Restless Leg Syndrome

D.M.W. Dharmakeerthi (MD)

Senior Registrar in Clinical Neurophysiology

Restless Leg Syndrome

•“The most common disorder some 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 diagnose RLS? International Restless Legs Syndrome

Study Group - 2003

Supporting Features Positive FHx (50-92%)

Involuntary limb movements (80%)

Sleep disturbance

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.

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

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.

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.

Secondary RLS

Iron deficiency Varicose vein folate deficiency magnesium deficiency sleep apnea uremia diabetes thyroid disease

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.

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

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.

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 optionsDrug Advantage Disadvantage

Iron Helpful if serum ferritin low

Slow response

Dopamine agonistPramipexole / ropinirole

High efficacy (70-100%)Less augmentation

Daytime sleepinessLong term effect not known

Dopaminergic agentCarbidopa / levodopa

Can be used PRN basisShown to be effective

Up to 80% develop augmentation

Pharmacological options

Drug Advantage Disadvantage

AnticonvulsantsGabapentin / 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

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

Thank you