If you have restless legs syndrome and want to find out the best evidence based advice
this video is for you!
My name is Simon and I’m a Consultant in Clinical Neurophysiology.
I’m going to explain to you what we now know about this common condition and how best
to manage it.
Restless Legs Syndrome (pause) or RLS, is very common and affects at least 2% of the
population.
It is a clinical diagnosis which was redefined in 2014 as matching 5 key criteria:
1.
An urge to move the legs which is usually accompanied by an unpleasant sensation in
the legs.
This is often described as a crawling sensation under the skin.
2. It is worse during periods of rest or inactivity
3. There is at least partial relief by movement
4. Clear evening or night time emphasis
5. It is not solely explained by another medical or behavioural condition
When it comes to understanding and therefore treating RLS - there are two major categories,
Primary and Secondary.
Let’s start with Secondary.
This means that there is an identifiable process driving the RLS and if so treatment is aimed
at addressing the underlying cause as well as managing symptoms.
Causes can include any of the following: Peripheral neuropathy in around 1/3rd.
This may be a large fibre or more commonly a small fibre neuropathy.
You can see separate videos explaining these and how they are tested by clicking on the
i-cards above.
Iron and to a much lesser extent magnesium deficiency can be causes, raised urea levels
from kidney failure, and Varicose Veins.
Medications including a variety of anti-depressants can also be a factor.
Pregnancy is also well recognised but self-resolves afterwards in the majority of cases.
Primary RLS is when there is no identifiable cause.
It’s quite different in that it tends to start at a much younger age and there is often
a positive family history in around 2/3rds of patients.
Research is ongoing into a variety of potential causative genes.
To understand how treatment works and why it can fail, we need to be clear on the underlying
disease mechanisms.
Current research has identified that multiple regions of the brain dysfunction especially
the Basal Ganglia which are important in initiating and controlling movement.
Many of the neural cells here rely on Dopamine which needs Iron as part of it’s formation.
Iron uptake by these cells is impaired for reasons, as yet unknown.
This leads to a relative fall in Dopamine production.
We can target either of these so patients who are Iron deficient, and this can be from
any cause of anaemia, can respond well to Iron replacement.
Medications that increase Dopamine levels directly such as Levo-Dopa or act like Dopamine
such as Ropinorole are also successfully used as treatments for this condition.
However, it’s not just these cells that dysfunction.
It is also important to recognise that the brains natural internal Opioid system may
also be depleted and this may be why the condition is often responsive to Opioid medications.
Many other structures which govern sensation, emotion, cognition, behaviour and movements
are also implicated.
This likely explains why so many patients have a multitude of other problems including
high rates of depression (up to 30%), impulsivity and problems with decision making.
Sleep disturbances are also very common.
Around 80% of RLS patients also have Periodic leg movements in sleep which are associated
with arousals and so further interrupt sleep quality.
This is a long term condition and whilst it can wax and wane, treatment often needs to
be provided for prolonged periods, even many years.
There is a significant issue with Dopamine replacement therapy which is called Augmentation.
This means that the treatment itself can in fact worsen the condition with a risk of this
happening of around 7% per year.
Signs of this developing include worsening intensity, spread of symptoms into other body
regions such as the arms, shorter duration between rest and symptoms and also earlier
onset of symptoms into the daytime.
Some medications are worse at doing this than others, particularly Levo-Dopa.
This is why it is no longer a first choice treatment.
The combined task force of the RLS-Foundation, European RLS Studdy Group and the International
RLS Study Group have produced their management recommendations in 2016.
You can find a link to the whole guidance in the link below.
But briefly
1. Non-dopamine medications such as Gabapentin Enacarbil, also called Horizant, should be
trialled first which should avoid the risk of Augmentation.
However, it is not yet universally licensed as a first line medication.
2. When dopaminergic medications are utilised these should be at the lowest possible doses
e.g. Pramipexole, Ropinirol or Rotigotine and the aim should be to reduce symptoms to
the point where quality of life isn’t impaired but not their complete eradication.
3. If augmentation does occur then anything exacerbating factors should be addressed such as iron replacement
if they have low Iron stores or avoidance of medications that can exacerbate augmentation
such as Anti-depressants and Anti-histamines should be reduced or avoided and any lifestyle
factors such as sleep deprivation addressed.
4. Other medications may need to be added at this point such as Horizant or even switching.
5. Opioids such as Oxycodone do have a place as treatment but are reserved for those with
severe augmentation symptoms not responding to all other means.
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