Background
Essential criteria | Supportive criteria | Associated features |
---|---|---|
An urge to move the legs, usually accompanied/caused by uncomfortable/unpleasant sensations in the legs. | Positive family history of RLS. | Natural clinical course of the disorder. |
Urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity. | Positive response to dopaminergic drugs. | Sleep disorders are a frequent but unspecific symptom of the RLS. |
Urge to move or unpleasant sensations are partially/totally relieved by movement, at least as long as the activity continues. | PLMW/PLMS as assessed with polysomnography or leg activity devices. | Medical evaluation/physical examination: The neurological examination is usually normal. |
Urge to move or unpleasant sensations are worse in the evening/night than during the day, or only occur in the evening/night. | Probable causes for secondary RLS should be excluded. |
Methods
Results
Barriers to diagnosis
The diagnosis of RLS
1. Urge to move the legs or other body parts usually accompanied or caused by unpleasant sensations
2. Urge to move or unpleasant sensations begin or worsen during rest or inactivity
3. Urge to move or unpleasant sensations are partially or totally relieved by movement
4. Urge to move or unpleasant sensations are worse in the evening or at night or occur only in the evening or at night
Potential barriers to diagnosis
Presentation of symptoms
The term "restless legs syndrome"
Creepy-crawly | Tearing |
---|---|
Insects/ants crawling | Throbbing |
Jittery | Tight feeling |
Pulling | Grabbing sensation |
Worms moving | Itching bones |
Soda bubbling in the veins | Electric current |
Electric current | Fidgets |
Pain | Twitching |
Burning | Water moving |
Tingling | Aching |
Differential diagnosis and mimics (see table 3)
Meeting Criteria | Comment | Disorder | |
---|---|---|---|
Urge to move & unpleasant sensations in the legs
Symptoms begin/worsen during periods of rest or inactivity.
Symptoms relieved with movement
Symptoms worse in the evening/night
| Definite RLS | Awake symptom diagnosis made by clinical history; uncomfortable urge to move with or without deep creepy-crawling sensation brought on at time of inactivity or rest (sitting or lying); immediate relief either complete or partial with movement; symptomatic relief is persistent as long as movement continues; presence of circadian pattern with peak around midnight and nadir in the morning |
RLS
|
Urge to move -
Symptoms begin/worsen during periods of rest or inactivity.
Symptoms relieved with movement
Orthostatic hypotension
| Neurological disorder with "urge to move" | Feeling of restlessness which may be localized in legs, brought on by sitting still; should not occur while lying down but might be relieved by movement; occurs in patients with orthostatic hypotension |
Hypotensive akathisia
|
Unpleasant sensations in the legs
Symptoms relieved with movement
Symptoms worse in the evening/night
No positive response to dopaminergic drugs
| Pain Disorder | Dysesthesias and pain in the legs, frequently one-sided, often radicular arrangement of sensory symptoms, atrophic changes of musculature, no urge to move the legs, symptoms can be initiated by sitting and lying and improve by movement, usually neurological and neurophysiological deficits, does not respond to dopaminergic therapy |
Radiculopathy
|
Unpleasant sensations in the legs
Symptoms relieved with movement
Symptoms worse in the evening/night - | Vascular Disorder | Dysesthesias and pain in the legs. May appear to occur with or after rest but is associated with or occurs after periods of standing/walking; ntensity increased by movement and usually relieved by prolonging rest often best in a lying position, no urge to move, no circadian pattern, usually no sleep disturbances, frequently associated with skin alterations and edemas. Often associated with vascular disease, circadian pattern if any relates more to activity levels |
Vascular claudication, neurogenic claudication
|
Urge to move
Symptoms begin/worsen during periods of rest or inactivity
Periodic limb movements
History of neuroleptics
| Neurological disorder with "urge to move" | Looks like very severe RLS affecting the whole body -but usually without any sensations of pain reported by RLS patients often no relief with movement;, should have a history of specific medication exposure |
Neuroleptic-induced akathisia
|
Unpleasant sensations in the legs
Symptoms begin/worsen during periods of rest or inactivity
No positive response to dopaminergic drugs
| Pain Disorder | Sensory symptoms commonly reported as numbness, burning, and pain; not as common in RLS; numbness is rare in RLS, no urge to move; sensory symptoms usually present throughout the day, less frequent at night, complete and persistent relief is not obtained while walking or during sustained movement |
Neuropathy
|
No periodic limb movements
| |||
Unpleasant sensations in the legs
Symptoms begin/worsen during periods of rest or inactivity. | Pain Disorder | Patients after surgeries frequently do not remember the origin of their complaints. They almost always report symptoms in the legs or in the back, when lying or sitting or during movement. |
Chronic pain syndrome (lumbal, cervical)
|
Unpleasant sensations in the legs
Symptoms relieved with movement
| Disorders without "urge to move" | Often comes on with prolonged sitting or lying in the same position but usually relieved by a simple change in position, unlike RLS, which often returns when change of position, movement, or walking is not continued, no circadian pattern |
