{"id":11381,"date":"2022-10-13T10:34:10","date_gmt":"2022-10-13T09:34:10","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=11381"},"modified":"2025-07-29T13:36:56","modified_gmt":"2025-07-29T12:36:56","slug":"restless-legs-syndrome-rls","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/neurology\/restless-legs-syndrome-rls\/","title":{"rendered":"Restless Legs Syndrome (RLS)"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Restless-legs-Advice-for-GPs-from-Neurology-Final-220125.pdf\" data-type=\"URL\" data-id=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Restless-legs-Advice-for-GPs-from-Neurology-March-2020-.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Download PDF<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">RLS is a common 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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Restless Legs Syndrome does not include hypnic jerks\/involuntary movement<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Do they need investigation in primary care?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">All suspected RLS should have a basic blood screen including glucose and serum ferritin.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Do they need to see a Neurologist?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Not necessarily but we are happy to advise\/see for diagnostic clarification or management problems. Treatment options are limited (see below).<\/p>\n\n\n\n<figure class=\"wp-block-table is-style-regular\"><table class=\"has-light-accent-blue-background-color has-background\"><tbody><tr><td><strong>Diagnostic Features<\/strong><\/td><\/tr><tr><td>Urge to move legs often with uncomfortable\/unpleasant sensations<\/td><\/tr><tr><td>Symptoms begin\/worsen during rest or inactivity<\/td><\/tr><tr><td>Symptoms relieved by movement (walking or stretching)<\/td><\/tr><tr><td>Symptoms occur\/worsen in evening\/night<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>M.A &amp; J.S. &amp; R.D. 09-01-25<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\">See Primary Care Management Section<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\">&nbsp;<strong>Do they need investigation in primary care?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">All with suspected RLS should have a basic blood screen including glucose and serum ferritin.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Do they need to see a Neurologist?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Not necessarily but we are happy to advise\/see for diagnostic clarification or management problems.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>General Lifestyle Advice<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Treatment of RLS<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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 <strong>augmentation<\/strong>; 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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Drug therapy for RLS is problematic.<\/strong> <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Currently only dopamine agonists and Targinact <em>(oxycodone\/naloxone)<\/em> are licensed for RLS; agonists are associated with augmentation and can cause serious impulse control disorders<strong>.<\/strong> Gabapentinoids are first line in many guidelines but are not licenced for RLS. We do not have additional drug therapies in secondary care.<\/p>\n\n\n\n<figure class=\"wp-block-table alignleft\"><table class=\"has-light-accent-blue-background-color has-background\"><tbody><tr><td><strong>First Line Therapy<\/strong><\/td><\/tr><tr><td>-Iron replacement: if serum ferritin is low\/low normal, then replace orally<br>-Identify and manage co-existing sleep disorders<br>-Ensure not on medications that may cause\/exacerbate RLS<\/td><\/tr><tr><td><strong>Second Line therapies: consider carefully whether drug therapy required, consider using the <\/strong><a href=\"https:\/\/biolincc.nhlbi.nih.gov\/media\/studies\/masm\/IRLS.pdf?link_time=2019-07-07_21:09:19.282153\" target=\"_blank\" rel=\"noreferrer noopener\">International Restless Legs Scale<\/a><strong> to assess severity or response<\/strong><\/td><\/tr><tr><td><strong>-Gabapentin <\/strong>(starting dose 100-300mg nocte, range 300-1200mg) or<strong> Pregabalin <\/strong>(starting dose 25-50mg nocte, range up to 300mg). Neither drug is licensed for RLS.<br>&#8211;<strong>Dopamine agonists (licensed for RLS but not included in the East Region Formulary although approved by SMC with restrictions)<\/strong>: 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 impulse control disorders (e.g. excessive gambling, shopping, hypersexuality etc). There have been successful legal actions against doctors who didn\u2019t counsel patients.<br>&#8211;<strong>Targinact (oxycodone\/naloxone)is licensed for RLS but we do not recommend its use in primary care*.<\/strong><\/td><\/tr><\/tbody><\/table><figcaption class=\"wp-element-caption\">* <em>https:\/\/www.nice.org.uk\/advice\/esnm67\/chapter\/full-evidence-summary#evidence-review-2<\/em><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Richard Davenport and Jon Stone, Consultant Neurologists, NHS Lothian 2024<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\"><strong>Patient information<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>RLS-UK<\/strong><a rel=\"noreferrer noopener\" href=\"https:\/\/www.rls-uk.org\/\" data-type=\"URL\" data-id=\"https:\/\/www.rls-uk.org\/\" target=\"_blank\"> <\/a><a rel=\"noreferrer noopener\" href=\"https:\/\/www.rls-uk.org\/\" data-type=\"URL\" data-id=\"https:\/\/www.rls-uk.org\/\" target=\"_blank\">https:\/\/www.rls-uk.org\/<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Advice for initial management in primary care information sheet <\/em>(printable PDF version): <a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Restless-legs-Advice-for-GPs-from-Neurology-Jan-2025-FINAL.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Restless-legs-Advice-for-GPs-from-Neurology-Jan-2025-.pdf<\/a><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Download PDF RLS is a common 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<\/p>\n","protected":false},"author":6,"featured_media":0,"parent":4173,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_searchwp_excluded":"","footnotes":""},"categories":[840],"class_list":["post-11381","page","type-page","status-publish","hentry","category-https-apps-testing28-scot-nhs-uk-refhelp-guidelines-restless-legs-syndrome-rls"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"heatherlevy","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/heatherlevy\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/neurology\/headache\/https-apps-testing28-scot-nhs-uk-refhelp-guidelines-restless-legs-syndrome-rls\/\" rel=\"tag\">Restless Legs Syndrome (RLS)<\/a>","rttpg_excerpt":"Download PDF RLS is a common 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","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/11381","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=11381"}],"version-history":[{"count":18,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/11381\/revisions"}],"predecessor-version":[{"id":24946,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/11381\/revisions\/24946"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4173"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=11381"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=11381"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}