Makindo Medical Notes

🦵 Restless Legs Syndrome (RLS) = irresistible urge to move legs, worse at night, relieved by movement. 🧠 Pathophysiology: dopamine dysregulation + iron deficiency (low ferritin). 🩸 First-line = correct iron deficiency + optimise lifestyle → drug therapy only if needed. 💊 Dopamine agonists (pramipexole, ropinirole, rotigotine) or gabapentin/pregabalin if persistent. ⚠️ Avoid levodopa long term (augmentation risk). 👩‍⚕️ Pregnancy RLS usually resolves after delivery → avoid drug therapy unless severe.

About

• Also known as Willis–Ekbom Disease 🧾.
• Neurological disorder causing an uncontrollable urge to move the legs 🦵, often with unpleasant sensations.
• Symptoms worse in evening/night 🌙, relieved by walking or stretching 🚶.
• Linked to dopamine imbalance in basal ganglia + iron deficiency 🩸.
• Can affect any age, but more common in older adults 👵👴. Women slightly > men.

Clinical Features

• 🔥 Unpleasant sensations (tingling, crawling, “creepy” feeling in legs).
• 🌙 Worse at night & at rest; improves with movement.
• 🛌 Causes insomnia, poor sleep, daytime fatigue.
• 🤲 Arms may be affected in severe cases.
• 💤 Often associated with periodic limb movements in sleep.

Causes & Risk Factors

• 🩸 Iron deficiency (ferritin < 50 µg/L).
• 💧 Chronic kidney disease / uraemia.
• 🤰 Pregnancy (esp. 3rd trimester).
• 🧬 Genetic predisposition (family history).
• 💊 Drugs that worsen RLS:
  • Antidepressants (SSRIs, TCAs) 😟
  • Antipsychotics 🧩
  • Antihistamines 🤧
  • Calcium channel blockers 💊
  • Lithium 🧪

Investigations

• 📊 FBC & Ferritin – rule out iron deficiency.
• 🧪 U&E – check renal function.
• 😴 Sleep study (polysomnography) only if unclear diagnosis.
• Diagnosis is usually clinical 👩‍⚕️.

Differential Diagnosis

• 🔁 Periodic Limb Movement Disorder (jerks in sleep, no sensory urge).
• 🧯 Peripheral neuropathy (sensory symptoms not relieved by movement).
• 🧑‍🦳 Parkinson’s disease (different movement pattern, not rest-triggered).
• 😴 Other sleep disorders (e.g., OSA).

Management (NICE-aligned)

• 🛌 Lifestyle & General
  • Good sleep hygiene 🌙
  • Reduce caffeine, alcohol, smoking 🚭
  • Stretch/exercise before bed 🧘
  • Review and stop aggravating drugs 💊❌
• 🩸 Correct iron deficiency – treat if ferritin < 50 µg/L (oral or IV iron if needed).
• 💊 Drug therapy (if persistent & severe)
  • Dopamine agonists: pramipexole, ropinirole, rotigotine patch (lowest effective dose).
  • Gabapentin or pregabalin: useful if painful RLS or contraindications to dopamine agonists.
• 🧩 Other/Rescue options
  • Levodopa (short-term, intermittent RLS only – avoid chronic use).
  • Benzodiazepines (e.g. clonazepam) – sleep benefit but use cautiously.
  • Opioids (e.g. codeine, tramadol) – refractory cases only.
• 🤰 Pregnancy: Usually resolves postpartum; avoid drug therapy unless very severe (specialist input).

Prognosis

• 📈 Usually chronic but variable course.
• 🤰 Pregnancy-related RLS often resolves post-partum.
• ⚖️ Good control possible with iron replacement, lifestyle changes, and tailored drug choice.

References

• NICE CKS: Restless Legs Syndrome
• NICE Neurological Conditions Guidance
• Allen RP et al. Restless legs syndrome: diagnostic criteria & epidemiology. Sleep Med. 2003.

Cases — Restless Legs Syndrome (RLS)

• Case 1 — Idiopathic RLS 🛏️: A 45-year-old woman reports an irresistible urge to move her legs in the evenings, worse at night and relieved by walking. She describes “creeping” sensations in her calves that delay sleep onset. No other neurological deficits. Diagnosis: Idiopathic RLS. Management: Sleep hygiene, avoid caffeine/alcohol; dopamine agonist (pramipexole, ropinirole) if severe.
• Case 2 — Iron Deficiency-Associated RLS 🩸: A 60-year-old man complains of unpleasant leg sensations at night with urge to move, disturbing his sleep. He also reports fatigue. Bloods: Hb 95 g/L, ferritin low. Diagnosis: Secondary RLS due to iron deficiency anaemia. Management: Oral/IV iron replacement; symptomatic dopamine agonist if persistent.
• Case 3 — RLS in Pregnancy 🤰: A 32-year-old woman in her third trimester reports nightly restlessness in her legs with difficulty falling asleep. She denies neurological history. Bloods: borderline low ferritin. Diagnosis: RLS in pregnancy (common, often transient). Management: Reassurance (usually resolves postpartum); iron supplementation; avoid dopamine agonists in pregnancy.

Teaching Commentary 🧠

RLS is a sensorimotor disorder characterised by an urge to move the legs, worse at rest/night, relieved by movement. 🔑 Associations: iron deficiency, pregnancy, CKD, Parkinson’s disease, neuropathies. Mnemonic = URGE: - Urge to move legs, - Rest worsens it, - Getting up helps, - Evening/night worse. Management = treat underlying cause (iron, CKD, pregnancy), lifestyle measures, dopamine agonists or gabapentin/pregabalin if severe.