Quality of life in restless legs syndrome: A systematic review of clinical trials and a critical review of instruments

Restless legs syndrome (RLS) is a neurological movement disorder characterized by sensory symptoms and motor disturbances. While the underlying cause remains unknown, it is suggested that 20–25% of people with RLS are affected seriously enough to require pharmacological treatment. Dopamine agonists (DAs) are the most common treatment and act by increasing the low levels of dopamine to which RLS is often attributed. A growing literature highlights the debilitating and distressing nature of this condition from the patient's perspective. While sleep problems are most commonly reported, the impact of RLS on quality of life (QOL) is wide ranging, affecting relationships with partners, sex life, family life, social life, leisure activities, friendships, everyday activities, concentration, travel, career/work, sleep, and health.

We conducted a systematic review of clinical trials in which DAs have been evaluated in terms of RLS-specific QOL, i.e. their impact on the QOL of people with RLS, and critically reviewed the development history and measurement properties of RLS-specific QOL instruments.

A systematic search using terms synonymous with RLS, DAs and QOL was conducted using Scopus software, which includes MEDLINE, PsycINFO, EMBASE, and CINAHL. Our search covered publications from 2000 (prior to which RLS-specific QOL measures did not exist) to August 2009. Trials were included in our review if they evaluated DAs for the treatment of adults with RLS and reported evaluation using an RLS-specific QOL measure. We also ran citation searches to identify papers reporting the development history and measurement properties of the identified RLS-specific QOL instruments.

Three measures of RLS-specific QOL have been developed in recent years and are reviewed here: the Restless Legs Syndrome Quality of Life (RLSQOL) questionnaire, the Restless Legs Syndrome Quality of Life Instrument (RLS-QLI), and the Quality of Life Restless Legs Syndrome (QOL-RLS) measure. Critical review indicates that each has limitations (particularly in terms of published developmental history and content validity). Eleven trials of DAs were identified that included assessment of RLS-specific QOL (nine using the RLSQOL and two using the QOL-RLS). In all studies, significant improvements in RLS-specific QOL were observed, although these were mostly short term (12 weeks) and large placebo effects were also noted.

In people with RLS, the use of DAs has been shown to improve RLS-specific QOL. Longer-term, large-scale studies may be needed to confirm these findings and demonstrate statistically significant improvements in RLS-specific QOL at lower doses. Further development of the RLS-specific QOL measures is needed to ensure that the full impact of RLS (and the full benefit of new treatments) on aspects of life identified as important to individuals is captured in future studies.

Are unilateral and bilateral patellar tendinopathy distinguished by differences in anthropometry, body composition, or muscle strength in elite female basketball players?

Background: Overuse injury to the patellar tendon (patellar tendinopathy) is a major reason for interrupted training and competition for elite athletes. In both sexes, the prevalence of unilateral and bilateral tendinopathy has been shown to differ. It has been proposed that bilateral pathology may have a different aetiology from unilateral pathology. Investigation of risk factors that may be unique to unilateral and bilateral patellar tendinopathy in female athletes may reveal insights into the aetiology of this condition.
Objectives: To examine whether anthropometry, body composition, or muscle strength distinguished elite female basketball players with unilateral or bilateral patellar tendinopathy.
Methods: Body composition, anthropometry, and muscle strength were compared in elite female basketball players with unilateral (n = 8), bilateral (n = 7), or no (n = 24) patellar tendinopathy. Body composition was analysed using a dual energy x ray absorptiometer. Anthropometric measures were assessed using standard techniques. Knee extensor strength was measured at 180°/s using an isokinetic dynamometer. z scores were calculated for the unilateral and bilateral groups (using the no tendinopathy group as controls). z scores were tested against zero.
Results: The tibia length to stature ratio was approximately 1.3 (1.3) SDs above zero in both the affected and non-affected legs in the unilateral group (p<0.05). The waist to hip ratio was 0.66 (0.78) SD above zero in the unilateral group (p<0.05). In the unilateral group, leg lean to total lean ratio was 0.42 (0.55) SD above zero (p<0.07), the trunk lean to total lean ratio was 0.63 (0.68) SD below zero (p<0.05), and leg fat relative to total fat was 0.47 (0.65) SD below zero (p<0.09). In the unilateral group, the leg with pathology was 0.78 (1.03) SD weaker during eccentric contractions (p<0.07).
Conclusions: Unilateral patellar tendinopathy has identifiable risk factors whereas bilateral patellar tendinopathy may not. This suggests that the aetiology of these conditions may be different. However, interpretation must respect the limitation of small subject numbers.

