Impact of aerobic physical exercise on Restless

ORIGINAL ARTICLE
Impact of aerobic physical exercise
on Restless Legs Syndrome
Impacto do exercício físico na Síndrome das Pernas Inquietas
Andrea Maculano Esteves1,2, Marco Túlio de Mello1,2, Ana Amélia Benedito-Silva3, Sérgio Tufik1
Abstract
Objective: Therapeutic approaches to the Restless Legs Syndrome
and Periodic Limb Movement sleep disorders are often implemented
concomitantly. The objective of this study was to assess the effect of
aerobic physical exercise on the symptoms of Restless Legs Syndrome.
Methods: The study included 11 patients who were diagnosed with
RLS and with on the severity scale established by the International
Restless Legs Syndrome Scale (IRLSS), which was translated and validated into Brazilian Portuguese. The patients completed 72 sessions
of aerobic exercises prescribed at Anaerobic Ventilatory Threshold Intensity on an ergometric cycle. Patients performed 3 50-minute sessions per week for approximately 6 months. Each patient completed
a severity scale questionnaire of Restless Legs Syndrome prior to the
first training session and after sessions 1, 36 and 72. Results: In response to aerobic physical exercise, the patients demonstrated a significant reduction in symptoms of Restless Legs Syndrome after 36
sessions (score: 24 to 15). This reduction was maintained even after 72
sessions (score: 7) of aerobic exercises (p<0.001). Conclusions: The
aerobic exercise proved to be efficient in diminishing Restless Legs
Syndrome symptoms.
Keywords: restless leg syndrome/therapy; exercice; sleep disorders;
exercise therapy.
Resumo
Objetivo: As abordagens terapêuticas para os distúrbios do sono, Síndrome das Pernas Inquietas e Movimentos Periódicos das Pernas, são
frequentemente implementadas concomitantemente. Assim, o objetivo deste estudo foi avaliar o efeito do exercício físico aeróbio sobre os
sintomas da Síndrome das Pernas Inquietas. Métodos: Foram estudados 11 pacientes diagnosticados com Síndrome das Pernas Inquietas
e com a escala de gravidade estabelecida pela International Restless Legs
Syndrome Study Group, que foi traduzida e validada para o português.
Os pacientes realizaram 3 sessões de 50 minutos por semana completando 72 sessões de exercício físico aeróbio prescrito na Intensidade do
Limiar Anaeróbio Ventilatório em um ciclo ergométrico. Foi preenchido um questionário de escala de gravidade de Síndrome das Pernas
Inquietas antes do início da primeira sessão de treino e depois das sessões 1, 36 e 72. Resultados: Em resposta ao exercício físico aeróbio,
os pacientes demonstraram uma redução significativa nos sintomas
da síndrome após 36 sessões (pontuação: 24 a 15). Essa redução foi
mantida mesmo após 72 sessões (pontuação: 7) de exercícios aeróbios
(p<0,001). Conclusão: Nossos resultados sugerem que o exercício
físico aeróbio é eficaz na diminuição dos sintomas da Síndrome das
Pernas Inquietas.
Palavras-chave: síndrome das pernas inquietas/terapia; exercício;
transtornos do sono; terapia por exercício.
Introduction
Therapeutic approaches to the Restless Legs Syndrome (RLS)
and Periodic Limb Movement (PLM) sleep disorders are often implemented concomitantly1,2.
The variability in the epidemiological data on RLS is
likely due to the non-standardized diagnosis of the disorder.
In 1995, the International Restless Legs Syndrome Study
Group (IRLSSG) published a standard for RLS diagnosis3.
The report defined RLS as a movement-relieved disorder,
citing the presence of discomfort in the legs that worsens
at night or when at rest as one of the diagnosis criteria. In
addition to differing diagnostic criteria, varying data collection strategies have been employed. These differences
may have also affected findings and lead to different types of
treatment. Depending on the severity of the sleep disorder
and its impact on patient health, several types of RLS/PLM
treatment have been described in the literature4.