Positional discomfort
|
Symptoms relieved with movement
Symptoms worse in the evening/night
| Neurological disorder with "urge to move" | Leg cramps or charley horse cramps can come on at night and are relieved with stretching or walking; no urge to move; experienced as a usually painful muscular contraction, often involving the calf muscles, unlike RLS sensations; sudden onset, occurs not regularly, short duration, usually palpable contractions |
Nocturnal leg cramps
|
Unpleasant sensations in the legs
Symptoms worse in the evening/night
Sleep disturbance
| Sleep-related Disorders | Involuntary muscle (myoclonic) twitch which occurs during falling asleep, described as an electric shock or falling sensation which can cause movements of legs and arms. Occurring once or twice per night, frequent in the population. |
Hypnic jerks
|
Unpleasant sensations in the legs
Symptoms worse in the evening/night
Sleep disturbance
| Psychiatric Disorders | Depressive disorder with somatic symptoms like psychomotor agitation and diverse somatic complaints, circadian pattern with early awakening in the morning, daytime sleepiness. |
Depression, various forms with somatic syndrome
|
Urge to move
No positive response to dopaminergic drugs
No sleep disturbance
| Neurological disorder with "urge to move" | Occurs in subjects who fidget, especially when bored or anxious, but usually do not experience associated sensory symptoms, discomfort, or conscious urge to move; symptoms do not bother the subject, usually lacks a circadian pattern, more of a type of psychic restlessness, less sleep disturbances, no response to dopaminergic medication |
Volitional movements, foot tapping, leg rocking
|
Urge to move
No positive response to dopaminergic drugs
No periodic limb movements
| Disorders without "urge to move" | Discomfort centered more in joints, may not have prominent circadian pattern as seen in RLS, increase of symptoms during movement .does not respond to dopaminergics, usually no PLMs |
Arthritis, lower limb
|
Urge to move
Sleep disturbance
| Disorders without "urge to move" | Multiple, alternating, multiform complaints in muscle groups and joints; sometimes leg-accentuated but mostly whole body affected; frequent sleep disorders, no circadian pattern, no relief by movement, no dopaminergic response |
Fibromyalgia
|
Urge to move
| Vascular Disorder | Discomfort in legs, some relief with massage or inactivity |
Varicose veins
|
Diagnostic algorithm
1. Leading symptoms: Insomnia and unpleasant sensations in the legs
2. The RLS Diagnostic Index (RLS-DI)
General treatment considerations
A chronic disorder requiring long-term treatment
Drug | Starting dose and maximum recommended dosage | Time to full effective therapeutic dose | Half-life | Side effects |
---|---|---|---|---|
Levodopa | 50 mg 200 mg | At first dose | 1.5-2 hours | Augmentation Rebound |
Ropinirole | 0.25 mg 4 mg | 4-10 days | 6 hours | Nausea, low blood pressure, dizziness, headache, nasal congestion |
Pramipexole | 0.125 mg 0.54 mg | At first dose | 8-12 hours | Nausea, low blood pressure, dizziness, headache, nasal congestion |
Rotigotine | 1-3 mg patches | 1 week | 5-7 hours | Skin irritation, nausea, low blood pressure, dizziness, headache, nasal congestion |
Pregabalin | 25-300 mg | 3-6 days | 10 hrs | Sleepiness, dizziness, headache, fluid retention |
Clonazepam | 0.50 mg 2.0 mg | First dose: effect mainly on sleep | 30-40 hours | Sleepiness, dizziness, morning drug hangover |
Gabapentin | 300 mg 2700 mg | 3-6 days | 5-7 hours | Sleepiness, dizziness, fluid retention |
Exacerbators of RLS
Diphenhydramine (and other over the counter cold remedies) |
Metoclopramide |
Prochlorperazine |
Chlordiazepoxide |
Traditional antipsychotics (phenothiazines) |
Atypical neuroleptics (olanzapine and risperidone) |
Antidepressants (especially norepinehrine or selective serotonin reuptake inhibitors) |
Anticonvulsants (zonisamide, phenytoin, methsuximide) |
Antihistamines |
Opiods |
Drug dosages should be kept to a minimum
When to treat?
Clinical significance
How to treat
Categories of treatment and which drugs to use (for recommended doses see the treatment algorithm Figure 3)
a) Intermittent vs. continuous
b) Primary vs. secondary
c) Daytime symptoms?
2. How long to treat
-
On the patient's request;
-
Following causal interventions (e.g. renal transplants);
-
Periodically, e.g., every year for a few days if possible, to evaluate whether there are any spontaneous fluctuations in disease severity. This is not applicable for all patients especially those who are severely affected
3. Treatment follow-up
Treatment complications
When to refer to a specialist?
-
an insufficient initial response despite an adequate dose and duration of treatment;
-
the response to treatment becomes insufficient after a time despite an increased dose;
-
there are intolerable side effects;
-
the patient reaches the maximum recommended dosage and treatment ceases to be effective;
-
augmentation develops;
-
In general, children should not be treated at the primary care level.
Augmentation
When should augmentation be suspected?
-
any maintained increase in symptom severity despite appropriate treatment;
-
any maintained increase in symptom severity following a dose increase, particularly if a dose reduction leads to an improvement in symptoms;
-
any earlier onset of symptoms in the afternoon/evening;
-
any spreading of symptoms to previously unaffected body parts;
-
any shorter latency to symptom onset during the day when at rest.