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Interviewer: Do you suffer from restless legs or you think you might? Well, we're going to talk about that next on The Scope.

Dr. Chris Jones is a neurologist and a sleep and movement disorders expert. And today, we want to dive into the topic of restless leg syndrome. Dr. Jones, let's start off first of all, what is restless leg syndrome?

Dr. Jones: Nobody really knows.

Interviewer: Oh, that's going to make a tough conversation today.

Dr. Jones: But every person with restless legs knows how bad it can be and that it's real even though there are no physical signs of illness.

Interviewer: Okay. So you could do all sorts of physical examinations and you wouldn't find anything with somebody reporting restless legs at night?

Dr. Jones: Exactly. It's easy for your doctor to overlook this.

Interviewer: Okay. So what do most patients report as the symptoms that you would define as restless leg syndrome?

Dr. Jones: An urge to move the legs particularly in the evening, usually it's below the knees. It's very difficult to describe what this is because it's not an itch, it's not a pain, a numbness, tingling or cramp. All I can tell you is it's very frustrating, and it gets worst in the evening, just when they want to fall asleep. There's a wide range of severity of restless legs symptoms and, to an extent, it may just be part of the human experience to have a little of this.

Interviewer: Yeah. If somebody does have it, what would they do about it?

Dr. Jones: First of all, they would find the nearest sleep center that advertises experience with restless legs syndrome, because it is very difficult to treat and very easy for the doctor to make it worse.

Interviewer: Okay. Is it usually one expert, or is it kind of a multidisciplinary team, an interdisciplinary team I should say?

Dr. Jones: It gets interdisciplinary when the restless legs facilitates the development of a chronic insomnia that's quite apart from the restless legs but instead is a learned inability to fall asleep at night.

Interviewer: So what could start out as just a physical sort of manifestation of the symptoms could then turn into a mental manifestation affecting your sleep?

Dr. Jones: Exactly.

Interviewer: And is that when most people tend to seek help when it's affecting their sleep, or should they come to you sooner than that?

Dr. Jones: Yes, they should come as soon as it's making an impact in their life, because the older you get the harder it is to treat.

Interviewer: Oh, okay. So when you first started noticing those symptoms you would find somebody, such as yourself, that is an expert in this sort of thing. And then what would that appointment look like? How do you track down a condition that is not easy to track down?

Dr. Jones: You should expect and request a thorough history rather than emphasizing the physical exam, that's number one. Number two, you should expect them to ask for a positive family history of leg problems at night. And if you're a female and there's any reason that you might be iron deficient, you need to have your iron status measured because low iron, even slightly low makes restless legs a lot worse. Iron deficiency is a major exacerbator of restless legs.

So if you are donating blood in any fashion to your hospital blood bank, to the fetus that's in your womb, to heavy menstrual bleeding, then you are at much higher risk of restless legs. And you may need your iron level bumped up, whatever it means, so the treatments can be a little more effective.

And then the physician should ask you what medications, including over-the-counter medications you take, because over-the-counter antihistamines and many antidepressants actually make restless legs worse. And, of course, restless legs tends to lower moods, so people tend to get on antidepressants, so we have a vicious circle there.

Interviewer: Is there a cure for restless legs syndrome, or can you just manage it as best you can?

Dr. Jones: Not only is there no cure, but it's very easy for physicians to make restless legs worse. Prescribing a category of medication called dopamine agonist, it slowly makes the brain have even more restless legs, which requires higher doses which makes the legs worse. And this can take a long, long time to resolve after stopping the dopamine agonist. So rule number one is do not, with all due respect, do not let your primary care provider try to treat this. This really is a complicated, difficult sleep medicine problem, and you should go to a sleep center that has experience with restless legs.

Interviewer: And out of the patients that you see with restless legs syndrome, what percentage find some relief?

Dr. Jones: Well, I think most people find some relief early on in treatment. But again, the best medications we have gradually make the symptoms worse. And when those medications fail, the backup are opioid drugs, and those are potentially addicting. They can cause shallower breathing in sleep. And so, again, you have to be working with a sleep center that understands these things and will keep you safe.

Interviewer: And we still, I'm going to try you one more time. We don't know what causes this.

Dr. Jones: There's only been one genetic alteration that's strongly related to restless legs, but we do not have right now as a clear picture of all the genetics of restless legs and how that might inform a more fundamental cure for this.

Interviewer: And do we know if it's neurological or physical?

Dr. Jones: This is definitely neurological, and it's been linked in mice to a part of the brain where dopamine and leg movements are coordinated.

Interviewer: So after you see a sleep specialist and they are able to help you manage your restless legs, if you're still encountering insomnia, what should you do at that point?

