Twist and Shout — Restless Legs Syndrome is Common, Miserable, and Treatable
Twist and Shout—Restless Legs Syndrome is Common, Miserable, and Treatable
Abstract & commentary
Synopsis: Restless Legs Syndrome probably afflicts one in 10 North Americans and is associated with modifiable behaviors and treatable risk factors. It responds well to medication.
Source: Phillips BA, et al. Arch Intern Med 2000;160:2137-2141.
This is a large, population-based telephone survey of Kentuckians. The Centers for Disease Control (CDC) conducts a nationwide Behavioral Risk Factor Surveillance Survey (BRFSS) annually. Individual states may include additional questions. We developed questions that incorporated the basic clinical features of Restless Legs Syndrome (RLS). The question was, "Do you have unpleasant feelings in your legs (e.g., creepy-crawling or tingly feelings) when you lie down at night that make you feel restless and keep you from getting a good night’s sleep?" The possible responses were (0) never, (1) rarely (once a month or less), (2) sometimes (2-4 times a month), (3) often (5-15 times a month), and (4) very often (16 or more times a month). Overall, 9.4% of the 1803 respondents self-reported these symptoms often or very often. This is very similar to the prevalence or RLS reported in surveys in other countries.1,2 What is new about this report was the association of RLS symptoms with lifestyle. RLS symptoms were associated with sedentary lifestyle, cigarette smoking, obesity, and self-reported poor mental health.
Comment by barbara a. phillips, md, msph
When given an opportunity to select and report on my own work as noteworthy, I couldn’t pass it up. The importance of this paper is that it is the largest RLS prevalence study to date in the United States. This paper indicates that about one in 10 individuals endorses frequent symptoms of RLS.
For those of you wondering what RLS is (and you’re not alone!) the recently-standardized criteria3 are: 1) the desire to move the limbs, usually associated with paresthesias; 2) motor restlessness; 3) symptoms worse or present exclusively at rest with at least partial and temporary relief by activity; and 4) symptoms worse in the evening or at night. The question we included in the 1996 KY BRFSS was developed with these criteria in mind and in conjunction with the RLS Foundation, but it probably did not address the "relief with activity" part. Our positive respondents may have included some individuals with neuropathy, leg cramps, Parkinson’s disease, medication side effects, or psychiatric illness. However, even if we overestimated by 100%, there are still a lot of people afflicted with this condition. Because the prevalence rate we found was remarkably similar to that reported in Canada1 and in Germany,2 and because the German study included a personal interview and physical examination, we think we are not far off the mark.
Like depression, the diagnosis of RLS is based on symptoms. A majority of people who have RLS also have Periodic Limb Movement Disorder (PLMD), which is a distinctive, rhythmic pattern of increased leg EMG activity noted during sleep testing. However, the majority of people who have PLMD do not have RLS, so the expense and inconvenience of sleep studies are generally not warranted in diagnosing RLS. Thus, there is, as yet, no biologic marker for RLS. Because of this, it has the potential to be both over- and under-diagnosed, much like Attention Deficit Hyperactivity Disorder (ADHD), and to arouse skepticism among busy clinicians.
If you suspect that a patient has RLS, it is reasonable to address modifiable behavioral contributors, which include obesity, smoking, and lack of exercise. Caffeine, alcohol, and many medications, notably antidepressants, have been reported by some to exacerbate RLS symptoms.1 It is a good idea to investigate the possibility of renal disease, diabetes, and iron deficiency, which are associated with this symptom complex.
Specific pharmacologic treatment includes at least four categories of medications: dopaminergic agents, anticonvulsants, benzodiazepines, and narcotics.
Dopaminergic agents. Both dopamine precursors and dopamine-receptor agonists are beneficial in RLS and PLMD treatment. Carbidopa/levodopa (Sinemet), pergolide (Permax), and pramipexole (Mirapex) are the best-studied agents for treatment of RLS. These agents can cause nausea, constipation, hypotension, or headache. Two specific concerns with Sinemet are the development of augmentation (a tendency for symptoms to develop earlier in the day) and rebound (worsening of symptoms after initiation of treatment). Use of controlled release (CR) preparations may help forestall this development. However, once augmentation and/or rebound occur, the patient should be switched to another medication, at least temporarily.
Opioids. Opioids are clearly helpful for some individuals with RLS. Oxycodone and propoxyphene have been studied. Codeine, pentazocine, methadone, fentanyl, and tramadol are also sometimes used but have not undergone formal study. While many clinicians are uncomfortable using chronic narcotics to treat symptoms for which there is no biologic measure, these agents have been used by RLS patients with long-term benefit, with little evidence for tolerance or addiction.
Anticonvulsants. Gabapentin and carbamazepine have both been studied in the treatment of RLS. This class of agents appears to have both considerable placebo effect and side effects. Anecdotally, Gabapentin appears to be particularly useful for RLS symptoms, which are characterized as painful or are associated with neuropathy.
Benzodiazepines. Clonazapam is the best-studied of the benzodiazepines for RLS symptoms, but triazolam, temazepam, and nitrazepam have also been evaluated in small studies. While these agents appear to be helpful for RLS patients, it may be because they enhance and consolidate sleep.
Other medications. Both clonidine and propranolol have been reported as being useful in treating RLS symptoms. Baclofen has been used to treat PLMD, but its effect on RLS symptoms is unknown.
An excellent consensus summary of treatment recommendations4 and review of the literature5 are available. Patients and physicians can benefit from visiting the RLS Foundation website, at www.rls.org.
References
1. Lavigne GJ, Montplaisir JY. Sleep 1994;17:739-743.
2. Rothdach AJ, et al. Neurology 2000;54:1064-1068.
3. The International Restless Legs Syndrome Study Group. Mov Disord 1995;10:634-642.
4. American Academy of Sleep Medicine Standards of Practice Committee Report. Sleep 1999;22:961-968.
5. American Academy of Sleep Medicine Standards of Practice Committee Report. Sleep 1999;20:970-999.
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