Restless Legs Syndrome (RLS), or Willis-Ekbom disease (WED) is one of the most common chronic sensorimotor neurological conditions encountered by clinicians. It occurs in 5% to 10% of the adult population in the United States and 2-3% is said to be moderate to severe requiring medical treatment.
The National Sleep Foundation estimates that only one-third of people who suffer from this debilitating disorder have been diagnosed. RLS occurs in people of all ages, even children, and strikes women about twice as often as men.
RLS is a serious neurologic disorder that increases cardiovascular risks such as high blood pressure, stroke and heart disease. The uncomfortable sensations may accompany an irresistible urge to move the legs. Here are five things to know about RLS, its diagnosis and treatment.
1. RLS was first described by Thomas Willis, a 17th century English physician of Charles II, who wrote a chapter in his 1664 book CerebriAnatome entitled Instructions for curing the Watching evil, where he described, “leaping and contractions of the tendons and so great a restlessness and tossing of the members ensure, that the diseased are no more able to sleep, than if they were in the place of the greatest torture!” The term Restless Legs Syndrome was coined by Professor Karl-Axel Ekbom and described in his 1945 publication “Restless Legs” – hence the name Willis-Ekbom disease.
2. There is no simple blood test to confirm the presence or absence of RLS. Rather, physicians must rely on symptomatic diagnostic criteria that include:
a. A strong urge to move the affected body parts, which is often accompanied by an unpleasant feeling such as tugging or a tingling sensation
b. Symptoms which intensify at night and are absent or negligible in the morning
c. Symptoms that are relieved with movement and return when activity stops
d. Symptoms worsen during rest, inactivity or sleep
e. Symptoms are not solely attributed to a medical condition or behavioral disorder such as arthritis, leg cramps, etc.
3. People with RLS are at twice the risk of stroke and other cardiovascular disease, and it can cause significant stress on relationships, family, education and work life. There is no cure for RLS, but the International Restless Legs Syndrome Study Group guidelines recommend dopamine agonists (DA) and alpha-2-delta ligands as first line treatment.
4. Augmentation is the severe worsening of RLS symptoms associated with long term of use treatment.
5. Because of widespread use of DA, new cases of augmentation are increasing at an alarming rate of 8% per year. Strategies utilized to prevent augmentation may include:
a. Keep dopaminergic load as low as possible. We try to keep dopaminergic load as low as possible or we simply use medication that has no risk of augmentation, such as gabapentin enacarbil, as the first-line treatment for de novo patients. The choice of medications should be individualized depending on the risk and benefits of each treatment option weighed against the risk of augmentation. Physicians must consider the patient’s previous response to treatment, possible drug-drug interaction, and patient comorbid conditions when initiating treatment. Consider a longer-acting DA.
b. When using DA, consider using a longer-acting DA since studies have shown that longer-acting DA may cause less augmentation. As with all DA, always avoid increasing the dose above the recommended level for RLS.
c. Consider intermittent dosing or dose reduction with DA. Since RLS symptoms vary and intensity fluctuates, physicians should consider intermittent dosing or dose reduction especially when RLS symptoms are mild or occur less than one or two times per week. -
For further information please go to "NoRestForRLS.com" and "RLS.org"
Daniel Lee, MD, FAAN, FAASM, is the author of numerous pivotal trials on restless legs syndrome, including the ropinirole and gabapentin enacarbil trials that led to their FDA approval. He has been lecturing nationally and internationally including Beijing, China, and Paris, France, on various sleep disorders.