Continuing Education Activity

Restless leg syndrome (RLS), or Willis-Ekbom disease, is a common chronic movement disorder in which patients have an irresistible urge to move their legs. The non-painful but strong perceived need to move their legs when their legs are at rest is relieved with leg motion. There is a diurnal pattern wherein symptoms worsen at night, and sleep disturbance is often a problem. There is an association with involuntary jerking movements of the legs during sleep, known as periodic leg movements of sleep. There are more than 3 million cases in the United States annually. This activity reviews how to properly evaluate for RLS and further steps that should be taken when presenting features are present. This activity highlights the role of the interprofessional team in caring for patients with this condition.

Objectives:

• Identify when restless leg syndrome should be considered in differential diagnosis.

• Assess the evaluation of restless leg syndrome.

• Evaluate the management strategies for restless leg syndrome.

• Communicate the importance of care coordination among interprofessional team members in managing patients with restless leg syndrome for better outcomes.

Introduction

Restless legs syndrome (RLS), or Willis-Ekbom disease, is a common, chronic, multifactorial movement disorder of the limbs in which patients have an irresistible urge to move their legs. This is often associated with abnormal, non-painful sensations that start at rest and are improved by activity. There is a diurnal pattern of worsened symptoms at night. Sleep disturbance is associated with involuntary jerking movements of the legs during sleep, known as periodic leg movements of sleep. There are more than 3 million cases in the United States annually. RLS is underdiagnosed, and there is a significant delay in diagnosis. The disorder may start in childhood, but the diagnosis is often not made until the third decade of life. Symptoms are worse at rest and sleep. Today, the condition can be treated with medications.

Etiology

There are 2 types of RLS, primary and secondary.[1] Commonly, RLS is a primary central nervous system disorder. This idiopathic disease may be familial in 25-75% of patients. In familial cases, RLS is observed to have autosomal dominant or recessive patterns. Patients with a familial type of RLS tend to present earlier (< 45 years) with slower disease progression. In some familial cases, a progressively decreasing age of onset in successive generations has been described ie, genetic anticipation. Psychiatric factors, stress, and fatigue may also exacerbate symptoms of RLS.

Secondary RLS can occur secondary to some disorders, including:

• Iron deficiency
• End-stage renal disease
• Diabetes mellitus
• Rheumatic disease
• Venous insufficiency
• Peripheral neuropathy
• Folate or magnesium deficiency
• Amyloidosis
• Lumbosacral radiculopathy
• Fibromyalgia
• Celiac disease
• Medications have been known to cause or exacerbate the symptoms of RLS. They include antidopaminergic medications (eg, neuroleptics), diphenhydramine, tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, alcohol, caffeine, lithium, and beta-blockers.[2][3] 

RLS affects close to 1/3rd of pregnant patients, but luckily, the symptoms subside in a few weeks after delivery. However, in a long-term, follow-up study, patients who developed RLS during pregnancy demonstrated a 4-fold increased risk of having chronic RLS as opposed to women with no RLS during pregnancy.[4] RLS has been observed in 25-50% of patients with end-stage renal disease; the symptoms in these patients are typically worse during hemodialysis. One study observed that anxiety, hyperphosphatemia, and coping mechanisms for stress were independently related to RLS in uremic patients undergoing hemodialysis.RLS may resolve after kidney transplantation.[5]

Epidemiology

Between 5% to 15% of the population may have RLS. Familial RLS tends to occur at ages younger than 45 years. Age can be from childhood to older than 90 years.  Women are affected more than men. African Americans are less frequently affected as compared to whites. This stands true for patients on hemodialysis.[6] Eleven percent to 29% of pregnant women are affected. It is threefold more common in pregnant women than in nonpregnant women and has a higher prevalence in the third trimester.[7][8] As many as 25% to 50% of patients with end-stage renal disease have RLS with symptoms, particularly during hemodialysis.[9][10]

Pathophysiology

The pathogenesis of RLS is not completely known.[5][11][12] In idiopathic RLS, a dysfunction of the dopaminergic system and iron stores in specific regions in the brain diminish. There may be an autosomal dominant inheritance; there have been reports of several large kindreds with different susceptibility loci with RLS. This suggests a genetic basis for the disease.[13][14] Calcium/phosphate imbalance, anemia, functional iron deficiency, and subclinical peripheral nerve abnormalities may be involved in the pathophysiology of uremic RLS. Vitamin D deficiency and calcium metabolism, pre-eclampsia, a strong family history, low serum iron, ferritin level, and high estrogen levels may also play a role in pregnancy. Polymorphisms in genes including BTBD9 and MEIS1 are associated with RLS. Human neuropathologic and imaging studies have shown decreased iron in different brain regions, including substantia nigra and thalamus. These areas also demonstrate a state of relative dopamine excess.[8][15][1] Restless leg syndrome is extremely common during pregnancy, especially during the third trimester.

