Dr Kevin Fernando discusses what to know about restless legs syndrome in primary care.
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-- TRANSCRIPT --
Laura is a 34-year-old nurse who consults you in clinic because she's waking frequently through the night with aching and jumpy legs. She often has to get out of bed to walk and stretch her legs to relieve her symptoms. As a result of this ongoing sleep disturbance, Laura feels tired all the time and is struggling to fulfill her work commitments. Laura probably has a restless legs syndrome (RLS). What do we need to know about RLS in primary care?

RLS, also known as Willis-Ekbom disease, is common in primary care. For some people, it's a simple annoyance; for others, symptoms are more severe and affect their quality of life and sleep. It is these individuals whom we often see in clinic.

The prevalence of RLS is estimated at 5%-10% of European and North American adults; of these individuals, 2%-3% experience moderate to severe symptoms that have a significant impact on their quality of life. Women are affected twice as often as men, and the average age of diagnosis is the fourth decade — just like our case patient, Laura. A positive family history is also very common, found in over 50% of cases.

RLS is characterized by an overwhelming urge to move the legs, with associated discomfort. These symptoms are partially or totally relieved by movement. It usually occurs in the evening or at night and can be accompanied by abnormal sensations such as burning or tingling; occasionally, individuals may describe the sensation of insects crawling under their skin.

Importantly, some people will not present with these classic symptoms and may present only with sleep disturbance or restlessness at night. Be sure to ask patients about symptoms of RLS during any sleep-related consultations.

The pathophysiology of RLS has not been fully elucidated, but it is related to iron and dopaminergic pathways in the brain. Differential diagnoses to consider include nocturnal leg cramps, which involve sudden, involuntary, and painful muscle contractions in the legs and are usually unilateral. We also need to exclude peripheral neuropathy, which has multiple etiologies including diabetes, excessive alcohol intake, certain medications, and vitamin B12 deficiency.

Hypnic jerks can also mimic RLS. These are sudden jerking movements that occur as you are about to drop off to sleep. Peripheral vascular disease needs to be excluded, though as we all know, intermittent claudication is usually related to exercise and is not generally worse in the evenings or at night.

Finally, it is important to exclude akathisia. The word akathisia is derived from the Greek for "inability to sit." It is a feeling of inner restlessness and an inability to sit, stand, or lie still for a reasonable period of time. It is often associated with the use of antipsychotic medication, and symptoms bear no relation to the time of day.

RLS is predominantly primary or idiopathic but can also be secondary to certain conditions. The three most common secondary causes of RLS are iron deficiency, pregnancy, and end-stage kidney disease.

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