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OP.02 Restless legs, periodic limb movements and breathing problems
  1. A Williams

    Adrian Williams graduated from University College Hospital, London and, after training in General Medicine there, took up a lectureship at The Cardiothoracic Institute, Brompton Hospital, investigating the pulmonary changes associated with chronic liver disease. In 1975 Dr Williams was recruited to Harvard Medical School, Boston where his interest in sleep began with the investigation of Sudden Infant Death Syndrome (S.I.D.S.) and publication of a definitive study implicating obstructive sleep apnoea (OSA) as one cause of this syndrome.

    An invitation to the University of California at Los Angeles in 1977 to take up a post as Chest Physician allowed this early interest in OSA in infants to extend into adult patients with the very first reports of OSA causing hypertension, and of oximetry as a natural diagnostic tool. In 1985 Dr Williams became tenured Professor of Medicine at UCLA and co-director of the UCLA Sleep Laboratory.

    As Sleep Medicine gelled as a specialty, Dr Williams was one of the first to take the Board exams in 1989 to become an accredited polysomnographer and later member of the American Academy of Sleep Medicine.

    In 1994 Dr Williams returned to London where he established the Sleep Disorders Centre at St. Thomas' Hospital. He has published extensively on Sleep Disorders including more than 100 peer reviewed original scientific papers and more than 80 other published papers including chapters and books.

    Dr Williams is a Diplomat of the American Board of Sleep Medicine, a founding member of The British Sleep Foundation, the Sleep Medicine Section of the Royal Society of Medicine as well as the RLS UK Group, and was recently appointed Professor of Sleep Medicine, King's College London.


Sleep complaints are among the commonest in medical practice and can be simply categorised as:

▶disturbances of getting to sleep or staying asleep, or unrefreshing sleep, that is insomnia,

▶excessive daytime (or more properly wake-time) sleepiness, that is, hypersomnia; and

▶things that disturb the individual's sleep commonly said to be “things that go bump in the night”, or parasomnias.

Although insomnia and parasomnias are prevalent, the hypersomnias are considered more prominently because of the potential impact on the household and on society.

Conditions that will produce excessive wake-time sleepiness are also relatively few, specifically

▶insufficient sleep,

▶interrupted sleep such as might be caused by Restless Legs with Periodic Limb Movements or breathing problems, and

▶intrinsic sleepiness or narcolepsy and its equivalents.

Restless Legs Syndrome (RLS) common with a general prevalence of 3–4%. It is a waking complaint easily diagnosed by history (discomfort usually in the legs, occurring at rest, relieved by movement and confined mostly to the evening), associated 80% of the time with periodic limb movements in and disturbing sleep which might result in sleep complaints such as insomnia or hypersomnia. RLS may be secondary to renal failure and occurs in pregnancy and is promoted by anti-dopaminergis medicines such as the antihistamines. RLS is highly heritable and the genetic associations have recently been identified. The diagnosis of periodic limb movements in sleep usually requires polysomnography, although we have recently reported pulse rate variability on oximetry to be very useful. Treatment of both with a licensed dopa-agonist is common and second line treatment with codeine derivatives or clonazepam possible. Breathing problems are ubiquitous, the common form being snoring with obstructive sleep apnoea which affects some 5% of the population. The hallmark symptoms are snoring, witnessed apnoeas and excessive sleepiness with resulting sleep related vehicle accidents. Medical consequences include cardiovascular disease particularly hypertension, atrial fibrillation, stroke, along with neurocognitive abnormalities such as poor concentration, depression. Diagnosis is by history supplemented by a sleep study, often oximetry. When associated with symptoms such as sleepiness treatment with continuous positive airway pressure is usually advised along with weight loss in the obese. An alternative therapy would be an oral appliance for mandibular advancement. Both are successful mechanical treatments aimed at making the collapsing pharyngeal airway more patent. Surgery is rarely used.

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