Aukerman et al. investigated a program of combined exercises (aerobic and muscular strength). The 11 volunteers who
participated in aerobic and strength exercises 3 times per week
for 12 weeks showed a statistically significant reduction in RLS
symptoms, compared with those in the control group (12 volunteers), by week 6. The International Restless Legs Syndrome
Scale (IRLSS) was used to analyze RLS-related variables at the
start of the program and after 3, 6, 9 and 12 weeks5.
Study carried out at Centro de Estudos em Psicobiologia e Exercício da Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
1
Departamento de Psicobiologia da Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
2
Centro de Estudos em Psicobiologia e Exercício da Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
3
Escola de Artes, Ciências e Humanidades da Universidade de São Paulo (USP), São Paulo (SP), Brazil.
Corresponding author: Andrea Maculano Esteves – Departamento de Psicobiologia da Universidade Federal de São Paulo – Rua Professor Francisco de Castro, 93 – Vila
Clementino – CEP 04020-050 – São Paulo (SP), Brazil – E-mail: [email protected]
Received: February 16, 2011 – Accepted: June 27, 2011
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46
Exercise and RLS
De Mello et al. recorded polysomnography (PSG) data
from athletes with spinal cord injuries while performing
acute exercise (maximum effort test level) and chronic exercise (training for 44 days at ventilatory threshold 1). They
found that PLM during sleep diminished significantly. The
effect of aerobic physical exercise did not significantly differ
from L-dopa treatment (the standard pharmacological treatment for RLS/PLM)6-9.
In a recent study conducted by our group, both acute (1
session) and chronic aerobic physical exercise (72 sessions)
were effective in reducing the levels of PLM and inducing
beta-endorphin release10.
The analyses presented here are an extension of the results obtained by Esteves et al.10. The results were not published together
because the IRLSS questionnaire had not yet been validated.
Therefore, the objective of the current study was to assess the reduction of RLS symptoms in response to aerobic physical exercise.
Materials and methods
The study was approved by the Ethics Research Committee of
Universidade Federal de São Paulo (UNIFESP), CEP n.º 481/01.
Candidate patients were initially contacted based on diagnoses provided by the Sleep Institute. The 11 (6 women)
participants selected were those who presented complaints
of leg discomfort and whose diagnosis was performed by a
physician. They displayed no other signs of sleep disorder
or clinical disease and had never received pharmacological treatment for RLS/PLM. All of the subjects underwent
ECGs at rest and during stress and were tested for any pathology that would contraindicate physical exercise. Based
on the results, experimental sample was standardized.
A full-night PSG was performed to analyze the baseline
parameters of each participant’s sleep11.
Experimental procedure
The volunteers performed 50 minutes of aerobic training on
an ergometric cycle 3 times per week. Over the course of 6
months, each patient completed 72 sessions.
The morning after the 36th and 72nd sessions of aerobic physical
exercise, each volunteer filled out the IRLSS questionnaire12,13.
Questionnaire adapted from IRLSS
The IRLSS questionnaire used in the current study contained
ten questions evaluating RLS symptoms based on severity,
frequency and impact on quality of life12. This questionnaire, translated into Brazilian Portuguese, demonstrated
good reliability and validity13.
Physical training regimen
Aerobic physical exercise was determined based on the Maximum Effort Test (MET) and Anaerobic Ventilatory ThreshSleep Sci. 2011;4(2):�����
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old (the point at which respiratory response to work deviates
from linearity). Stretching was performed for 10 minutes
before and after sessions14.
Maximum Effort Test
The MET was used to measure aerobic capacity and to determine the volume and intensity of aerobic physical exercise for each individual. Tests were conducted at a controlled
temperature (24oC±2) on an ergometric cycle (Life Cycle
9.500 HR, USA). The respiratory and metabolic variables
were generated by measuring gaseous respiratory exchanges
with a metabolic system (COSMED PFT4, ITALY). After
an initial warm-up for 3 minutes at 33 watts, a progressive
load of 25-watts was added every 2 minutes. The test was
terminated when the volunteer reached exhaustion or the
maximal heart rate (HRmax=220 - age)14.
Statistical analysis
Repeated measures of ANOVA were used for statistical analysis followed by the Tukey test. Data are expressed as the
means and standard errors (SE). The significance level was
set at 5% (p≤0.05), and calculations were performed with
the aid of the software Statistica, version 7.
