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Introduction for the Questionnaires for Restless Legs Syndrome
Korean J Clin Geri 2022 Jun;23(1):23-26
Published online June 30, 2022;  https://doi.org/10.15656/kjcg.2022.23.1.23
Copyright © 2022 The Korean Academy of Clinical Geriatrics.

Jung A Park1 , Keun Tae Kim2

1Department of Neurology, Daegu Catholic University School of Medicine, Daegu; 2Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
Correspondence to: Keun Tae Kim, Department of Neurology, Keimyung University School of Medicine, 1095 Dalgubeoldae-ro, Dalseo-gu, Daegu 42601, Korea. E-mail: 6k5upa@gmail.com
Received February 4, 2022; Revised March 11, 2022; Accepted March 18, 2022.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Abstract
Restless legs syndrome refers to a common sensory-motor sleep disorder that affects sleep and quality of life, and it belongs to sleep-related movement disorder. Since the diagnosis of restless legs syndrome depends on the patient's subjective symptoms, it is challenging to differentiate restless legs syndrome from other neurological diseases such as polyneuropathy or radiculopathy. Therefore, systematic and detailed assessment of the clinical presentation of restless legs syndrome plays a pivotal role in diagnosis and follow-up. Here, we introduce the questionnaires for diagnosis and assessment of restless legs syndrome.
Keywords : Dyssomnias, Intrinsic, Restless legs syndrome, Sleep, Sleep disorders, Surveys and questionnaires
INTRODUCTION

As the name suggests, sleep-related movement disorder (SRMD) is a sleep disorder classified according to the pattern of motor symptoms. Restless legs syndrome (RLS) is an SRMD characterized by the urge to move the legs, affecting sleep and life quality. The diagnosis of RLS is based on the subjective symptoms of the patients. This diagnostic criterion itself is the main symptom of RLS. The diagnostic criteria of RLS by the International Restless Legs Syndrome Study Group consist of 5 items [1]: First, an urge to move the leg. Second, the symptom begins or worsens when immobile. Third, these symptoms are relieved with the movement of the legs. Forth, the symptom aggravates in the evening or night before sleep. Fifth, the symptom is not attributed to other medical disorders.

QUESTIONNAIRES FOR RLS

The questionnaires are essential for diagnosing and evaluating RLS. While other SRMDs are usually diagnosed with polysomnography or typical clinical symptom, the recognition and diagnosis of RLS is based on the patient’s subjective symptoms. Thus, the items of RLS questionnaires are focused on its cardinal symptoms or differential diagnoses of RLS. The questionnaires used for the diagnosis and evaluation are classified in Table 1.

Table 1 . Questionnaires for RLS.

CategoryQuestionnaireCharacteristicsValidationKorean Version
DiagnosisCambridge-Hopkins diagnostic questionnaireSelf-reported questionnaire used to diagnose RLSYesAvailable
Result: RLS, non-RLS, possible RLSSensitivity 87.2%
Specificity 94.4%
Hopkins telephone diagnostic interviewFor telephone interviews performed by a trained investigatorYesAvailable
Result: definite, probable, or possible RLS or as not having RLSSensitivity 97%
Specificity 92%
Restless Legs Syndrome diagnostic indexIncludes helpful items for RLS differentiation from the mimicsYesNot available
Sensitivity 93.0%
Specificity 98.9%
Pediatric emory Restless Legs Syndrome diagnostic questionnaireFor pediatric RLS diagnosisNot validatedNot available
SeverityInternational Restless Legs ScaleThe most widely used scale to evaluate severity of the RLSYesAvailable
Ten questions with a scale of 0 (no symptoms) to 4 (very severe) for each
Result: mild (0-10), moderate (11-20), severe (21-30), and very severe (31-40)
Quality of LifeThe Restless Legs Syndrome quality of life questionnaire,A tool to evaluate the quality of life in patientsYesAvailable
Eighteen items (total score=0-100), the lower score means the lower quality of life
Kohnen Restless Legs Syndrome-Quality of Life instrumentA self-completed questionnaire designed to evaluate the effects of RLS upon the quality of lifeYesNot available
12 questions on 6-point Likert scale in 5 groups
AugmentationAugmentation Severity Rating ScaleA tool to evaluate the augmentation of RLS,YesNot available
Three Questions: 0-24Sensitivity 82%
Specificity 92%
(with cut-off value at 5)

Others.

Visual Analog Scale, Clinical Global Impressions-Severity, Clinical Global Impressions-Improvement.



1. Cambridge-Hopkins diagnostic questionnaire

Cambridge-Hopkins diagnostic questionnaire is a self-reported questionnaire that can be used to diagnose RLS. It was developed in 2009 for epidemiologic investigation of RLS with additional questions to exclude RLS mimics, such as sleep-related leg cramp and postural leg discomfort [2]. The result of the questionnaire is classified into 3 groups: “RLS,” “non-RLS,” “possible RLS.” This questionnaire consists of 2 core features of RLS and following 11 questions to differentiate mimics. The reliability and validity of the Korean version was studied [3]. For diagnosis of RLS, the sensitivity and specificity of this questionnaire was 87.2% and 94.4%, respectively [2].

