Date of Assessment:
ID #:
Clinic/Lab Address: _________________________________________________
Phone:
_________________________________________________
Fax:
____________________________________________________
Email:
__________________________________________________
Suggested
v Immobilization Test (SIT)
Time: 45 minutes
Instructions: The individual conducting the test should follow the instructions below.
1. Ask the child
to sit still in bed,
w/ their head up
at a 45°angle &
legs extended.
2. (OPTIONAL) apply the
portable EMG apparatus or
Actigraph (that specifically
records PLMs) to the
thickest part of calf, and
then turn on the device.
5. Allow the child to mark down the
severity of their leg discomfort on the
scales below in 5-minute periods. At
the end of 45 minutes you should have
10 completed scale scores.
4. Record the
SIT on a
camera/mobile
phone for a 45minute period
.assistance
3. Ask the child
to relax and not
have any
tension in their
legs
Parent/Guardian: Allow the child to mark down the severity of their leg discomfort at the start of the test and at the indicated time
intervals. The ranking of discomfort needs to be made very clear to the child. Begin by asking the child for a word or phrase
(example: “uncomfortable”, “tingly”) that best describes how he/she is feeling and then equate that with the lowest (0)/ highest (10)
ranking (example: least/most “uncomfortable”, or least/most “tingly"). Allow the child to express their leg discomfort in their own
words. Please do not suggest words to the child.
Remind the child that their legs must be relaxed and not tense; you may check this manually.
The score can reflect a whole number such as 2, or decimal places such as 2.3 or 2.5.
If the child is unable to finish the test, record the
number of minutes they were able to sit still before moving:
Start time:
End time:
SIT (at home
Please mark on the diagram
provided how uncomfortable
your legs feel at the indicated
5-minute intervals
2.25
assessment)
Click the areas where
you feel discomfort:
FRONT
Example:
0
1
2
3
4
5
6
7
8
9
10
Start (Time zero)
5 minutes
10 minutes
15 minutes
20 minutes
25 minutes
30 minutes
35 minutes
BACK
40 minutes
45 minutes
Had observable movement patterns
Twitches in feet/toes
Described sensations
An urge to move
Increased tension (e.g. raising heels/legs/ body)
Sensations in legs
Rubbing or clenching of feet/toes
Sensations in legs
Repetitive movements of toes/feet/legs
Sensations in feet/toes
Sensations in legs
Other: Comment
Unable to specify
Other:
Comment
No observable movement patterns
Did not report any sensations
Additional details
Assessment Form | WED/RLS Assessment
Walters (Vanderbilt University, USA); Team Ipsiroglu, Copyright(c) Sleep/Wake-Behaviours Clinic & Research Lab
Dept. of Paediatrics BC Children’s Hospital, University of British Columbia