History and Physical

Patients describe sensations such as crawling, creeping, pulling, itching, drawing, or stretching, all localized to deep structures rather than the skin. Pain and tingling paresthesia of the type that occurs in painful peripheral neuropathy is usually absent, and there is no sensitivity to skin touching. Symptoms can range from some patients experiencing very mild problems to others having major disruption of sleep and impairments in quality of life. Symptoms typically worsen towards the end of the day and are maximal at night when they appear within 15 to 30 minutes of reclining in bed. In severe cases, symptoms may occur earlier in the day while the patient is seated, interfering with attending meetings, sitting in a movie theater, and other activities. In milder cases, patients will fidget, move in bed, and kick or massage their legs for relief. Occasionally, the arms may be affected. Patients with more severe symptoms feel forced to get out of bed and pace the floor to relieve symptoms. Periodic leg movements of sleep are characterized by involuntary, forceful dorsiflexion of the foot lasting 0.5 to 5 seconds and occurring every 20 to 40 seconds throughout sleep. There may be limb twitching during sleep. These occur in 80% of patients with RLS. The physical examination is usually normal in patients with RLS. It is performed to identify secondary causes. 

Essential diagnostic criteria (all must be met):

• An uncontrollable urge to move the lower extremities and unpleasant and uncomfortable sensations may accompany it.
• The urge to move the extremities is less during the day but progressively worsens in the evenings and at night. The symptoms also appear at rest or during periods of sleep and inactivity.
• The urge to move the lower extremities may partially or completely be relieved by ambulation or stretching the legs. The symptoms are mild or absent as long as the activity is continued.
• The urge to move the lower extremities worsens in the evenings and makes sleeping impossible. Thus, the patient is often fatigued during the day.
• The presence of these symptoms must not be attributed to other behavior conditions, such as tardive dyskinesia, leg cramps, muscle spasms, or discomfort from the position.[16] 

The leg movements are usually involuntary and may involve sudden dorsiflexion motions that may last 1-5 seconds and recur every 30-40 seconds throughout sleep. Positive family history is common in children. The physical exam is usually normal. However, the patient must be examined to rule out a neurological disorder, radiculopathy, or Parkinson disease.

Evaluation

There are no tests to diagnose RLS except the ones to rule out secondary causes. Blood work is done to rule out other causes as well. Electromyography and nerve conduction studies are done if one suspects radiculopathy or neuropathy. Polysomnography is often done to quantify the frequency of leg movements and characterize the sleep pattern. Iron studies should be done in all patients with symptoms of RLS.[17] Detailed iron studies, including serum iron, transferrin saturation, ferritin, and total iron-binding capacity, should be done; however, if a complete iron panel is not obtainable, then at a minimum, a ferritin level should be done. Patients whose RLS is under control but who have a reemergence or augmentation of their symptoms should again go through an assessment of their iron status. Augmentation means the presence of 1 or more of the following:

• Symptoms occurring earlier in the evening
• Symptoms are more intense in the morning
• Symptoms extend to the upper parts of the body

If a secondary cause is suspected, then other laboratory tests should be carried out, such as a complete blood count and an evaluation of levels of the following:

• Blood urea nitrogen
• Fasting blood glucose
• Creatinine
• Magnesium
• Vitamin B-12
• Thyroid-stimulating hormone
• Folate

In terms of the nervous system, even if the neurological examination is normal, nerve conduction studies and needle electromyography should be considered if radiculopathy or polyneuropathy appears probable on clinical examination.

Treatment / Management

Treatment for RLS usually does not commence in patients with sporadic or mild symptoms.[18] A holistic management plan may involve pharmacotherapy and nonpharmacologic measures tailored to the patient’s symptoms.[18] Patients should be followed up by their primary care provider or a neurologist for the worsening of the disease. In 2014, the US Food and Drug Administration approved a device for improving sleep to be used commercially for patients with RLS. The device counter-stimulates the patient's legs with vibrations. The approval came after 2 randomized studies showed improvement in sleep with the device as opposed to a placebo pad. Patients should be advised to avoid caffeine, antidepressants, antipsychotics, dopamine-blocking anti-emetics, and centrally-acting antihistamines. Short daily dialysis in renal failure patients, iron replacement, exercise, massage, and heat can all alleviate the symptoms. Dopamine agonists, including pramipexole, ropinirole, rotigotine, and cabergoline, have reduced symptoms and improved sleep quality and quality of life. Pramipexole and ropinirole have adverse effects, including gambling addiction and extreme weight gain. The rotigotine transdermal patch can also be used. It is well tolerated and has a relatively low risk of clinically significant augmentation of RLS.

