This document discusses Restless Leg Syndrome (RLS), including its symptoms, causes, diagnosis, and treatment options. Some key points: - RLS is a neurological movement disorder characterized by an irresistible urge to move the legs when at rest, usually accompanied by uncomfortable sensations. - It is estimated to affect 5 million people in the UK, with a prevalence of 2-15%. It can be primary or secondary to other medical conditions. - Diagnosis involves assessing symptoms, family history, and ruling out secondary causes through examinations and blood tests. - Treatment includes lifestyle changes, medications like dopamine agonists or gabapentin, and in severe cases referral to a specialist may be considered.

1. Restless Leg Syndrome
D.M.W. Dharmakeerthi (MD)
Senior Registrar in Clinical
Neurophysiology

2. Restless Leg Syndrome
•“The most common
disorder some have
never heard of.”

3. What are Restless legs?
 Neurological movement disorder
 Irresistible urge to move legs when at
rest
 Difficulty sleeping
 Involuntary periodic leg movements
 Uncomfortable sensation in limbs
subjective & difficult to describe
 Symptoms eased by movement

4. Why should we know about it?
 Excess 5 million in UK are sufferers (MEMO
2000)
 Estimated prevalence 2-15%
 Sufferers will present to primary care
 Important physical cause of sleep
disturbance
 Clinical diagnosis which can be made in
primary care

5. Why should we know about it?
 Unrecognised & under-diagnosed
 Incorrectly labeled as stress / anxiety
 Managed poorly

6. Wide spectrum
 Affects any age group
 More common in middle age + women
 Mild
 Minimal distress
 Severe
 Episodes occur >2 per week
 Can be disabling

7. Why is it important?
 Large impact on quality of life: (REST Study)
 Poor sleep
 Inability to get comfortable / relax
 Poor concentration / fatigue
 Pain
 Depression
 Problems in day to day functioning / employment
 Implications for partner

8. Common descriptive terms
used by patients

9. How do we diagnose RLS?
 International Restless Legs Syndrome
Study Group - 2003

10. Supporting Features
 Positive FHx (50-92%)
 Involuntary limb movements (80%)
 Sleep disturbance

11. Classification
 Primary
 No underlying cause found.
 Positive FHx >50%
 Earlier onset / slower progression
 Secondary
Sudden onset.
Often occurs after the age of 40
Most associated with specific medical
conditions or the use of certain drugs.

12. Pathophysiology
 Genetic
 Susceptibility loci identified on 3
chromosomes
 Genetic anticipation
 Positive FHx >50%
 Neurochemical
 Dopaminergic dysfunction - universal
response to dopaminergic agents
 Ferritin level - inverse relation between
severity and serum ferritin

13. Primary RLS
 Idiopathic.
 Familial in 25-75% of cases(AD).
 Progressive decrease in age at onset
with subsequent generations ( genetic
anticipation).
 Begins before approximately 40 to 45
years of age, and can even occur as
early as the first year of life.

14. Primary RLS
 Onset is often slow.
 RLS may disappear for months, or even
years.
 Often progressive and gets worse as
the person ages.
 RLS in children is often misdiagnosed
as growing pains.

15. Secondary RLS
 Iron deficiency
 Varicose vein
 folate deficiency
 magnesium deficiency
 sleep apnea
 uremia
 diabetes
 thyroid disease

16. Secondary RLS
 Auto-immune disorders (
Sjögren's syndrome, celiac disease and
rheumatoid arthritis)
 Acute intermittent porphyria
 Fibromyalgia
 Cholesterol peripheral microemboli.
 RLS can also worsen in pregnancy.

17. Neurologic conditions linked to
RLS
 Parkinson disease
 Spinal cerebellar atrophy
 Spinal stenosis
 Lumbosacral radiculopathy
 Charcot-Marie-Tooth disease type 2.

18. What investigations should we
do?
 Exclude secondary cause.
 Vascular dx / Neuropathy / nocturnal
cramp / anxiety
 Examination
 Neuro / vascular
 Bloods
 FBC, ferritin, B12, Folate, U&E, Glucose,
TFT, Auto immune screening etc.

19. What are the treatment
options?
 Non Pharmacological
 Preventative measures
 Symptomatic control
 Pharmacological
 PRN treatment - mild / intermittent
 Maintenance treatment - moderate / severe
 Majority of treatments used ‘off license’

20. Non pharmacological
treatment
 Preventative
 Avoid caffeine / alcohol / nicotine
 Avoid medication which may aggravate

SSRI / antihistamine / antiemetic / CaChannel blockers
 Keep active into evening
 Good sleep hygiene
 Symptom control
 Mental alerting activities
 Walking / stretching
 Massage
 Hot / cold bath
 Relaxation / biofeedback

21. Pharmacological options
Drug Advantage Disadvantage
Iron Helpful if serum
ferritin low
Slow response
Dopamine
agonist
Pramipexole /
ropinirole
High efficacy
(70-100%)
Less
augmentation
Daytime
sleepiness
Long term effect
not known
Dopaminergic
agent
Carbidopa /
levodopa
Can be used
PRN basis
Shown to be
effective
Up to 80%
develop
augmentation

22. Pharmacological options
Drug Advantage Disadvantage
Anticonvulsants
Gabapentin /
Carbamazepine
Useful in
neuropathy /
associated pain
Side effect profile
Benzos PRN use + help
sleep
Cognitive
impairment,
dependence
Opioids PRN use /
daytime use
Cognitive
impairment,
dependence

23. Rx Flow chart - RLS:UK

24. Mirapexin (pramipexole)
 First drug treatment / ONLY treatment
licensed in EU for RLS
 For use in moderate / severe disease
 Quick onset of symptom relief (<1/52)
 Start low dose 125mcg od
 Titrate up (max 750mcg od)

25. What should we be doing?
 Have raised awareness about diagnosis
 Exclude / treat secondary causes
 Symptoms generally mild +
reassurance & non-pharmacological
measures suffice
 In moderate / severe cases consider
onward referral

26. Useful Info
 Resources
 www.ekbom.org.uk
 www.restlesslegs.org.uk
 www.restlesslegs.com
 Review
 DTB Nov 2003
 Bandolier 118

27. Thank you