Influence of preexercise muscle glycogen content on transcrptional activity of metabolic and myogenic genes in well-trained humans

To determine whether preexercise muscle glycogen content influences the transcription of several early-response genes involved in the regulation of muscle growth, seven male strength-trained subjects performed one-legged cycling exercise to exhaustion to lower muscle glycogen levels (Low) in one leg compared with the leg with normal muscle glycogen (Norm) and then the following day completed a unilateral bout of resistance training (RT). Muscle biopsies from both legs were taken at rest, immediately after RT, and after 3 h of recovery. Resting glycogen content was higher in the control leg (Norm leg) than in the Low leg (435 ± 87 vs. 193 ± 29 mmol/kg dry wt; P < 0.01). RT decreased glycogen content in both legs (P < 0.05), but postexercise values remained significantly higher in the Norm than the Low leg (312 ± 129 vs. 102 ± 34 mmol/kg dry wt; P < 0.01). GLUT4 (3-fold; P < 0.01) and glycogenin mRNA abundance (2.5-fold; not significant) were elevated at rest in the Norm leg, but such differences were abolished after exercise. Preexercise mRNA abundance of atrogenes was also higher in the Norm compared with the Low leg [atrogin: 14-fold, P < 0.01; RING (really interesting novel gene) finger: 3-fold, P < 0.05] but decreased for atrogin in Norm following RT (P < 0.05). There were no differences in the mRNA abundance of myogenic regulatory factors and IGF-I in the Norm compared with the Low leg. Our results demonstrate that 1) low muscle glycogen content has variable effects on the basal transcription of select metabolic and myogenic genes at rest, and 2) any differences in basal transcription are completely abolished after a single bout of heavy resistance training. We conclude that commencing resistance exercise with low muscle glycogen does not enhance the activity of genes implicated in promoting hypertrophy.

Is growth inhibited in non-elite competitive female gymnasts?

PURPOSE
We asked: 1) is statural growth inhibited in non-elite competitive female gymnasts?; and 2) if growth is reduced, is the effect similar for legs and spine?

METHODS
Height(Ht), sitting height(StHt) and leg length(LL) were measured in gymnasts and controls at baseline and every 12 mths for 2 yrs. Pubertal status was assessed by Tanner stage. Gymnasts were from USGF levels 4–10 and trained 7.5 to 22.5 hrs/wk. Age-adjusted Z-scores were determined for gymnasts on the anthropometric measures and based on linear regression analyses of data for 45 controls.

RESULTS
At baseline, pre-(N=40), peri-(N=16) and post-pubertal(N=11) gymnasts were shorter than controls(-0.9 to -1.3 SD, p < 0.01). In pre- and peri-pubertal gymnasts, this was due to a reduction in StHt (-0.8 to -1.3 SD) and LL (-0.8 to -1.1 SD)(p < 0.01). In post-pubertal gymnasts, StHt (-0.8 SD) was reduced (p < 0.05). No differences were observed in z-score deficits between pubertal groups, nor were there any differences in StHt and LL deficits. During 12 mths follow-up in 39 gymnasts, deficits in Ht z-scores were reduced further in pre-pubertal gymnasts (-0.2 SD, p < 0.001) due to a greater increase in the deficit in LL (-0.3 SD, p < 0.001). While the magnitude of z-score deficits for peri-pubertal gymnasts remained unchanged, Ht z-scores improved in post-pubertal gymnasts(+0.2SD, p < 0.05) due primarily to an increase in StHt (+0.4 SD, p < 0.01). Similar results were found in 16 gymnasts followed for 2 yrs.

CONCLUSION
Although small size may relate to self-selection for gymnastics, some non-elite female gymnasts may experience attenuated growth during early puberty due mainly to reduced leg growth. The increased growth observed in post-pubertal gymnasts is consistent with catch-up growth associated with delayed maturation.

Banding and radio-tracking juvenile powerful owls in Melbourne, Victoria : trials and tribulations

