Contributions Sommeil Neurophysiologie & autres ..

Spontaneous Reporting vs. Real Prevalence : Under-recognition of Restless Legs Symptoms in 239,876 Routine Health Check-ups

Didier Cugy — 2026-05-15T08:04:38Z

Context
Restless Legs Syndrome (RLS) is a common neurological condition impairing sleep and quality of life. In primary care, prevalence estimates often rely on standardized questionnaires, yet less is known about symptom identification during routine consultations without systematic screening.
Objectives
To assess the frequency of spontaneously reported restless legs symptoms during routine health check-ups in a primary care setting, and to explore associated demographic, sleep-related, biological and clinical factors.
Methods
We conducted a retrospective observational study based on 239,876 adult health check-ups performed between 2004 and 2022 in a French primary care prevention centre. Restless legs symptoms were identified solely through spontaneous patient complaints recorded during the clinical interview and coded as present or absent. Analyses were stratified by age and sex. Associations were examined with poor sleep complaints, Epworth Sleepiness Scale (ESS ; categories <7, 7–13, ≥14), haemoglobin level and cervical pain. A multivariable logistic regression model included sex, age, poor sleep, haemoglobin, cervical pain and ESS category.
Results
Out of 239,876 exams, only 581 patients reported symptoms (frequency : 0.24%). The "typical" case was a woman (68% of cases, ratio 2.1:1) between 35 and 65 years old.
Key findings : Risk factors : Female sex (OR=3.0), aging (OR=2.0), and poor sleep (OR=1.6). The "Spine" connection : We found a clear cranio-caudal gradient. The risk was high for cervical pain (OR=2.1) but disappeared for low back pain (OR=1.3, NS). Sleepiness : Higher ESS scores were directly linked to more complaints.
Discussion
The observed frequency (0.24%) is markedly lower than the 2–10% usually reported in the literature, indicating substantial under-recognition of RLS in routine primary care when relying solely on spontaneous symptom reporting. Despite this, associated factors align with known clinical characteristics of RLS. Improved recognition is clinically relevant, particularly in light of emerging evidence suggesting a possible association between RLS and increased cardiovascular risk.
Conclusion
Restless legs symptoms are rarely identified during routine primary care assessments based on spontaneous complaints alone. Simple and systematic screening in patients presenting with sleep complaints or chronic pain may improve earlier recognition of RLS and facilitate appropriate management of associated comorbidities.

Can Simple Postural Assessment Help Identify Obstructive Sleep Apnea in Primary Care ?

Didier Cugy — 2026-05-15T08:04:36Z

Context
Obstructive sleep apnea (OSA) is frequent but remains underdiagnosed in primary care.
Screening strategies mainly rely on questionnaires and anthropometric measurements, while clinical observation is often underused.
General practitioners routinely observe patients' posture during consultation. Clinical experience suggests that patients with suspected OSA frequently present common postural characteristics, such as forward head posture (FHP) and shoulder curl, which may reflect chronic upper airway constraints and altered autonomic regulation.
These postural features are easily observable and reproducible, and could represent an additional clinical approach to improve early identification of patients at risk for OSA in routine primary care practice.
Methods
A retrospective study included 523 patients referred for suspected sleep disorders. Postural parameters (FHP assessed by inion–vertical distance, shoulder curl, shoulder antepulsion) were measured in standing position and correlated with polysomnographic and autonomic parameters using regression analysis and ANOVA.
Originality
This study explores postural assessment as a novel, equipment-free clinical screening approach tailored for primary care. While posture is routinely observed by clinicians, it has rarely been formally evaluated in relation to sleep apnea severity.
The originality lies in the use of simple, standardized postural measurements and their correlation with both respiratory and autonomic markers in a large clinical cohort.
Lessons learned and future implications
Simple postural assessment can provide additional clinical clues in patients with suspected obstructive sleep apnea in primary care.
FHP and shoulder curl appear to be relevant markers, while not all postural parameters are clinically useful.
Integrating postural observation into routine consultation may help improve early identification, guide referral for sleep investigations, and support non-CPAP management strategies, including postural and rehabilitative approaches.
Future research should focus on prospective validation and on integrating postural assessment into simplified clinical screening tools for general practice.
Discussion
FHP and shoulder curl are associated with OSA severity (p < 0.01) and autonomic parameters, suggesting that posture reflects a clinically relevant respiratory phenotype.
Not all postural measures are informative, underlining the importance of targeted clinical observation.
Conclusion
Simple postural assessment, especially forward head posture and shoulder curl, may support earlier identification of obstructive sleep apnea in primary care and encourage integrated, clinically grounded management strategies for patients.

