Dr. Kamran (00:00)

For many years it’s been treated as a neurological condition with medications which are, lot of them are anti-seizure medication and only when things don’t work as well the dosage is increased and you’re pretty much on it for lifetime.

 

thank you very much, Aimee for joining us on this podcast, as always. So I’m a vascular general surgeon. I deal with a lot of vein disease. So you might say, why am I so interested in restless leg

 

been doing this for over 20 years. And I…

 

found out that over time a lot of my patients who quote unquote had restless leg syndrome were getting better or getting cured after we treated their venous insufficiency. I still remember one of my patients, this is almost 10 years ago, said, Dr. Kamran, my restless leg is gone. I’m so thankful. I’m actually off my medication and we’ll talk about this a little later.

 

So having found that out, and you and I did some literature search, so when we looked at the Cleveland Clinic, National Institute of Health, and we looked at Johns Hopkins, when you go online, Google restless leg syndrome, is very little mention of a vascular component that should be in list of your differential diagnosis. So that was a red flag right there. when we think about restless leg syndrome, why don’t we think about that? we, know, the physicians have gotten more and more specialized and we got them busier and busier. So you go to your primary care physician and you say, you know, constantly moving my leg

 

can’t sleep at night because of restless leg. And the doctor says, okay, let me send you to a specialist. So now, without getting too much more history, the patient is sent to a neurologist. And the neurologist, it’s been a long time since they started looking at the venous insufficiency and arterial disease.

 

You end up automatically assuming that this is all neurological and try to treat them. ⁓ So core purpose of this podcast and the next few podcasts is going to be ⁓ if you have restless leg syndrome, let’s look at it very critically and see is this a neurological condition? Is it neuropathy or could it be vascular? And could it be a combination of all?

 

because usually most things are a combination. For example, just as you mentioned earlier, 7 to 10 % of the population have restless leg syndrome. Now, we also know that, it depends what you read, 35 to 40 % of the population have venous insufficiency. So if you walk into my office and you say that restless leg syndrome, the odds are if I thought about venous insufficiency, I have a better chance of making the right diagnosis than just calling it restless leg. 

 

So…We’ve got to start thinking very critically, especially patients who have treated for a long, long time. We’ve got to go back and start revisiting our diagnosis. Is this indeed what they have?

 

So I hope that at the end of this conversation today, if you could only raise awareness about Restless leg syndrome and what does it mean and what does a diagnosis mean, then I think we certainly have achieved our goal, which is to help the public as much as we can through this podcast.

 

The essential diagnostic criteria for restless leg syndrome from the International Restless Leg Syndrome Study is that you require all four symptoms. Number one, urge to move the legs. Symptoms begin or worsen during rest. Sitting, lying down, or long travel makes it worse. You should have relief with movement, walking, stretching, or leg motion, at least temporarily. It also says

 

a predominance of it happening at night and evenings. Now, if you look at the symptoms of venous insufficiency, pretty much all the four. Usually they get a lot worse at night when you’re on a plane ride because of negative, pressure in the airplanes. A lot of people complain about leg swelling in the Patients

 

say that their cramps or restless leg is a lot worse at night. And when they move, it gets better because when you move, your calf muscles move, which is a pump for your venous insufficiency, it pumps the blood out and you feel really, I would argue that those four symptoms, which is supposed to meet the main criteria for restless leg syndrome, are also identical to what you see with venous insufficiency. So.

 

You say, okay, Dr. Kamran great. So how are you gonna make a diagnosis? Well, I would start off by, first of all, asking those questions a little bit more critically. In other words, let’s dig hard. Do you also get some swelling in your leg? Because restless leg doesn’t go swelling. Do you find that when you wear compression stocking, you don’t have as much restless leg? So that should start making you.