The Powerful Owl (Ninox strenua) is Australia's largest owl. Considering their large size they are a very cryptic species, with limited sexual dimorphism, silent fight and a highly camouflaged presence amongst secluded canopy vegetation. These features enable Powerful Owl presence to often go unnoticed and even for the trained eye, extremely difficult to study. Our research has focused on monitoring the behaviour of individual Powerful Owls in urban Melbourne, Australia.
The leg banding of Powerful Owls is a somewhat contentious issue in Australia and here we report on the suitability of different types of legs bands placed on the tarsus of juvenile Powerful Owls. There has been some debate over the band size that should be used and the consequent effects bands may pose for the owls as they mature. We also investigate the usefulness of bands as a technique to identify Powerful Owls once they have dispersed from the natal territory.
Radio-tracking juvenile Powerful Owls was also undertaken during this study, primarily to determine individual behaviour from post fledging until dispersal. This is the first study in Australia to attempt radio-tracking juvenile Powerful Owls and the results from this research highlight behavioural characteristics, mortality rates post fledging and dispersal movements for the twelve months post fledging.
Overall we found that aluminium legs bands are a useful tool for individual identification of juvenile Powerful Owls post fledgling, however, their presence is somewhat difficult to determine on mature adults as the tarsus feathers tend to cover the band and make vision from the ground difficult. Aluminium leg bands are also useful as an identification tool for deceased birds. Leather leg bands are more suitable than aluminium bands when attaching radio-transmitters as these provide more flexibility and can be removed by the owl if they become irritating.
Radio-tracking juvenile Powerful Owls provided invaluable information relating to juvenile behaviour and movements, showing that juveniles actually remain in territories adjacent to their natal territory for the twelve months post fledging. This information is vital for the successful conservation of this species, particularly in relation to habitat conservation and home-range modelling.

Gender differences in muscle inflammation after eccentric exercise

Unaccustomed exercise is followed by delayed-onset muscle soreness and morphological changes in skeletal muscle. Animal studies have demonstrated that women have an attenuated response to muscle damage. We studied the effect of eccentric exercise in untrained male (n = 8) and female (n = 8) subjects using a unilateral exercise design [exercise (Ex) and control (Con) legs]. Plasma granulocyte counts [before (Pre) and 48 h after exercise (+48h)] and creatine kinase activity [Pre, 24 h after exercise (+24h), +48h, and 6 days after exercise (+6d)] were determined before (Pre) and after (+24h, +48h, +6d) exercise, with biopsies taken from the vastus lateralis of each leg at +48h for determination of muscle damage and/or inflammation. Plasma granulocyte counts increased for men and decreased for women at +48h (P < 0.05), and creatine kinase activity increased for both genders at +48h and +6d (P < 0.01). There were significantly greater areas of both focal (P < 0.001) and extensive (P < 0.01) damage in the Ex vs. Con leg for both genders, which was assessed by using toluidine blue staining. The number of leukocyte common antigen-positive cells/mm2 tissue increased with exercise (P < 0.05), and men tended to show more in their Ex vs. Con leg compared with women (P = 0.052). Men had a greater total (Ex and Con legs) number of bcl-2-positive cells/mm2 tissue vs. women (P < 0.05). Atrophic fibers with homogeneous bcl-2-positive staining were seen only in men (n = 3). We conclude that muscle damage is similar between genders, yet the inflammatory response is attenuated in women vs. men. Finally, exercise may stimulate the expression of proteins involved in apoptosis in skeletal muscle.

Reliability of surface EMG measurements of the quadriceps during maximal isometric contractions following water immersion

Background: The influence of water immersion on neuromuscular function is of importance to a number of disciplines; however, the reliability of surface electromyography (SEMG) following water immersion is not known. This study examined the reliability of SEMG amplitude during maximal voluntary isometric contractions (MVICs) of the vastus lateralis following water immersion.

Methods: Using a Biodex isokinetic dynamometer and in a randomized order, 12 healthy male subjects performed four MVICs at 60° knee flexion on both the dominant and nondominant kicking legs, and the SEMG was recorded. Each subject's dominant and nondominant kicking leg was then randomly assigned to have SEMG electrodes removed or covered during 15 min of water immersion (20°C–25°C). Following water immersion, subjects performed a further four MVICs.

Results: Intraclass correlation coefficient (ICC) and the relative standard error of measurement (%SEM) of SEMG amplitude showed moderate to high trial-to-trial reliability when electrodes were covered (0.93% and 2.79%) and removed (0.95% and 2.10%, respectively).

Conclusions: The results of the this study indicate that SEMG amplitude of the vastus lateralis may be accurately determined during maximal voluntary contractions following water immersion if electrodes are either removed or covered with water-resistive tape during the immersion.

Using a knowledge management evaluation framework for improving an ERP system - a Hong Kong construction industry case study

Organisations need to rely on leadership, information support and human capital in order to ensure a knowledge advantage over their competitors. Knowledge management (KM) provides organisations with sustainable competitive advantage, because it becomes extremely difficult for an organisation to cut expenditure and increase revenue by simply reengineering its business model. Project delivery and success has been traditionally viewed and measured as management of a three-legged stool, with the legs defined as cost, schedule and quality. However, KM can be linked to success by organisations becoming more effective as well as being more efficient.

This paper uses a KM framework, the Knowledge Advantage (K-Adv), developed initially for use by construction organisations. It assesses the impact of leadership and its supporting information communication technology infrastructure on the ability of people (by effectively creating, sharing, disseminating and using knowledge) to facilitate sustainable competitive advantage.