Algorithm-based validation of sleep apnea treatment : lessons from primary care after one year

Didier Cugy — 2026-05-15T08:04:34Z

Context
Algorithm-based validation of medical prescriptions is increasingly used to standardise care. Since June 2024 in France, prescriptions for continuous positive airway pressure (CPAP) therapy for sleep apnea must be validated through a national algorithm based on French National Authority for Health (HAS) criteria. While this system aims to improve efficiency and equity, its impact on complex, real- life primary care situations—where clinical judgement is essential—remains poorly documented.
Methods
We conducted a practice-based retrospective review of electronically submitted CPAP prescriptions between June 2024 and September 2025. Data from 127 submissions were analysed to document algorithm-based decisions, administrative outcomes at the Commission de Recours Amiable (CRA), and the role of the general practitioner (GP) in the appeal process.
Originality
This contribution provides a rare real-world primary care perspective on the practical limits of algorithm-based medical validation. It explores how digital decision-support systems may outweigh general practitioners' clinical assessment of treatment benefit. Rather than a theoretical evaluation of artificial intelligence, this reflection highlights how administrative frameworks can shape the balance between algorithms and professional judgement in everyday practice.
Lessons learned and future implications
The analysis showed that 30% of prescriptions were rejected by the validation system. Rejections mainly concerned patients whose clinical profiles were consistent with international recommendations but did not meet national threshold-based criteria. Several patients had an apnea–hypopnea index below 15/h but significant respiratory events during REM sleep or in the supine position. The appeal process relied exclusively on the initial algorithm-based opinion, without medical reassessment, and did not integrate the GP's documentation of clinical improvement. Older patients with multimorbidity or cognitive impairment were particularly affected.
Discussion
This reflection highlights tensions between algorithm-driven decision-making and the realities of primary care. Reliance on global numerical thresholds may overlook clinically meaningful situations, while the absence of a medical reassessment pathway during appeals undermines continuity of care and professional responsibility.
Conclusion
Algorithm-based validation should support, not replace, clinical judgement. Digital decision-support systems need to evolve to integrate contextual clinical information and observed treatment benefit, ensuring that standardisation does not limit patient- centred care.

Quelle place pour les algoritmes dans la validation des prescriptions médicales en rapport avec les évènements respiratoires du sommeil ?

Didier Cugy — 2025-03-28T09:38:00Z

Objectif : La convention médicale signée entre les syndicats médicaux et l'assurance maladie entrée en vigueur le 21 Juin 2024 introduit, dans son article Article 61-8 "Pertinence des traitements pour apnée du sommeil », la dématérialisation des prescriptions "selon un algorithme de décision actualisé avec la société savante de pneumologie".
Méthodes : Mise en oeuvre de la prescription dématérialisée via le site Ameli-pro dans la semaine suivant l'entrée en vigueur de la convention. Respect strict des items figurant sur le téléservice. Recueil des avis rendus par l'algorithme. Dénombrement des type d'avis, des échanges avec le médecin conseil et des procédures contentieuses introduites.
Résultats : du 26 Juin au 25 Février 2025, 97 demandes d'accord préalable ont été effectuées au moyen du web service Améli-pro. Parmi ces 97 demandes, 7 correspondaient à des demandes itératives concernant 3 patients suite à des refus de prise en charge. Pour deux d'entre eux un accord a été obtenu à la 2ème demande, pour la troisième il a été notifié trois refus malgré une motivation rapide de l'efficacité thérapeutique par certificat du médecin traitant.
Au total 97 patients ont été concernés par les demandes (56 hommes et 41 femmes). 65 Avis favorables et 32 avis défavorables ont été émis sur la base de l'algorithme. Les avis défavorables concernent principalement les femmes (43% hommes, 56% femmes, p=0.05) : - 13 patients présentant un index global < 15/h , 9 patients avec un index compris entre 15 et 30/h et 10 patients avec un index > 30/h ; - 12 prescriptions d'orthèse et 20 prescriptions de PPC ; - 25 patients avec un nombre de signes < 3 et 7 patients avec un nombre de signes ≥ 3.
Sur le plan clinique, les patients pour lesquels l'algorithme a émis un avis défavorable (repris par le médecin conseil) consistaient : pour 14 d'entre eux à un état associé à une pathologie neuro-chirurgicale (6 post AVC, 1 malformation de Chiari, 1 méningiome, 3 lésions C3-C4, 3 trauma crânien) ; 6 syndromes positionnels et trois syndromes d'apnées spécifique du sommeil paradoxal. Il est rappelé que les items figurant sur le télé-service sont restrictifs et n'incluent pas les état séquellaires neurologiques. A titre d'exemple comment évaluer une nycturie chez une personne sondée ? Quid de l'évaluation d'une asthénie chez une personne paraplégique, etc… ? Quid des maladies rares ?
Conclusion : La prescription dématérialisée permet de faciliter le traitement des demandes d'accord préalable avec un retour immédiat pouvant faciliter les prises en charge. L'algorithme mis en œuvre basé sur l'arrêté du 13 Décembre 2017 présente des limites nécessitant impérativement l'intervention d'un médecin conseil du service médical de l'assurance maladie pour la validation de la demande d'accord préalable. Les cas particuliers nécessitent de la part des médecins conseils une intégration clinique complexe, une compréhension des mécanismes physio-pathologiques sous-jacents et une connaissance de la bibliographie… A noter que l'algorithme présente des avis genrés…
Il apparaît ainsi que la mise en œuvre de l'algorithme sans confrontation avec la clinique peut conduire à des décisions délétères pour le patient et particulièrement coûteuses pour la société, en raison des retards de prise en charge induits par des décisions médico-administratives inappropriées.