2. Hopkins telephone diagnostic interview

Hopkins telephone diagnostic interview is a questionnaire for the diagnosis of RLS. Another name of this questionnaire is Hening Telephone Diagnostic Interview. This questionnaire is not for self-report, but for telephone interviews since the original purpose of this questionnaire is a large-scale and telephone-based survey. A trained investigator checks and evaluates the patient's responses [4]. This questionnaire was translated into Korean, and the reliability and validity was studied [5]. The sensitivity and specificity of this questionnaire was 97% and 92%, while those of the Korean version were 89.7-97.7% and 93.9-97.7% [5].

3. Restless legs syndrome diagnostic index

This questionnaire was developed in 2009 and included helpful items for RLS differentiation from the mimics [6]. A total of 10 items consisting 5 essential diagnostic criteria established by the International RLS Study Group, 3 supportive criteria, and 2 RLS-associated features. The time period of assessment is past 7 days. In this questionnaire, the presence of periodic limb movements should be determined by actigraphy, or polysomnography with or without the suggested immobilization test. Therefore, the presence of periodic limb movement during sleep is optional for Restless Legs Syndrome Diagnostic Index. The sensitivity and specificity of this questionnaire was 93.0% and 98.9%, respectively. The positive and negative predictive value was 98.8% and 93.9%, respectively [6].

4. Pediatric emory restless legs syndrome diagnostic questionnaire

As a questionnaire for pediatric RLS diagnosis, it was initially developed for pediatric patients with kidney disease [7,8], however, it is not validated. The questionnaire consists of 2 separated parts, where 47 and 46 questions for 8-12- and 13-18-years old subjects, respectively. The 5 questions in the first part are for the screening, and if RLS is suspected, a questionnaire by age groups is conducted for detailed symptoms. The questions are completed by the parent (s) or the primary caregiver.

5. International restless legs scale

International Restless Legs Scale is the most widely used scale for the evaluation of the severity of the RLS. It has been used to evaluate children as well as adolescents [9-11]. This questionnaire evaluates the symptom severity of the patient’s RLS symptom for the past 2 weeks from the examination. The examiner asks the patient a total of 10 symptom severity questions, and the patient responds on a scale of 0 (no symptoms) to 4 (very severe), for a total score of 40. The higher score presents the worse symptom. This questionnaire has been validated in Korean and is open to the public [12]. The symptom severity is stratified as mild (0-10), moderate (11-20), severe (21-30), and very severe (31-40) [12].

6. The restless legs syndrome quality of life questionnaire

By the Johns Hopkins Hospital group, the Restless Legs Syndrome Quality of Life Questionnaire was developed as a tool to evaluate the quality of life in patients with RLS in emotional wellbeing, social life, and work life. It consists of a total of 18 items asking the patient’s quality of life for the past 4 weeks [13]. The total score ranges from 0 to 100, and the lower score implies the lower quality of life. Its Korean version is open to the public, and the reliability and validity was been studied [12].

7. Kohnen restless legs syndrome-quality of life instrument

Kohnen Restless Legs Syndrome-Quality of Life instrument is a self-completed questionnaire that is designed to evaluate the effects of RLS upon quality of life. It consists of 12 questions on 6-point Likert scale in 5 groups (symptoms of RLS, daily life and mood, pain and adverse effects of medications, behaviors for RLS, and overall quality of life) that ask the patient’s past one week [14].

8. Augmentation severity rating scale

As a tool to evaluate the augmentation of RLS, this questionnaire evaluates the augmentation symptoms over the past 7 days. It consists of three questions that identify the onset time of RLS symptoms, the incubation period, and the body part where the symptoms occur [15]. The score of each question ranges from 0 to 8 points. Compared to baseline, improvement during treatment was scored 0, while symptoms worsened from 1 to 8. The total score ranges from 0 (no augmentation) to 24 (very severe augmentation). The authors recommended a score of 5 as the cutoff value, with area under the curve value of 86.6% [15].

CONCLUSIONS

The approach to RLS begins with the identification of the symptoms, which are repetitive and typical sleep-related. The diagnostic approach includes not only detailed history taking but also the exclusion of RLS mimics. The clinical manifestations of SRMDs are often vague or atypical; therefore, a comprehensive approach including the clinical assessment, laboratory tests, and appropriate use of the questionnaires is needed.

We recommend the Cambridge-Hopkins diagnostic questionnaire with face-to-face interview for the real-world practice in sleep clinics; whereas Hopkins telephone diagnostic interview is appropriate to epidemiologic study. International Restless Legs Scale is a well-known tool for initial assessment and follow-up with the symptom severity function. However, no tool is omnipotent. It should be kept in mind that a combination or utilization of appropriate questionnaires is needed in RLS treatment or research.

References
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June 2022, 23 (1)