Restless legs

Question 1

What are the diagnostic criteria for RLS? (Ekbom Syndrome)

Answer 1

RLS can be confirmed if the patient has all of the following four features:

a.Desire to move the extremities usually associated with discomfort or disagreeable sensations in the
extremities.
b. Motor Restlessness-patients move to relieve the discomfort
c. Symptoms are worse at rest with at least temporary relief by activity.
d. Symptoms are worse later in the day or at night.

Question 2

What are the common symptoms?

Answer 2

• Urge to move legs upon resting
• Urge is mostly in the legs but can be present in the arms too
• About 85% of the patients with RLS have periodic lower limb movements in sleep which ar ebrief, kerky and stereotyped movements

Question 3

What are the differential diagnosis for RLS?

Answer 3

• Anaemia
• Iron deficiency
• Uraemia
• Hypothyroidism
• Pregnancy (ceases within weeks of delivery)
• Medications such a antihistamines, anti-emetics, antidepressants, lithium and antihypertensives
• Parkinsons
• Coeliac disease
• Rheumatoid arthritis
• Vascular/neurogenic claudication

Question 4

What Ix need to be performed ?

Answer 4

• Ix performed to exclude other causes
• FBC/UEC/TSH/Iron studies.

Question 5

How to classify restless legs?

Answer 5

Resltess legs rating scale can be used

• Mild-1-10
• Modertae-11-20
• Severe-21-30
• Very severe-31-40

Question 6

What are the non-pharmacological approaches to restless legs?

Answer 6

• Modest amount of walking before bed
• Stretching exercises particularly the hamstring and calf muscles for five minutes before bed
• Healthy diet, avoid caffeine, alcohol and smoking
• Good sleep hygiene including regular sleep hours, gradual relaxation at bed time

Question 7

What are the risk factors?

Answer 7

• Iron deficiency
• Genetic predisposition
• Reduced dopaminergic activity in the brain

Question 8

What are the pharmacotherapies for restless legs?

Answer 8

• Oral iron therapy if ferritin <50
• Dopaminergic agents such as pramipexole and ropinirole are considered first line; anticonvulsants are second line
• Opioids are used in very severe cases where other therapies have failed
• Combination therapies in upto 20% of cases
• Gabapentin and pregabalin are second line agents
• Oxycodone or tramadol are used for very severe cases
• Gabapentin and pramipexole are first line for secondary RLS
• Iron and opioids preferred in pregnancy

Question 9

What are the common side effects of medications used to treat RLS?

Answer 9

• The common side effects of dopamie agonists and anticonvulsants include nausea, headache, dizziness, oedema. Impulse control disorders are specific for dopamine agonists
• Augmentation (worsening of symptoms) is a side effect of dopamine agonists after prolong used; needs shifting to another agent or another class of drugs based ons everity of symptoms