Dr. Jones: At that point, you may well have a learned chronic insomnia, and cognitive behavioral therapy for insomnia is far and away the cheapest, the safest, and really the most effective over the long term. Unfortunately, there are not very many cognitive behavioral therapists for insomnia out there so you have to hunt around for a sleep center that has one.

updated: April 13, 2022
originally published: May 3, 2017

Dr. Miller: What is carpal tunnel syndrome? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope. Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Doug Hutchinson. He's a Professor of Orthopedic Surgery here at the University of Utah. Doug, what is carpal tunnel syndrome? What is that?

Dr. Hutchinson: Tom, carpal tunnel syndrome is a common diagnosis, and frankly, it's commonly missed diagnosed in the lay public. Carpal tunnel syndrome primarily is numbness in your fingers. Carpal tunnel syndrome is not primarily wrist pain. That's the first misconception I'd like to solve. So if you have wrist pain, it's a different story. If you primarily have numbness, sometimes it comes with pain, but mostly it's numbness.

Dr. Miller: What causes that numbness?

Dr. Hutchinson: What's happening is the median nerve, with is a main nerve that goes into your hand through your wrist, goes through a tight tunnel where all the tendons for your fingers are also located, and basically our assumption is that the space is so limited that if you use your tendons a lot, which we all do over the course of years, there will be a little bit of a buildup of tissue in there, and maybe a little bit of inflammation, though it's not much, but enough to make it so that the nerve feels claustrophobic, if you will, and pressured. Therefore, pressure on a nerve creates numbness where that nerve is going or coming from, and in this case that nerve is coming from those fingers.

So carpal tunnel syndrome is numbness in most of your fingers. Sometimes they feel as though it's all their fingers. Usually it's the thumb, index and third finger primarily. It usually comes at night because of the way we sleep on our wrists, and that is part of the treatment right there, is to change the way we sleep with our wrists bent. Dr. Miller: Now, are some people at greater risk of developing carpal tunnel than others?

Dr. Hutchinson: The common person who has carpal tunnel is 40s, 50s, 60s, and a little bit more often in a female than in a male. There's a lot of history of whether these come from repetitive activities and computers, and probably the bias and my answer is it doesn't. It's primarily genetic. It's primarily something that you were going to get anyhow even if you lived in rubber room your entire life and didn't do anything with your hands. It's just something that eventually can happen to some people because the nerve's in a tight spot in the wrist, and certain movements and certain positions will make that nerve a little bit unhappy over time and it will want a little bit of a bigger house.

Dr. Miller: Does it usually occur in the dominant hand or in both hands?

Dr. Hutchinson: Usually it's in the dominant hand first, but it usually occurs in both hands eventually.

Dr. Miller: Now, I heard that it's more common in pregnant women. Is that true?

Dr. Hutchinson: Pregnant women are very common, and anybody else who has major fluid changes, etc., and even can come in some women around their periods because of that type of change. Post-menopausal women are clearly the most common when it comes in. So yeah, there are changes that can occur. Some people will have something like a ganglion cyst that will actually put pressure in that area, and that can cause carpal tunnel syndrome. But usually it's idiopathic, and that means that there's no real cause for it, it just is happening to them.

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Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: My name is Vivian Lee. I'm the senior vice president for health sciences at the University of Utah, and today we're going to talk about the cold. This can mean dangerous medical problems for people that are exposed to the cold for long periods of time and even short periods of time. Joining me today is Dr. Amalia Cochran, assistant professor of medicine at the University of Utah's department of surgery. She's also an attending surgeon in the university hospital's burn unit and a leading expert on frostbite. Welcome to the show.

Dr. Amalia Cochran: Thank you very much.

Interviewer: We had an experience that made me have to go online and look up frostbite and I realized there wasn't as much information as I would hope. My daughter came back. She was fine after a whole day of skiing, and then she got into the bathtub and she started screaming because she said her feet were really painful and then the tips of her toes were dark red, almost bluish. At that point in time you can imagine I just panicked and tried to look online. I thought, here you are, the expert, let me ask you, what was happening with her? How could I have prevented that?

Dr. Amalia Cochran: It honestly sounds to me like she probably had a case of frost nip. When you're out skiing you've got a prolonged exposure, as does anyone who's outdoors during this weather. The fact that prior to that exposure to the warm water bath she hadn't really had any significant complaints and you hadn't really noticed anything different . . .

Interviewer: No, and is that because you have numbness so you don't even realize what's happening?

Dr. Amalia Cochran: Precisely. There is numbness with frost nip and you see very few changes in the skin if someone has a case of frost nip.

Interviewer: Frost nip is different from frost bite?

Dr. Amalia Cochran: Frost nip is the extremely mild form of frost bite. The way that we tend to differentiate between them is that frost bite involves tissue changes where the skin will actually blister up versus frost nip where there is some of that damage to the skin and the soft tissue but not to the level where it blisters.

