Restless Leg Syndrome

Overview

Restless legs syndrome (RLS) is a disorder associated with a poorly defined feeling of discomfort in the legs and an often-overwhelming urge to move.

Patients often find it very difficult to describe the feeling in the legs. Commonly used terms include:

• Achy
• Itchy on the inside
• Crawling
• Like the urge to yawn, but in the legs

Alongside these unpleasant sensations is a strong urge to move, shake or stretch the legs, or walk, which can give momentary relief from the sensation.

These symptoms are most commonly felt in the legs, but may also occur in the arms.

Most cases of RLS have no underlying cause, in which case it is referred to as primary or idiopathic RLS, however there are a number of exacerbating factors including alcohol, nicotine, caffeine and lack of sleep.

In a minority of cases RLS is associated with an underlying condition, such as end stage chronic kidney disease, iron deficiency and multiple sclerosis, and can be a feature in a fifth of women during their third trimester of pregnancy.

Association with Periodic Limb Movement Disorder (PLMD)

In RLS, the motor urge to move the limbs can continue into sleep and manifest as recurrent repetitive movements of the legs, ankles, toes or hips, and occasionally the arms. These are called periodic limb movements during sleep (PLMS) and can wake the patient up, or jump them from a state of deeper sleep to a state of lighter sleep

If patients have no symptoms of RLS during wakefulness, and only PLMS interfering with sleep, then this is diagnosed as the sleep disorder Periodic Limb Movement Disorder (PLMD).

PLMD (without RLS) is uncommon, and the treatment is the same as RLS.

Who to refer

RLS-PLMD can be generally managed in primary care and referral is rarely indicated. If management in primary care is unsuccessful and symptoms are distressing, then patients can be referred.

Diagnosis

Diagnosis is clinical and should be based on fulfilling all the following criteria set out by the International RLS study group (IRLSSG)

1. The urge to move the legs, with or without an accompanying uncomfortable sensation
2. The symptoms
   1. Begin or worsen during periods of rest, such as sitting or lying down
   2. Are partially or totally relieved by movement
   3. Only occur, or are worse, in the evening or night
3. The symptoms cannot be wholly attributed to another cause

The severity of RLS should be gauged using the IRLSSG rating scale. This is very useful in attempting to quantify what can be quite a difficult condition to define, and should be serially repeated in order to objectively track the response to treatment.

Attention should be given to identifying the underlying causes above, in particular iron deficiency. RLS may occur secondary to other sleep disorders including insomnia and obstructive sleep apnoea, and appropriate attention should be given to ruling these out. Reconsider the diagnosis if the symptoms are unilateral or if leg cramps are present.

Management in primary care

Conservative management

There are both preventative and alleviative treatment measures available.

Preventative:

• Smoking cessation
• Reduction of alcohol and caffeine
• Sleep hygiene
• Regular moderate exercise and stretching

Alleviating:

• Relaxation and distraction
• Walking and stretching
• Hot baths and leg massage

Pharmacological management

• Iron supplementation - Iron is thought to facilitate dopamine uptake in the basal ganglia. Ferritin should be measured, and iron supplements given to maintain a ferritin above 75mcg/L.
• Gabapentin and pregabalin – often used off label, but as the first line for RLS. A common starting dose for gabapentin is 300mg and pregabalin 75 mg taken once in the evening, an hour before symptoms typically start (have greater caution in elderly). Higher doses are not recommended unless discussed with a specialist.
• Dopaminergic drugs – these can be effective at reducing symptoms. Side effects can be problematic although are less likely at the initial low doses advised here. Ropinirole (blue on Formulary) at an initial dose of 250 micrograms or pramipexole (Green for RLS) at an initial dose of 88 micrograms pramipexole-base given 1-2 hours before bed or the anticipated onset of symptoms is often used. See BNSSG formulary.
• Sleeping tablets – where RLS occurs exclusively, or is significantly worse, in response to sleep deprivation, then a short course of sleeping tablets can be used alongside sleep hygiene or CBT for insomnia treatment

Treatment is based on a ratio of risk to benefit, with lifestyle measures including sleep hygiene having been tried first.

Services

• Neuropsychiatry Sleep Disorders clinic - NBT

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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