RLS is a common condition although most people do not reach doctors; the diagnosis is clinical (see box) along with the exclusion of alternative explanations. It is diurnal, worse in the evening/night and thus affects sleep. It is often associated with Periodic Limb Movements of Sleep (PLMS). Some will have a family history. It may occur at any age. Symptomatic mimics include peripheral neuropathy, cramps, varicose veins, akathisia, anxiety, spinal stenosis.
Restless Legs Syndrome does not include hypnic jerks/involuntary movement
Other leg movements, especially involuntary hypnic jerks, are commonly misdiagnosed as RLS . Hypnic jerks are sudden jerky movements people have normally as they fall off to sleep which can be amplified in people with sleep disorders, on opiates and with anxiety. They are not RLS and should not be treated with medications below
| Diagnostic Features |
| Urge to move legs often with uncomfortable/unpleasant sensations |
| Symptoms begin/worsen during rest or inactivity |
| Symptoms relieved by movement (walking or stretching) |
| Symptoms occur/worsen in evening/night |
Do they need investigation in primary care?
All with suspected RLS should have a basic blood screen including glucose and serum ferritin.
Do they need to see a Neurologist?
Not necessarily but we are happy to advise/see for diagnostic clarification or management problems.
General Lifestyle Advice
Most people with RLS can be managed with resorting to drugs. Good sleep hygiene is important including avoidance of stimulants in the evening. CBT for insomnia may be effective. Relaxation therapy, walking or stretching before bedtime, warm evening bath and/or massage may be helpful. Some drugs, notably Tricyclic antidepressants such as amitriptyline, may worsen symptoms.
Treatment of RLS
Most will require nothing more than reassurance and sensible lifestyle advice as above, drug therapy should be reserved for the most distressing cases. Treatment responses are often accompanied by augmentation; this is the worsening of symptoms or manifestation earlier in the day after a period of successful dopaminergic treatment. The lowest possible doses such be used to try and avoid this effect.
| First Line Therapy |
| • Iron replacement: if serum ferritin is low/low normal, then replace orally. |
| Second Line therapies (consider carefully whether drug therapy required) |
| • Dopamine agonists (only licensed drugs for RLS): oral ropinirole 0.25-4mg, pramipexole up to 0.75 base (i.e. 0.088 tablets salt x 3) or rotigotine patch 1-3mg/day. Counsel for possibility of impulse control disorders (e.g. excessive gambling, shopping, hypersexuality etc). • Levo-dopa (co-careldopa or co-beneldopa) • Gabapentin (starting dose 300mg nocte, range 300-1200mg) or Pregabalin (starting dose 50-75mg nocte, range up to 300mg). |
March 2020