A case study that is presented is based upon the experience of a leading construction company using an Enterprise Resources Planning (ERP) system to demonstrate the effectiveness of KM from a cost management business unit perspective. Results are evaluated using a capability maturity model (CMM) - that forms the core of the K-Adv tool - to help improve processes that meet the needs of the organisation operating in a highly dynamic business environment. The case study is part of a broader doctoral research project that uses action learning to facilitate and measure ERP improvement.

Restless leg syndrome caused by olanzapine: a case series

Restless leg syndrome (RLS) is a common disorder associated with significant distress. We report three cases of drug induced RLS caused by olanzapine. In each case, RLS commenced after initiation of treatment with olanzapine and resolved after ceasing olanzapine. All three patients were subsequently treated with other atypical antipsychotics, risperidone, quetiapine or aripiprazole, without re-emergence of RLS. RLS is associated with central dopaminergic dysfunction. Dopamine agonists and l-dopa reduce the symptoms of RLS, and some agents that block the dopaminergic system aggravate RLS. Greater awareness of potential causes of RLS, and its differentiation from akathisia and illness related agitation might help in reducing the distress associated with it and improving patient compliance.

Risk factors for Mycobacterium ulcerans infection, southeastern Australia

Buruli/Bairnsdale ulcer (BU) is a severe skin and soft tissue disease caused by Mycobacterium ulcerans. To better understand how BU is acquired, we conducted a case-control study during a sustained outbreak in temperate southeastern Australia. We recruited 49 adult patients with BU and 609 control participants from a newly recognized BU-endemic area in southeastern Australia. Participants were asked about their lifestyle and insect exposure. Odds ratios were calculated by using logistic regression and were adjusted for age and location of residence. Odds of having BU were at least halved for those who frequently used insect repellent, wore long trousers outdoors, and immediately washed minor skin wounds; odds were at least doubled for those who received mosquito bites on the lower legs or lower arms. This study provides new circumstantial evidence that implicates mosquitoes in the transmission of M. ulcerans in southeastern Australia.

Observation-switching linear dynamic systems for tracking humans through unexpected partial occlusions by scene objects

This paper focuses on the problem of tracking people through occlusions by scene objects. Rather than relying on models of the scene to predict when occlusions will occur as other researchers have done, this paper proposes a linear dynamic system that switches between two alternatives of the position measurement in order to handle occlusions as they occur. The filter automatically switches between a foot-based measure of position (assuming z = Q) to a head-based position measure (given the person's height) when an occlusion of the person's lower body occurs. No knowledge of the scene or its occluding objects is used. Unlike similar research [2, 14], the approach does not assume a fixed height for people and so is able to track humans through occlusions even when they change height during the occlusion. The approach is evaluated on three furnished scenes containing tables, chairs, desks and partitions. Occlusions range from occlusions of legs, occlusions whilst being seated and near-total occlusions where only the person's head is visible. Results show that the approach provides a significant reduction in false-positive tracks in a multi-camera environment, and more than halves the number of lost tracks in single monocular camera views.

Reduction in corticospinal inhibition in the trained and untrained limb following unilateral leg strength training

This study used transcranial magnetic stimulation to measure the corticospinal responses following 8 weeks of unilateral leg strength training. Eighteen healthy, non-strength trained participants (14 male, 4 female; 18–35 years of age) were matched for age, gender, and pre-training strength; and assigned to a training or control group. The trained group participated in unilateral horizontal leg press strength training, progressively overloaded and wave periodised, thrice per week for 8 weeks. Testing occurred prior to the intervention, at the end of 4 weeks and at the completion of training at 8 weeks. Participants were tested in both legs for one repetition maximum strength, muscle thickness, maximal electromyography (EMG) activity, and corticospinal excitability and inhibition. No changes were observed in muscle thickness in either leg. The trained leg showed an increase in strength of 21.2% (P = 0.001) and 29.0% (P = 0.007, compared to pre-testing) whilst the untrained contralateral leg showed 17.4% (P = 0.01) and 20.4% (P = 0.004, compared to pre-testing) increases in strength at 4 and 8 weeks, respectively. EMG and corticospinal excitability did not change; however, corticospinal inhibition was significantly reduced by 17.7 ms (P = 0.003) and 17.3 ms (P = 0.001) at 4 and 8 weeks, respectively, in the trained leg, and 25.1 ms (P = 0.001) and 20.8 ms (P = 0.001) at 4 and 8 weeks, respectively, in the contralateral untrained leg. This data support the theory of corticospinal adaptations underpinning cross-education gains in the lower limbs following unilateral strength training.