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Practice

Restless legs syndrome

Philippe Rizek and Niraj Kumar
CMAJ February 13, 2017 189 (6) E245; DOI: https://doi.org/10.1503/cmaj.160527
Philippe Rizek
Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ont.
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  • For correspondence: philippe.rizek@trilliumhealthpartners.ca
Niraj Kumar
Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ont.
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Restless legs syndrome is the most common movement disorder, characterized by an irresistible, often uncomfortable, urge to move the legs when at rest

Restless legs syndrome affects 5%–10% of the population, most commonly in women older than 35 years of age. Of all people seeking medical care, 2%–3% will have restless legs syndrome that affects their sleep, daytime productivity, cognition or mood, and will require treatment.1 Restless legs syndrome may be primary (age at onset usually < 45 yr) or secondary to a medical condition (e.g., iron deficiency, renal disease) that presents later.1 Although the syndrome may be intermittent (< 2 times/wk in the past year with ≥ 5 lifetime events), most cases are chronic (> 2 times/wk in the past year).1

The diagnosis of restless legs syndrome is clinical

The syndrome is diagnosed based on specific criteria,1 using the mnemonic “URGES”: Urge to move the limbs, usually associated with paresthesias or dysesthesias; Rest brings out symptoms or worsens them; Getting up and moving leads to at least partial relief; Evenings are when symptoms worsen; and Secondary causes must be excluded (e.g., myalgia, venous stasis, leg edema, arthritis, cramps, positional discomfort, neuropathy or drug-induced akathisia).1

Secondary causes of restless legs syndrome and exacerbating factors should be recognized and treated

This includes managing renal impairment,2 treating serum ferritin below 50 μg/L,3 eliminating antidopaminergic drugs, addressing sleep hygiene, and reducing caffeine and alcohol intake. About two-thirds of patients resort to alternative treatments. 2 Regular physical activity and cognitive behavioural therapy may improve mood, anxiety and sleep, but require high-quality randomized controlled trials to confirm their efficacy.2

Restless legs syndrome is not associated with an increased risk of developing a neurodegenerative disorder, such as Parkinson disease

Although dopamine deficiency is implicated in restless legs syndrome, it involves areas outside the nigrostriatal pathway affected in Parkinson disease.3 The risk of restless legs syndrome in Parkinson disease increases with disease and treatment duration, independent of antiparkinsonian drug dosages.4

Treatment may be required for life

The best evidence exists for use of dopaminergic and anticonvulsant agents in treating primary restless legs syndrome (Appendix 1, at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.160527/-/DC1), with dopamine agonists favoured.5 Augmentation, which consists of symptoms that occur earlier in the day with worsening severity, involvement of other body parts or shortened medication effect, may appear with chronic dopaminergic therapy and can be managed by splitting the dose, taking the medication earlier or switching to a longer-acting dopamine agonist or patch.3

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

  • Contributors: Both of the authors were responsible for the conception of the article. Philippe Rizek drafted the manuscript. Niraj Kumar revised the article for important intellectual content. Both of the authors approved the final version to be published.

References

  1. ↵
    1. Allen RP,
    2. Picchietti DL,
    3. Garcia-Borreguero D,
    4. et al
    . Restless legs syndrome/Willis–Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria — history, rationale, description, and significance. Sleep Med 2014;15:860–73.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Bega D,
    2. Malkani R
    . Alternative treatment of restless legs syndrome: an overview of the evidence for mind-body interventions, lifestyle interventions, and neutraceuticals. Sleep Med 2016;17:99–105.
    OpenUrl
  3. ↵
    1. Ondo WG
    . Restless legs syndrome: pathophysiology and treatment. Curr Treat Options Neurol 2014; 16:317.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Trenkwalder C,
    2. Allen R,
    3. Högl B,
    4. et al
    . Restless legs syndrome associated with major diseases: a systematic review and new concept. Neurology 2016; 86:1336–43.
    OpenUrl
  5. ↵
    1. Aurora RN,
    2. Kristo DA,
    3. Bista SR,
    4. et al
    . Update to the AASM Clinical Practice Guideline: “The treatment of restless legs syndrome and periodic limb movement disorder in adults — an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses. Sleep 2012;35:1037.
    OpenUrlPubMed
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Canadian Medical Association Journal: 189 (6)
CMAJ
Vol. 189, Issue 6
13 Feb 2017
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Restless legs syndrome
Philippe Rizek, Niraj Kumar
CMAJ Feb 2017, 189 (6) E245; DOI: 10.1503/cmaj.160527

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Restless legs syndrome
Philippe Rizek, Niraj Kumar
CMAJ Feb 2017, 189 (6) E245; DOI: 10.1503/cmaj.160527
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  • Article
    • Restless legs syndrome is the most common movement disorder, characterized by an irresistible, often uncomfortable, urge to move the legs when at rest
    • The diagnosis of restless legs syndrome is clinical
    • Secondary causes of restless legs syndrome and exacerbating factors should be recognized and treated
    • Restless legs syndrome is not associated with an increased risk of developing a neurodegenerative disorder, such as Parkinson disease
    • Treatment may be required for life
    • Footnotes
    • References
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