Clinical Care: Restless Leg Syndome

Question 1

(1) RLS is an uncomfortable “creeping, crawling” sensation or “pins and needles feeling”
in the limbs, especially in the legs.
(2) RLS tends to occur during periods of inactivity, particularly the evenings
(3) During sleep patients with RLS have periodic limb movements of sleep (PLMS)
which may or may not awake a patient from sleep
(4) The uncomfortable sensations are temporarily relieved by limb movement

Answer 1

Overview of restless leg syndrome (RLS)

Question 2

(1) Pathophysiology is not completely understood but there is identifiable evidence that
there is a combination of CNS and PNS abnormalities
(2) CNS abnormalities
(a) Reduced iron stores in CNS
(b) Alterations in dopaminergic systems
(c) Circadian physiology
(d) NT imbalances of glutamate and GABA
(3) PNS abnormalities
(a) Patients with RLS have been founds to have static hyperalgesia where their
response to pinprick pain ratings were significantly elevated.

Answer 2

Pathophysiology Restless leg syndrome (RLS)

Question 3

(1) Hallmark symptom is unpleasant or uncomfortable urge to move legs (occasionally
arms) that is transiently relieved with movement
(2) Sensations can be described as:
(a) Urge to move
(b) Crawling
(c) Tingling
(d) Restless
(e) Cramping
(f) Creeping
(g) Pulling
(h) Electric
(i) Soreness
(3) Sensations are described as deep rather than superficial
(4) Exacerbating factors
(a) Antihistamines (diphenhydramine or hydroxyzine)
(b) Dopamine receptor antagonists (example: anti nausea medication likemetoclopramide)
(c) Antidepressants like SSRIs and SNRIs

Answer 3

Clinical presentation Restless leg syndrome (RLS)

Question 4

Foot tapping, bouncing, leg rocking
(a) Usually lack circadian rhythm pattern and not associated with “urge”

Answer 4

Volitional movements

Question 5

Intense desire to move
(a) Do not typically complain of limb paresthesia or unpleasant sensory phenomena
(b) Less relief when limb is moved compared to RLS

Answer 5

Akathisia

Question 6

(a) Common disorganized spasms of muscles that is associated with palpable muscle
contraction

Answer 6

Nocturnal leg cramps

Question 7

(a) Urge to move legs usually accompanied or caused by unpleasant sensation in legs
(b) Unpleasant sensations worsen during periods of rest or inactivity such as lying or sitting
(c) Unpleasant sensations are partially or totally relieved by movement
(d) Symptoms are worse during the evening or night
(e) Symptoms are not solely accountable for other medical or behavioral condition (i.e. volitional movements)

Answer 7

Diagnosis Restless leg syndrome (RLS)

Question 8

(1) Low iron
(a) Start treatment is serum ferritin level <75mcg/L
(b) Ferrous sulfate - iron supplement
1) Dose: 325 mg three times daily for 3-6 months, is the preferred therapy.
2) MOA: Provides iron, an essential component in hemoglobin, myoglobin, and
various enzymes
3) Adverse Reactions: Dyspepsia, N/V, constipation, dark stools
4) Contraindications: Hemolytic anemia, peptic ulcer disease, ulcerative colitis
5) Note: Ferrous sulfate is very constipating so will likely need a stool softener
or laxative with it. It turns patient’s stool black
6) Most common reason for it not working is patient non- compliance

(c) Non-pharmacologic treatment
1) Avoidance of aggravating drugs and substances like caffeine
2) Increase exercise
3) Leg massage

(d) Refractory RLS may need referral to MO.

Answer 8

Treatment of RLS

Question 9

Urge to move limbs

Answer 9

RLS

Question 10

hyperalgesia

Answer 10

RLS where their
response to pinprick pain ratings were significantly elevated.

Question 11

Hallmark symptom is unpleasant or uncomfortable urge to move legs (occasionally arms) that is transiently relieved with movement

Answer 11

RLS

Question 12

Serum ferritin

Answer 12

Iron studies should be considered in evaluation for RLS