. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2018:174-195.
• Gamaldo AA, Gamaldo CE, Allaire JC, et al. Sleep complaints in older blacks: do demographic and health indices explain poor sleep quality and duration? J Clin Sleep Med. 2014;10(7):725-731.
• Gamaldo CE, Gamaldo A, Creighton J, et al. Evaluating sleep and cognition in HIV. J Acquir Immune Defic Syndr. 2013;63(5):609-616.
• Gamaldo CE, Gamaldo AA, Hou LT, et al. When a private community neurology practice executes home sleep apnea testing. Sleep Health. 2018;4(2):217-223.
• Gamaldo CE, Spira AP, Hock RS, et al. Sleep, function and HIV: a multi-method assessment. AIDS Behav. 2013;17(8):2808-2815.
• Gunnarsdottir KM, Kang YM, Kerr MS, et al. A look at the strength of micro and macro EEG analysis for distinguishing insomnia within an HIV cohort. Conf Proc IEEE Eng Med Biol Soc. 2015;2015:6622-6625.
• Kang YM, Gunnarsdottir KM, Kerr MS, et al. To score or not to score? A look at the distinguishing power of micro EEG analysis on an annotated sample of PSG studies conducted in an HIV cohort. Conf Proc IEEE Eng Med Biol Soc. 2015;2015:6626-6629.
• Le HH, Salas RME, Gamaldo A, et al. The utility and feasibility of assessing sleep disruption in a men’s health clinic using a mobile health platform device: a pilot study. Int J Clin Pract. 2018;72(1):e12999.
• Mahajan A, Rosenthal LS, Gamaldo C, et al. REM sleep behavior and motor findings in Parkinson’s disease: a cross-sectional analysis. Tremor Other Hyperkinet Mov (N Y). 2014;4:245.
• Tanner JA, Rao KT, Salas RE, et al. Incorporating students into clinic may be associated with both improved clinical productivity and educational value. Neurol Clin Pract. 2017;7(6):474-482.
• Thorpe RJ Jr, Gamaldo AA, Salas RE, Gamaldo CE, Whitfield KE. Relationship between physical function and sleep quality in African Americans. J Clin Sleep Med. 2016;12(10):1323-1329.

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