 

wonder, you know, is it venous insufficiency or restless leg? so is just certainly a good start, but then every diagnosis, whether you’re a neurologist or if you are an internist, you take a history, you have to a physical exam. Look at the patient’s leg. Patients can look at their own leg. If you have restless leg, look at your own leg. If your ankles are all swollen or you’ve got some

 

veins pooching out or you’ve got hyperpigmentation which is dark discoloration around the or you have ankle flares which is like a spider’s around the inside of your ankle or if for example you have venous dermatitis where you have a rash, have itching, maybe you start thinking about even if you

 

have pure restless leg, you also have a component of venous insufficiency. So with that in mind, I think the next stage usually if you went to a neurologist is that they try to do a sleep study and they try to measure your iron level because it’s been shown that serum ferritin level should than 50 to And if you obviously

 

Less than that, one should have restless leg syndrome, well, at least confirms the diagnosis. And also, even if you have got a normal hemoglobin. Again, I don’t mean to get too clinical. I’m hoping that my colleagues, both in neurology, internal medicine, primary care, physician, surgeons are listening to this. I think we all have a lot to learn.

 

Don’t just go with one diagnosis. Always remember, human body is very complicated. Always think about other criteria. So forward in our next episodes.

 

I would like to invite my family nurse practitioner who was in clinical medicine for a long time and neurologist for long time to be a guest. So now that she’s been working with me, taking care of venous insufficiency and vascular condition, been in both camps.

 

I’m hoping all the people out there, and I know there’s plenty who are throughout the world, who are suffering from restless leg syndrome, hopefully help is on the way, hopefully through education, which is what this ⁓ podcast is about. We can educate not only you, but also your physicians who are treating you to look at more critically in your diagnosis and your treatment.

 

and make sure we don’t stay in that bubble. We reach out across the aisle and look at other specialties and see if they agree with our diagnosis or they can contribute in making the diagnosis.

 

biggest problem I think in life, if you ask me now, having been in medicine for kind of almost over 40 it is not the doctor or the treatment, it’s the diagnosis. If you don’t make a right diagnosis, doesn’t matter how great your treatment is, you’re not curing the patient.

 

start taking an adequate history, do a proper physical exam, reach across the aisle, get opinion from other physicians as well. And if you feel it could be neurological, obviously get them involved. If you are a neurologist and you think it could be vascular, get them involved. And at the end, when we all do what we’re supposed to do and do it the best that we can, our patients will not suffer.

 

Aimee Bowen (09:01)

think the interdisciplinary approach bringing as many brains into solving these puzzle pieces, the whole picture together something that patients really appreciate. For me on the patient standpoint,

 

something I think is such an interesting piece of the equation in medical discussions that are taking place now, especially in podcasts and things like that,

 

it’s best to work with your physician to uncover these things instead of trying to use Dr. Google to diagnose. But there is real value in patients

 

taking an accurate ⁓ record of your symptoms, tracking them,

 

That’s been the game changer in those conversations when they’re connecting with their physicians. So with restless leg syndrome in particular, if more patients know the possibility of restless leg syndrome symptoms also being a similar constellation of symptoms for vein disease, that does

 

arm them with a little bit more knowledge to be able to just enter that as a talking point into their next discussion with their physician too.

 

Dr. Kamran (10:05)

Absolutely. And you know, there’s one thing we didn’t talk about, and now we’ve talked about anybody who’s listened to our other podcasts, and I strongly urge our audience to listen to our podcast because we’ve talked about venous disease for a long time. It is now…

 

pretty much a very easy way of treating it. You don’t have to go to the hospital, there’s no IV, there’s no cutting, no stitching, there’s ⁓ no pain afterwards. So it’s so much easier to treat it and much less riskier. So why would you withhold a treatment which is so easy on the patient that you can do in an office setting if indeed that’s going to help the patient? What about the cost?

 

when medication is expensive and if you’re on medicine for the rest of your life, just do the math. How much is it going to cost you for a medicine that you didn’t even probably need or it wasn’t even

 

all are on some kind of medication, and now you’re adding some seizure medication, and you’re adding more and more.

