Restless Legs Syndrome
· Overwhelming urge to move the legs, usually
accompanied by uncomfortable sensations or pain
- Symptoms
start, or worsen, with rest or inactivity
- Symptoms
relieved by movement or other stimuli e.g. rubbing the legs
- Symptoms
worse in the evening
- Legs
always involved (but it may spread to affect other limbs)
- Normal
physical examination, including neurological and vascular
- A positive
family history
- Frequent
involuntary limb movements when asleep or awake
- in most people it is a
primary idiopathic disorder; 50% have a family history suggesting a genetic basis
- The 3 major causes of secondary RLS are:
- Pregnancy (occurs in 20% of pregnant women, usually in the last
trimester and usually resolves within a few weeks of delivery)
- Iron deficiency (present in 25% of people with RLS)
- Renal failure (CKD stage 5, occurs in 20% of people undergoing
dialysis, often resolves after transplantation)
- There are associations with
a wide range of other conditions
e.g.
- Parkinson’s, Peripheral
neuropathy, Hypothyroidism, Diabetes, Rheumatoid
- Drugs
can exacerbate it:
- Antidepressants and
lithium
- Neuroleptics and sedating
antihistamines
- Dopamine blocking
anti-emetics e.g. metoclopramide
- Calcium channel blockers
- Serum ferritin in all
patients
- Treat with iron if
<50mcg/ml
- If renal failure or
inflammatory disease, ferritin may of course be elevated in which case
look at transferrin saturation (<20% suggests iron deficiency)
- Consider renal function,
FBC, TFTs, glucose and B12 guided by history and exam
·
Reducing caffeine and alcohol
·
Taking regular aerobic exercise
·
Regular massage therapy
Because of the association with depleted iron stores, it
is routine practice to recommend iron supplementation if the serum ferritin is
low. However a recent iron
supplementation in RLS Cochrane review failed to show evidence of benefit.
Œ Make the diagnosis…using diagnostic criteria above
Is it primary (family history?) or secondary (associated conditions or drugs)?
Ž Investigations
- Check
iron studies in all
- Consider
U and E, FBC, TSH, glucose, B12
- Review
medication and stop/change exacerbating drugs
- Mild RLS: advice and reassurance sufficient
- Good
sleep hygiene
- Reduce
caffeine and alcohol, stop smoking
- Increase
physical activity
- Simple
walking, stretching, relaxation exercises
- Mental distraction techniques and massaging affected limbs
-
Moderate to severe RLS, consider
drug treatment
- Intermittent
symptoms (<3 times per week), off-label levodopa taken when symptoms occur or are anticipated
- If frequent or daily symptoms, dopamine agonist is treatment of choice (e.g. ropinirole, pramipexole are licensed for RLS, doses in the BNF). Warn patients regarding the risk of 'impulse control disorders' with these drugs, and best avoided if at risk e.g. current or past problems with behavioural or chemical addiction.
- Gabapentin, taken regularly, is
an option though it has less evidence to support it
- Referral
to neurologist?
- suggested
if doubt re the diagnosis, or symptoms refractory to treatment or if
augmentation to levodopa or a dopamine agonist is needed
Causes of insomnia in
primary care http://www.ingentaconnect.com/content/rcgp/bjgp/2012/00000062/00000595/art00025
Dopamine agonists for RLS http://www.ncbi.nlm.nih.gov/pubmed/21412893
Levodopa for RLS http://www.ncbi.nlm.nih.gov/pubmed/21328278
Iron therapy http://www.ncbi.nlm.nih.gov/pubmed/22592724
CKS review http://cks.nice.org.uk/restless-legs-syndrome#!topicsummary
AFA review http://www.aafp.org/afp/2008/0715/p235.html