Results
Table 1 shows the physical characteristics and baseline parameters of the participants’ sleep.
Statistical analysis of the RLS data showed a significant decrease in questionnaire scores after sessions 36
Table 1. Physical characteristics and parameters of participants’ sleep (n=11)
Physical characteristics
Age (years)
50.2±3.78
Gender
6F/5M
Height (cm)
164±0.02
Body mass (kg)
66.45±3.33
BMI (kg/m2)
24.50±0.94
Sleep parameters - PSG
Total sleep time (hour)
5.08±0.60
Sleep efficiency (%)
65.03±7.77
Sleep latency (min)
39.4±9.50
REM sleep latency (min)
143.22±25.19
Wake time during TST (min)
109.22±25.23
Wake index per hour
10.45±2.06
Stage 1 (%)
5.21±1.78
Stage 2 (%)
72.21±3.42
Stage 3 (%)
1.90±0.63
Stage 4 (%)
5.17±2.07
REM (%)
15.50±2.82
Apnea index per hour
3.68±1.93
PLM index per hour
27.21±4.73
Values are expressed as mean and standard deviation.
BMI: body mass index; PSG: polysomnography; PLM: periodic limb
movement; REM: rapid eye movement; TST: total sleep time.
Esteves AM, Mello MT, Benedito-Silva AA, Tufik S
and 72, compared with baseline values (F(2, 20)=48.438;
p<0.001) (Figure 1).
Discussion
The results demonstrate that aerobic physical exercise, performed at Anaerobic Ventilatory Threshold intensity, was
efficacious in diminishing symptoms of RLS.
Symptoms of RLS were significantly reduced after 36
sessions (12 weeks) of training. Aerobic physical exercise
improved RLS symptoms in a time frame similar to that of
pharmacological treatment for RLS/PLM15,16.
The current findings corroborate the results presented in
Aukerman et al., in which a 12-week program of combined
aerobic and resistance exercise improved RLS scores5.
Data presented in Garcia-Borreguero et al. demonstrated
a correlation between IRLS scores and the objective parameters of PLM motor dysfunction, thus demonstrating a common pathophysiological mechanism17.
The present study found that aerobic exercise at Anaerobic Ventilatory Threshold intensity was efficient in diminishing RLS symptoms after 36 sessions (as scored by the
IRLSS). A previous study found a similar result for PLM
indexes after 72 sessions (evaluated by PSG)10.
The perceived improvement in symptoms of RLS before the reduction of PLM with the practice of physical
exercise may be associated with the different forms of
evaluation. Unlike the results obtained from the IRLSS
questionnaire, PSG data reflect a particular night and do
not exclude the possibility of the volunteer being exposed
to external factors that affect their night’s sleep. The reduction in perceived symptoms of RLS may directly or
indirectly suggest that aerobic physical exercise improved
the participants’ quality of life. However, the improvement of RLS symptoms likely preceded the diminished
PLM symptoms because the subjective evaluation is more
readily perceived by the patients.
Thus, the results of this study demonstrate that aerobic
physical exercise reduces symptoms of RLS. However, future studies are needed to determine the relationship and
pathophysiology of these disorders and why physical exercise is effective in the improvement of their symptoms.
Acknowledgments
This work was supported by grants from Fundação
de Amparo à Pesquisa do Estado de São Paulo (FAPESP),
number 03/06297-3, and Centros de Pesquisa, Inovação e
Difusão (CEPID), number 98/143033; the Psychopharmacological Research Support Foundation (AFIP); the
Psychobiology and Exercise Research Center (CEPE); and
research agencies National Counsel of Technological and
Scientific Development (CNPq) and Fundo de Auxílio aos
Docentes e Alunos (FADA).
30
25
IRLSS
20
*
15
10
*
5
0
Baseline
36ª
72ª
Physical Exercise Session
* Differs from baseline (ANOVA - Tukey).
Figure 1. International Restless Legs Syndrome Scale (IRLSS) questionnaire scores for the baseline period and after training sessions 36 and 72. Data
expressed as mean±standard errors.
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48
Exercise and RLS
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