Restless Legs Syndrome
Julie Adkins
Definition
A.Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a neurologic disorder usually involving throbbing, pulling, creeping, or other unpleasant sensations of the legs with sometimes an overwhelming urge to move them. Symptoms occur usually at night when in a relaxing, resting position, but can increase in severity throughout the night. Moving the legs usually relieves the discomfort causing disorders of sleep. Left untreated, RLS can cause exhaustion and fatigue, which is often associated with daytime concentration and memory, and can cause depression.
Incidence
A.As much as 10% of Americans may have RLS. Moderate to severe symptoms affect 2% to 3% of adults.
B.RLS occurs in both men and women, but the incidence is about twice as high in women.
C.It may begin at any age. Symptoms seem to become more frequent and last longer with age.
Pathogenesis
A.RLS is classified as a movement disorder as people are required to move their legs to get any relief. More than 80% of people with RLS also may experience a condition, periodic limb movement of sleep (PLMS), which involves leg twitching or jerking movements during sleep occurring every 15 to 40 seconds. Although many patients with RLS develop PLMS, most people with PLMS do not have RLS or any other cause of PLMS. Periodic limb movement disorder (PLMD) may be a variant of RLS and responds to similar treatments. The cause of RLS is unknown; however, it may have a genetic component. Nearly half of people with RLS also have a family member with the condition. Evidence indicates that low levels of iron in the brain may be responsible for RLS.
B.Considerable evidence suggests that RLS is a dysfunction in the brain’s basal ganglia that uses the neurotransmitter dopamine. Disruption of this pathway frequently results in involuntary movements.
C.Alcohol and sleep deprivation may aggravate or trigger RLS symptoms.
Predisposing Factors
A.Alcohol use.
B.Sleep deprivation.
C.Chronic diseases such as kidney failure, diabetes, anemia, and peripheral neuropathy.
D.Certain medications such as antiemetics, antipsychotic drugs, antidepressants, and some cold and allergy medications.
E.Pregnancy, especially during the third trimester.
F.Family history of RLS.
G.Varicose veins.
Common Complaints
A.A classic feature of RLS is that the symptoms are worse at night with a distinct symptom-free period in the early morning.
B.Uncomfortable sensations in the legs with an irresistible urge to move the limb. Sensations may occur on only one side of the body, but most often affect both sides.
C.Need to keep legs in motion such as pacing the floor, moving legs while sitting, and tossing and turning in bed.
Other Signs and Symptoms
A.May vary day to day, in severity and frequency, and from person to person.
B.Triggering factors may include long car trips; sitting for long periods of time, such as at a movie theater or long-distance flights; immobilization of a cast; or relaxation exercises.
C.Worsening of symptoms occurs with sleep deprivation.
D.In severe cases, interruption and impairment of daytime function occur.
Subjective Data
A.Ask the patient to describe the sensations (urge to move legs) of which he or she is complaining. Do sensations occur in one or both legs?
B.What makes symptoms worse? What makes symptoms better?
C.What does the patient do to make the sensations better?
D.Do symptoms occur during rest or activity? Is there a particular activity that usually makes the symptoms worse or better? Do they improve with movement?
E.How often are symptoms present? Do the symptoms occur during the daytime or nighttime? Daily, nightly, several times a day, once a week, and so forth?
F.Does the patient have other medical or behavioral conditions that can be attributed to the symptoms that occur?
G.Are symptoms triggered by rest, relaxation, or sleep?
H.Determine sleep patterns and disturbances.
I.Review current medications being taken and discuss chronic conditions.
J.Inquire regarding the amount of alcohol ingested each day.
K.Inquire regarding the use of tobacco.
L.If pregnant, are symptoms new during the pregnancy or has she always had the symptoms?
Physical Examination
A.Check blood pressure (BP), pulse, respirations, and weight.
B.Inspect:
1.Overall appearance and hygiene.
C.Auscultate:
1.Heart.
2.Lungs.
D.Neurologic examination:
1.Perform full neurologic examination.
Diagnostic Tests
A.Laboratory tests may be performed to rule out other conditions, which include the following:
1.Iron studies: Serum ferritin level.
2.Complete blood count (CBC).
3.Vitamin B12 and folic acid.
4.Complete metabolic panel (CMP).
5.Hemoglobin A1c (HgbA1c).
6.Thyroid studies.
B.Sleep study.
Differential Diagnoses
A.RLS: There is no specific test for RLS. The basic criteria for diagnosing the disorder are the following:
1.Symptoms are worse at night and are absent or negligible in the morning.