Interviewer: Is it blistering because the tissue is actually freezing? What's actually happening there in the skin?

Dr. Amalia Cochran: There are really two different things that occur in the skin with a frost bite or a frost nip injury. One of those is the direct cold injury from the temperature. That impacts the tissues. They do freeze. Little crystals form in them. The other phenomenon that occurs in association with that is ischemia where there is poor blood flow to the cold effected areas. Initially, when the outdoor temperature drops or when we're exposed to lower temperatures somewhere in the neighborhood of 50 degrees fahrenheit, there's a cold induced phase of dilation that occurs.

Interviewer: Blood vessels expand. All of a sudden this blood rushes back in, and then what happens?

Dr. Amalia Cochran: Right. But then after that they constrict. They narrow back down and so the blood flow diminishes.

Interviewer: One of the things about this that worries me is that because of the numbness the kids don't even seem to know that it's happening, so how do we know that that damage is occurring?

Dr. Amalia Cochran: Cold checks are what are recommended in the Alpine mountaineering literature. I think they apply to those of us that are recreational outdoor in the winter as well. The concept of cold checks is that you get yourself to a relatively sheltered location, and I phrase it that way since this is from the Alpine mountaineering literature because there would be a relative shelter if you're skiing, you can say, hey, let's take a hot chocolate break after an hour and a half, and go in and check fingers, check toes.

Interviewer: We do them every half hour sometimes.

Dr. Amalia Cochran: Some days that's really appropriate. You can check everyone's fingers, check everyone's toes. If you notice that the fingertips or the toes are looking particularly pale, if they start getting a little bit woody in terms of how they feel, if they're not as soft as they normally feel, any of those sort of characteristics, that would make you concerned that you may have the early phases of a cold injury occurring.

Interviewer: How can we prevent it?

Dr. Amalia Cochran: Preventing it is a little bit tough if you have a love for winter sports. One of the things is that if you are someone who knows that you have circulatory challenges finding ways to keep your fingers and toes warm.

Interviewer: So even when it's not that cold our fingers and toes get kind of cold. We're particularly sensitive to developing it.

Dr. Amalia Cochran: Absolutely. Be mindful. I tell people I have something known as Raynaud's phenomenon, which means that when I get cold my blood vessels in my fingers and my toes clamp down. So I not only very easily get cold fingers and toes but I'm at higher risk for cold injury. So when I ski I have heaters in my boots and my mittens.

Interviewer: Those hand warmer, toe warmer type things?

Dr. Amalia Cochran: They're actually battery packs.

Interviewer: Oh, I didn't know they made that.

Dr. Amalia Cochran: Yeah, they're a little spendy but they're worth it. I whine a lot less and I have to take fewer breaks.

Interviewer: But short of that, you recommend the hand warmers and toe warmers?

Dr. Amalia Cochran: They're definitely helpful.

Interviewer: Dr. Cochran, you're not only an expert in frostbite but you're also a leader in burn injuries. I noticed we recently had an avalanche victim who had frostbite and was cared for in our burn unit. Maybe you can explain to us this relationship. Why are the frostbite patients and the burn patients all cared for by the same people?

Dr. Amalia Cochran: That surprises people and I know our avalanche victim was a little confused when I showed up and introduced myself and said I was a burn surgeon. She gave me this puzzled look. I said, "Trust me. This is going to be okay." There are a couple of reasons that frost bite victims end up in the care of the burn unit, and one of those is because the mechanism of injury, the way that the body works to generate the frostbite injury or the cold injury is actually very similar to what ends up happening if people have a burn injury. The underlying pathophysiology, to use the big fancy word for it, of what causes the tissue damage is very similar. The other part of it is that with more major cases of frostbite when people have blisters or if they don't get treatment in a timely fashion they can even have gangrene where the tissues die, we are experts in managing soft tissue loss and getting areas of soft tissue loss closed or covered because of the fact that that's what we do with burns. So it ends up making our frostbite practice a very logical extension of what we're already doing.

Interviewer: One of the things I read online when I was reading about this was that you're not supposed to rub the tissues. Why not?

Dr. Amalia Cochran: That's an old wives tale. Historically, people were advised to remove their gloves and their boots and rub the area with snow even to help with cold injury if they thought they were getting cold injury. The problem with doing that is you extend the damage in the soft tissues with the friction. So it's actually not helpful to do that

Interviewer: So the tissue is already pretty fragile and if you're rubbing it you're just making the damage worse.

Dr. Amalia Cochran: Right. So the recommendation for rewarming now is a 40 degree centigrade, which is around 100 degree fahrenheit, warm water bath.

Interviewer: Is 100 degrees about a normal temperature bath?