 

So these drugs are not exactly without risk. and then as we get older our kidney and liver doesn’t work quite as well, so you can build up a toxic level of the medication, your body.

 

why when something could have been by making the right diagnosis. often tell my patients, I when you withhold information from your doctor,

 

really hurting yourself because your doctor is only as smart as what you tell So don’t tell him everything which is wrong with you or as much of it as you can and describe it, it’s not just I have a pain in the leg. What kind of pain do you have? Is it the stabbing? Is it cramping? Is it at night? Is it that day? During the daytime? Because all those things allows you to make a diagnosis

 

So when you say, I’ve got leg pain, the doctor automatically thinking about, could it be musculoskeletal, could it be venous, could it be arterial? And the next thing you say, well, it only hurts when I walk, so now he’s taking more arterial. then, so the more you tell him,

 

And sometimes, like a compression is stocking, it’s both diagnostic and therapeutic. So if you think you’ve got venous insufficiency or you think your restless leg is caused by venous insufficiency, keep a compression is stocking. That does nothing neurological condition. But if you put it on and your restless leg gets better, you better start thinking, could this be venous related?

 

Now, let’s say you’ve got restless leg, you’ve also got arthritis, you’ve also got vein disease. You put the compression stocking, doc, all my pain is gone. that you’ve already made diagnosis because that’s the only thing compression stocking is doing. it is a more convoluted, and you know, we love to do test, test, test. Let’s do a CAT scan, and they’re supposed to tell us everything wrong. The majority of diagnosis are made on history and then a good physical exam and then test. For example, if you’re into neurology and you say you’ve got restless leg syndrome,

 

They’re assuming everything else has been checked, which is fine. So you don’t even hopefully need to go there if somebody looked at your leg and said, man, you.

 

you’ve got every indication there have been insufficiency before you start doing a sleep study and measuring your ferritin level, let’s look at these two other conditions, see what’s going on.

 

I said, this almost sounds like a monologue because I’m talking, I’m looking at it through the angle of a vascular surgeon. Going forward for our next few episodes, we’re going to have neurologists and other experts seeing it from their angle. And at the end, you, the consumer, is going to be the sole beneficiary of it because you’re going to hear all these opinions and you come up with your own conclusion because still medicine is more.

 

Art and Science.

 

Aimee Bowen (13:44)

Well Dr. Kamran, before we conclude today’s episode, you know, for patients, if they are currently being treated for restless leg syndrome or if they suspect they have restless leg syndrome, what should they ask their physicians if treatments haven’t helped so far or if just general symptom relief suggestions haven’t helped so far?

 

Dr. Kamran (14:03)

That’s a very good question. I think the most important thing is be very honest with your doctor. Don’t worry about their feelings, trust me. They will appreciate that. Say, Doc, ⁓ Could it be another diagnosis? Could this be vascular? Don’t mean to be funny, but I’m going to be a little funny here. You could say that I…

 

Just listen to this podcast by Dr. Kamran, and he says, vascular, know, venous insufficiency could be a cause of it. Doc, do I have venous insufficiency? Do you think you could send me to somebody who understands venous insufficiency, can run tests to show, for example, an ultrasound that I have venous insufficiency? So

 

I honestly, I’ll always encourage my patients to get another opinion because unless we are perfect and there’s no searching as perfection, we could not, you know, it’s quite possible that we are wrong about our diagnosis and that’s why you always got to encourage the patients to question you and be honest with you. Don’t tell your doctor, hey, no, no, this is working great for me. It’s not about his feelings, it’s about your health.

 

They will appreciate the fact that you’re questioning that is the treatment working or not. Getting a little bit better is not the answer. And always ask the doctor, am I going to be on this medicine for the rest of my life? What are the potential dangers of this medicine that I’m on? What is the potential risk of interaction with all these other medications that I’m on?

 

So, ask those critical questions and get yourself educated. Have a patient advocate. If you have a friend who’s a nurse, a doctor, a PA, ⁓ Google. Educate yourself because your health depends on it.