2.A strong and often overwhelming need or urge to move the affected limb(s), often associated with parasthesias or dysesthesias
3.Sensory symptoms that are triggered by rest, relaxation, or sleep
4.Sensory symptoms that are relieved with movement, in which the relief persists as long as the movement continues
5.None of the previously noted symptoms are caused by another medical condition.
B.Sleep apnea.
C.Alcoholism.
D.Specific vitamin deficiencies.
E.Pregnancy (third trimester).
F.Parkinson’s disease (PD).
Plan
A.General interventions:
1.Activities that worsen symptoms should be discontinued.
2.Medications can be prescribed and are effective for many patients.
3.Some chronic conditions may contribute to RLS, such as diabetes or peripheral neuropathy, or vitamin deficiency, and should be evaluated.
B.Patient education:
1.Advise patient to discontinue activities that worsen symptoms.
2.Lifestyle changes may be suggested such as discontinuing the use of alcohol, tobacco, and caffeine.
3.Bedtime rituals and regular sleep patterns should be encouraged. Avoid exercise at least 1 to 2 hours before bedtime. Encourage relaxation techniques before going to bed.
4.The use of relieving techniques, such as massage, warm bath, or warm/cold compresses, is encouraged.
C.Pharmaceutical therapy:
1.Dopaminergic agents (increase dopamine) are recommended first-line treatment for frequent or nightly symptoms. However, caution should be used. Long-term use can lead to worsening symptoms as early as a few months after initiation of drugs. Augmentation manifests as earlier onset of RLS symptoms during the evening, shorter latency to onset after assuming a restful position, increased intensity, or extension of the symptoms to the upper body. Rebound refers to an increase in severity of symptoms occurring in the morning. This is reversible with withdrawal of the medication. Medications are best initiated at low doses and taken 1 to 2 hours before bed-time to allow for sufficient absorption.
a.Food and Drug Administration (FDA)- approved nonergotamine dopamine agonists for moderate to severe RLS include the following:
i.Ropinirole (Requip): 0.25 mg orally at bedtime. May titrate the dose every three nights, for a maximum dose of four tablets at bedtime, until symptoms are resolved.
ii.Pramipexole (Mirapex): Initial dose: 0.125 mg one tablet at bedtime. May increase dose every three nights, for a maximum dose of four tablets at bedtime, until symptoms are resolved. Requires dosage adjustment in renal impairment.
iii.Rotigotine (Neupro) transdermal patch: 1 mg/24 hr patch; apply new patch nightly at alternating sites. May increase patch weekly to a maximum dose of 3 mg/24 hr.
b.Gabapentin enacarbil (Horizant) is also FDA approved for RLS treatment:
i.Recommended dose 600 mg once daily taken with food about 5 p.m.
ii.Should not be cut, crushed, or chewed.
iii.Not recommended for patient with a CrCl <30 mL/min or on hemodialysis.
b.Levodopa formulation:
i.Levodopa/carbidopa or levodopa/benserazide: 50/12.5 mg starting dose; may increase to maximum dose of 200/50 mg.
2.Pregabalin 2 mg starting dose and may increase to a maximum dose of 300 mg until symptoms improved.
3.Analgesics, such as acetaminophen (Tylenol), nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids, may be used as needed for pain.
4.Benzodiazepines, such as clonazepam 0.5 to 2.0 mg at bedtime, may be used as needed.
6.Vitamin deficiencies should be treated with appropriate vitamins as diagnosed.
Follow-Up
A.Follow up in 1 to 2 weeks to evaluate effect(s) of medications.
B.Evaluate severity or minimization of symptoms.
C.Reassure patients that a diagnosis of RLS does not indicate the onset of another neurologic disorder such as PD.
Consultation/Referral
A.Consider referral to a neurologist if symptoms are not improving with treatment.
Individual Considerations
A.Pregnancy:
1.Symptoms are usually worse in the third trimester.
2.Based on animal data, gabapentin enacarbil (Horizant) may cause fetal harm.
B.Geriatrics:
1.Symptoms progress with age. Other chronic diseases are also usually present; it can be difficult to pinpoint the diagnosis of RLS because of other chronic problems.
2.Use of medications to treat RLS increase the risk for the following geriatric syndrome:
a.Falls: Side effects of medications include dizziness, somnolence, and dyskinesia.
b.Perform a fall risk assessment when prescribing medications for RLS.
3.Beers Criteria caution: Benzodiazepines should be avoided in the elderly.
Resources
Restless Legs Syndrome Foundation: www.rls.org
National Sleep Foundation: www.sleepfoundation.org