In a large meta-analysis involving 3286 participants, pramipexole improved the symptoms of patients with primary moderate-to-severe restless leg syndrome and maybe better than ropinirole. In a small study, rotigotine improved periodic limb movements and restless leg syndrome symptoms in the short term among end-stage renal disease patients. The use of alpha2-delta calcium-channel ligand (gabapentin or pregabalin) should be considered for the initial treatment of those patients who have severe sleep disturbance, comorbid insomnia, anxiety, pain, or a previous history of an impulse control disorder.[19][20][21] The drugs are effective for 1-5 years, but they also have adverse effects that reduce compliance. Today, the first-line treatment is either an alpha2 delta calcium channel ligand or a dopamine receptor agonist. Supplemental iron is recommended for all patients who have low serum ferritin levels.

Restless leg syndrome in pregnancy usually resolves after delivery. Many patients benefit from exercise, but it is often not realistic in the middle of the night. International Restless Legs Syndrome Study Group developed a guide for the long-term pharmacologic management of RLS.[22] The Task Force based the following recommendations on the results of 61 studies:

• Pregabalin: Effective for up to a year in treating RLS
• Ropinirole, pramipexole, and rotigotine: Effective for up to 6 months
• Gabapentin enacarbil for 1 year, levodopa for 2 years, and rotigotine for 5 years: Probably effective for durations ranging between 1 and 5 years
• Pergolide and cabergoline: Due to safety concerns, they are not being used in treating RLS

All patients with a ferritin of less than 50 ng/mL should receive the iron replacement.[18] For iron deficiency, ferrous sulfate (325 mg) could be given with vitamin C (250 mg). It should be taken on an empty stomach, and not eat anything for 60 minutes to increase the absorption. Parenteral iron could also be required to treat RLS because of iron deficiency.[23] In terms of nonpharmacological measures, the following should be recommended to patients:

• Sleep hygiene
• Exercise
• Hot or cold bath
• Limb massage
• Vibratory or electrical stimulation of the feet
• The elimination of caffeine before bedtime

Differential Diagnosis

Conditions to be considered while making the diagnosis of RLS are:

• Tardive dyskinesia
• Akathisia
• Leg cramps
• Vascular disease
• Muscle spasms
• Radiculopathy

Prognosis

In about 70% of patients, the symptoms progress and become moderate to severe. In addition to the legs, some patients may experience the same symptoms in the arms. Overall, the symptoms are less severe in the morning and worsen during the evening and night. In some patients, the symptoms are so severe that they are disabling, interrupting sleep, and causing daytime fatigue. Studies show that restless leg patients are prone to hypertension, headaches, and sleep difficulties. The quality of life for most patients is poor. By 50 years of age, RLS usually worsens and causes daily sleep disruption, resulting in decreased daytime alertness. RLS is associated with poor quality of life.[24][25]

Complications

Complications of the disease itself are limited to the quality of life due to disturbed sleep and fatigue. In most patients, the symptoms progress over time and cause significant quality of life issues.

Deterrence and Patient Education

Patients should be educated on the disease's progressive nature and various nonpharmacological treatment modalities to alleviate symptoms. The patients can do the following to make themselves feel better at home:

• Massaging their legs themselves or by someone else
• Using heating pads or a warm bath to warm the legs
• Avoidance of medicines that can make RLS worse
• Activities that keep their minds alert during the day, eg, crossword puzzles
• Moderate regular exercise

Pearls and Other Issues

With prolonged use of dopamine agonists, symptoms may increase in severity despite appropriate treatment. An increase in the dose may be required, with earlier onset of symptoms, spreading to unaffected parts, and shorter duration of action of the medication. This is known as augmentation. Restless leg syndrome may gradually worsen with age. The progression is slower in patients with the disease's idiopathic form than in those who have an associated medical condition.

Enhancing Healthcare Team Outcomes

The diagnosis and management of restless leg syndrome are complex. The condition can be disabling and is best managed by an interprofessional team that includes a nurse practitioner, neurologist, internist, physical therapist, and primary care provider. The primary care provider should emphasize the importance of good sleep hygiene. The patient should be discouraged from consuming alcohol and caffeinated beverages. The physical therapist should educate the patient on the types of exercise that can be done while in bed. Since many patients develop anxiety and depression, a mental health nurse should be consulted. The pharmacist should educate the patient on the types of drugs used to treat restless leg syndrome and their potential adverse effects. While many drugs are used to treat this disorder, none is superior to other classes. Plus, these drugs are not reliable or consistent in their efficacy. Relapses are common. More importantly, many patients develop adverse reactions to the drug, and non-compliance is a major problem in the long run. Overall, the quality of life of patients with RLS is poor.[26] To prevent this disorder's high morbidity, close communication between the team members is vital to ensure that the patient is receiving optimal care and support.