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Restless Leg Syndrome

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  1. See Also
    1. Leg Pain
    2. Movement Disorder
  2. Epidemiology
    1. Fourth leading cause of Insomnia
    2. Family History of restless legs in 50-60%
    3. Incidence in adults: 6%
    4. Incidence in adults over age 65 years: 10-28%
  3. Pathophysiology: Possible etiologies
    1. Dopamine deficiency in brainstem or spinal cord
    2. Endogenous opiate deficiency
    3. Small fiber Peripheral Neuropathy
  4. Causes
    1. Idiopathic in most cases
    2. Iron Deficiency Anemia
    3. Renal Dialysis
    4. Pregnancy (as high as 19%)
    5. Hypothyroidism
    6. Diabetes Mellitus
    7. Electrolyte disturbance
      1. Decreased Serum Magnesium
      2. Decreased Serum Folate
    8. Leg varicosities
      1. May be relieved with sclerotherapy
    9. Drug-induced causes
      1. Selective Serotonin Reuptake Inhibitors (common)
      2. Antihistamines (e.g. Benadryl)
      3. Antipsychotics
      4. Antiemetics
        1. Phenergan
        2. Metoclopramide
        3. Prochlorperazine
      5. Tricyclic Antidepressants (e.g. Elavil)
        1. Treat with Propranolol 40 mg PO tid
      6. Substances
        1. Caffeine
        2. Tobacco use
  5. Differential Diagnosis
    1. Night Cramps (Leg Cramps)
    2. Peripheral Vascular Disease
    3. Anxiety Disorder
    4. Drug induced Akathisia
    5. Peripheral Neuropathy
    6. Tic Disorder
  6. Symptoms
    1. Timing
      1. Symptoms worsen in the afternoon, evening and bedtime
    2. Uncomfortable leg sensations (Akathisia)
      1. Creeping or crawling restlessness
      2. Wormy or boring sensation
      3. Tingling, pins and needles, or prickly sensation
      4. Pulling or drawing sensation
    3. Severity
      1. Symptoms can cause very significant morbidity (to point of Suicidal Ideation)
    4. Palliative
      1. Movement temporarily relieves sensation
    5. Provocative
      1. Prolonged period of inactivity (e.g. car travel)
      2. Prolonged sitting (e.g. classes or meetings)
      3. Lying down or sleeping
  7. Signs
    1. Periodic flexions
      1. Occur every 20-40 seconds during non-REM Sleep
  8. Labs
    1. Serum Ferritin (<50 ng/ml associated with restless leg)
    2. Serum Glucose
    3. Serum Creatinine
    4. Consider other lab testing
      1. Thyroid Stimulating Hormone
      2. Serum Magnesium
      3. Serum Folate
  9. Management: General measures
    1. Discontinue provocative habits
      1. Discontinue caffeine usage
      2. Tobacco Cessation
      3. Alcohol cessation
    2. Encourage relaxing bedtime routine
      1. Avoid vigorous Exercise 2 hours before bedtime
      2. Avoid sexual activity 2 hours before bedtime
      3. Adjust schedule to allow awakening later
    3. Correct Iron Deficiency Anemia
    4. Local massage
    5. Cold compress application
    6. Consider adaptive changes at work or school
      1. Work at high desk with stool
      2. Sit in aisle seat on trips or meetings
  10. Management: Medications
    1. Analgesics at bedtime
      1. Acetaminophen (Tylenol)
      2. NSAIDS (e.g. Ibuprofen)
      3. Nighttime Opioid Analgesics may also be effective
    2. Dopamine agonists
      1. Carbidopa and Levodopa
        1. Sinemet 12.5/50 mg PO qhs
        2. Sinemet CR 25/100 mg PO qhs
      2. Pergolide (Permax) 0.05 to 1 mg
        1. First dose at dinner
        2. Second dose one hour before bed
      3. Pramipexole (Mirapex)
        1. Initial dose: 0.125 mg one tablet orally at bedtime for three nights
      4. Ropinirole (Requip) 0.25 mg PO qhs
    3. Anticonvulsants
      1. Gabapentin (Neurontin) 100-300 mg PO qhs
        1. Effective in RCT at 1800 mg/day (600 mg tid)
        2. Garcia-Borreguero (2002) Neurology 59:1573
    4. Benzodiazepines
      1. Clonazepam 0.5 - 2.0 mg PO qhs
    5. Alpha adrenergic agonists
      1. Clonidine 0.1 mg PO qhs
  11. Course
    1. Symptoms progress with age
  12. Resources
    1. Restless Legs Syndrome Foundation
      1. http://www.rls.org
  13. References
    1. (2000) Am Fam Physician 62:108
    2. Clark (2001) J Am Board Fam Pract 14:368
    3. Henning (1999) {a 19171} 22:970
    4. Paulson (2000) {a 6611} 55:35

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