Restless Leg Syndrome

•“The most common

disorder you have
never heard of.”
 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
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
Why should we know about it?

 Unrecognised & under-diagnosed

 Incorrectly labeled as stress / anxiety

 Managed poorly
Wide spectrum
 Affects any age group
 More common in middle age + women
 Mild
 Minimal distress
 Severe
 Episodes occur >2 per week
 Can be disabling
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
Common descriptive terms
used by patients
How do we diagnosis RLS?
 International Restless Legs Syndrome
Study Group - 2003
Supporting Features
 Positive FHx (50-92%)

 Involuntary limb movements (80%)

 Sleep disturbance
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
Aetiology
 Primary
 No underlying cause found.
 Positive FHx >50%
 Earlier onset / slower progression
 Secondary
 Fe deficiency
 Pregnancy
 End stage renal disease
 Peripheral neuropathy / DM / RA / Fibromyalgia
 Later onset / more severe
Pathophysiology
 Genetic
 Susceptibility loci identified on 3
chromosomes
 Positive FHx >50%
 Neurochemical
 Dopaminergic dysfunction - universal
response to dopaminergic agents
 Ferritin level - inverse relation between
severity and serum ferritin
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’
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
Pharmacological options
Drug Advantage Disadvantage

Iron Helpful if serum Slow response

ferritin low

Dopamine High efficacy Daytime

agonist (70-100%) sleepiness
Pramipexole / Less Long term effect
ropinirole augmentation not known
Dopaminergic Can be used Up to 80%
agent PRN basis develop
Carbidopa / Shown to be augmentation
levodopa effective
Pharmacological options

Drug Advantage Disadvantage

Anticonvulsants Useful in Side effect profile

Gabapentin / neuropathy /
Carbamazepine associated pain
Benzos PRN use + help Cognitive
sleep impairment,
dependence
Opioids PRN use / Cognitive
daytime use impairment,
dependence
Rx Flow chart - RLS:UK
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)
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
Useful Info
 Resources
 www.ekbom.org.uk
 www.restlesslegs.org.uk
 www.restlesslegs.com
 Review
 DTB Nov 2003
 Bandolier 118