Dr. Amalia Cochran: It would be a warm bath.

Interviewer: A warm bath.

Dr. Amalia Cochran: Yes.

Interviewer: I was always told that you need to keep your central body really, really warm and if you kept your trunk warm your extremities would sort of take care of themselves. But you're sort of saying, no, those hand warmers are important too.

Dr. Amalia Cochran: Yes, it's both. You need to keep your core warm because of the risk of hypothermia, but when you're looking at a risk for frostbite you need to look at keeping your extremity areas, your fingers, your toes, even your nose is an area that's at risk for lower blood flow when you get really cold.

Interviewer: So those face warmers too.

Dr. Amalia Cochran: Yes.

Interviewer: Well, Dr. Amalia Cochran, thank you so much for being my guest today.

Dr. Amalia Cochran: Thank you, Dr. Lee.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope. University of Utah Health Sciences Radio.

Interviewer: First he had a heart attack, then he had a stroke.
We're here with Dr. Troy Madsen from the University of Utah Hospital and Emergency Medicine, and the question is, "Is it common after heart failure to then go on to have a stroke like in Randy Travis' case?"

Dr. Troy Madsen: Well, you know with Randy Travis it's hard to know exactly what happened there. Obviously they protect a lot of that health information so they're not going to release a lot of details. But from what I understand he had heart failure, then they did a procedure to try and help his heart out because he was in such serious condition, and then he had a stroke.
So in terms of what happened, he may have had a stroke somehow related to the heart failure or it may have been a complication of the surgery. And both of those are things that we do see, not on a very regular basis, but we do see here and there.

Interviewer: And what exactly is a stroke from a medical standpoint? What's going on there?

Dr. Troy Madsen: Another way to think of a stroke is as a brain attack. We think of heart attacks. We think of a blood clot causing decreased flow to the heart. Same thing happens to the brain, exactly the same thing. You have the arteries that feed the brain, that give the brain the oxygen it needs to work. If something gets lodged in there, either it breaks off from somewhere else in the body, or it just builds up in that artery that feeds the brain, then you have a stroke. You have decreased blood flow to the brain that causes problems.
So in terms of what we can take away from this for ourselves, you have to watch out for strokes in yourself and other people. So the big things to watch for are numbness or weakness generally on one side of the body, difficulty speaking, confusion, difficulty walking. Those are all signs of a stroke and if someone has these symptoms call 911 because if we get to you early enough, if we can get you in the ER and get you the treatment you need, we can oftentimes reverse those symptoms and spare the brain and make sure you're going to be back to normal or at least back to pretty good functioning.

Interviewer: I've heard just recently that literally every minute counts when it comes to a stroke as far as getting that patient seen and some sort of treatment started.

Dr. Troy Madsen: Yes, every minute counts in terms of trying to get people the help they need. There's actually just a study that just came out this last month. It looked exactly at that. It looked at how much time from the patient's symptoms until they got the treatment. They found the sooner they got that treatment the better off they were, the lower the risk of complications.

Announcer: Medical news and research University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to the Scope. Scot: Sometimes it's a tough decision to make. Should you go to the Emergency Room or is Urgent Care going to be good enough to take care of whatever it is you have? Here with Dr. Troy Madsen, Emergency Medical Physician at the University of Utah Hospital. The question today: Emergency Room or Urgent Care, how can one make that decision?
Dr. Troy Madsen: So one way to really think about the ER is if this is something that involves your ABC's. When we talk about ABC's we're talking about airway, breathing, and circulation. If you're having trouble breathing, if your airway is tight, like from asthma or allergy, if it's a circulation issue, meaning a heart issue, if you're having chest pain. Those are all things that absolutely I would go to the ER for. One thing we think about as well is strokes. That involves the circulation too, so if you're feeling numbness or weakness, any difficulty speaking, again that's a reason to go to the ER and in those situations I would call 911 to get an ambulance and get you there quickly. If it's something besides that you're probably okay in an Urgent Care. I think the biggest thing to think about between an Urgent Care and an ER, number one is an Urgent Care can take care of a lot of things, but if it requires a specialist, if it requires some kind of an emergent, more serious intervention, they really can't take care of it there. So when we're talking about things Urgent Cares can take care of, we're talking about sprains, cuts, if you need to just have something sewn up, if you need a tetnus booster, maybe if you've just got some mild abdominal pain, they can check some blood work on you. But if you need anything more, or if you need to have a CT scan done or need to have surgery, need to have any specialists involved, they're really not equipped to handle that. So that's kind of the biggest thing in my mind, I think about, in terms of saying, hey, you're probably okay to go to an Urgent Care, versus going to an ER. Announcer: We're your daily dose of science, conversation, medicine. This is the Scope. The University of Utah Health Sciences Radio.