Restless Legs Syndrome (RLS), also known as Willis-Ekbom Disorder (WED) is a motor-sensory neurological sleep disorder characterized by uncomfortable sensations in the lower extremities that are accompanied by an almost irresistible urge to move the legs or arms. These uncomfortable experiences are typically described as creeping, crawling, tingling, burning, or itching sensations. Symptoms typically occur at night and are relieved by movement.
The diagnosis of RLS is a clinical diagnosis, and primarily on patient self-report and history. The symptoms of RLS can delay sleep onset and awaken the individual from sleep and are associated with significant sleep fragmentation. The relief obtained from moving the legs may no longer be apparent in severe cases. RLS is associated with daytime sleepiness and is frequently accompanied by significant clinical distress or functional impairment.
An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by all of the following:
The symptoms in Criterion A occur at least 3
times per week and have persisted for at least 3
months.
The symptoms in Criterion A are accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
The symptoms in Criterion A are not attributable to another mental disorder or medical condition (e.g., arthritis, leg edema, peripheral ischemia, leg cramps) and are not better explained by a behavioural condition (e.g., positional discomfort, habitual foot tapping).
The symptoms are not attributable to the physiological effects of a drug of abuse or medication (e.g., akathisia).
URGE
can be used to remember the core features of RLS:U
- Urge to move limbsR
- Rest worsens the sensationG
- Getting up to move offers temporary reliefE
- Evening is worse for symptomsPLMD = PLMs plus sleep dysfunction.
Important differential diagnoses to consider include:
Polysomnography demonstrates significant abnormalities in RLS, commonly increased latency to sleep, and higher arousal index. Polysomnography with a preceding immobilization test may provide an indicator of the motor sign of RLS, periodic limb movements, under standard conditions of sleep and during quiet resting, both of which can provoke RLS symptoms.
If there is iron deficiency, it is reasonable to start with iron supplementation as a first-choice and might be an easy “fix” if the serum ferritin level is <75.
First-line treatment for RLS is with dopamine agonists.[5]
1st line (α2δ Subunit Gaba-ergic Agonists) | • Gabapentin (300 to 2000 mg PO q evenings
) • pregabalin (50 to 450 mg PO daily) |
---|---|
2nd line (Dopamine agonists) | • Rotigotine (Neupro) patch (1 mg to 4 mg patch/24 hours) • Pramipexole (0.125 to 0.5 mg PO qHS ) L-dopa should no longer be used due to the high risk for augmentation! |
3rd line | Opioids: Codeine (15 to 120 mg PO daily), Tramadol (50 mg to 100 mg PO prn), methadone (5 to 30 mg PO daily) Benzodiazepines: Clonazepam (0.5 to 3 mg PO daily), temazepam (15 to 30mg PO daily) Other treatments: Clonidine, baclofen, carbamazapine, B12, folate |