RLS is a common condition although most people do not reach doctors; the diagnosis is clinical (see below) 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 (e.g. associated with psychiatric medication), anxiety, spinal stenosis.
Restless Legs Syndrome does not include hypnic jerks (myoclonic jerks as falling asleep)/involuntary movement.
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.
Diagnostic Features
Patient may not necessarily need to be referred for RLS; however but the team are happy to advise/see for diagnostic clarification or management problems.
Do patients need investigation in primary care?
All with suspected RLS should have a basic blood screen including glucose and serum ferritin (aim for levels > 100micrograms/L).
Do patientsneed to see a Neurologist?
Not necessarily but we are happy to advise/see for diagnostic clarification or management problems.
General Lifestyle Advice
Many people with RLS can be managed without 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. However, some people find cooling down prior to bed e.g. a gentle walk outside, standing on a cool floor without shoes / socks, more helpful than heat. Some drugs, notably Tricyclic antidepressants such as amitriptyline, serotonin reuptake inhibitors may worsen symptoms.
Treatment of RLS
Many 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 augmentation; 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.
First Line Therapy
Second Line therapies (consider carefully whether drug therapy required)
Refer to neurology if above not helpful. Try to avoid starting dopamine agonists and avoid levodopa. These are very effective but cause augmentation and dopamine agonists carry a high risk of impulse control disorders (obtain written consent before starting). Below for information.
Patient information
RLS-UK https://www.rls-uk.org/
Borders Ref Help Toolkit