Restless Leg Syndrome evidence based treatment

by Herb Belt


If you have restless legs syndrome and want
to find out the best evidence based advice this video is for you! My name is Simon and I’m a Consultant in
Clinical Neurophysiology. I’m going to explain to you what we now
know about this common condition and how best to manage it. Restless Legs Syndrome (pause) or RLS, is
very common and affects at least 2% of the population. It is a clinical diagnosis which was redefined
in 2014 as matching 5 key criteria: 1. An urge to move the legs which is usually
accompanied by an unpleasant sensation in the legs. This is often described as a crawling sensation
under the skin. 2. It is worse during periods of rest or inactivity 3. There is at least partial relief by movement 4. Clear evening or night time emphasis 5. It is not solely explained by another medical
or behavioural condition When it comes to understanding and therefore
treating RLS – there are two major categories, Primary and Secondary. Let’s start with Secondary. This means that there is an identifiable process
driving the RLS and if so treatment is aimed at addressing the underlying cause as well
as managing symptoms. Causes can include any of the following: Peripheral
neuropathy in around 1/3rd. This may be a large fibre or more commonly
a small fibre neuropathy. You can see separate videos explaining these
and how they are tested by clicking on the i-cards above. Iron and to a much lesser extent magnesium
deficiency can be causes, raised urea levels from kidney failure, and Varicose Veins. Medications including a variety of anti-depressants
can also be a factor. Pregnancy is also well recognised but self-resolves
afterwards in the majority of cases. Primary RLS is when there is no identifiable
cause. It’s quite different in that it tends to
start at a much younger age and there is often a positive family history in around 2/3rds
of patients. Research is ongoing into a variety of potential
causative genes. To understand how treatment works and why
it can fail, we need to be clear on the underlying disease mechanisms. Current research has identified that multiple
regions of the brain dysfunction especially the Basal Ganglia which are important in initiating
and controlling movement. Many of the neural cells here rely on Dopamine
which needs Iron as part of it’s formation. Iron uptake by these cells is impaired for
reasons, as yet unknown. This leads to a relative fall in Dopamine
production. We can target either of these so patients
who are Iron deficient, and this can be from any cause of anaemia, can respond well to
Iron replacement. Medications that increase Dopamine levels
directly such as Levo-Dopa or act like Dopamine such as Ropinorole are also successfully used
as treatments for this condition. However, it’s not just these cells that
dysfunction. It is also important to recognise that the
brains natural internal Opioid system may also be depleted and this may be why the condition
is often responsive to Opioid medications. Many other structures which govern sensation,
emotion, cognition, behaviour and movements are also implicated. This likely explains why so many patients
have a multitude of other problems including high rates of depression (up to 30%), impulsivity
and problems with decision making. Sleep disturbances are also very common. Around 80% of RLS patients also have Periodic
leg movements in sleep which are associated with arousals and so further interrupt sleep
quality. This is a long term condition and whilst it
can wax and wane, treatment often needs to be provided for prolonged periods, even many
years. There is a significant issue with Dopamine
replacement therapy which is called Augmentation. This means that the treatment itself can in
fact worsen the condition with a risk of this happening of around 7% per year. Signs of this developing include worsening
intensity, spread of symptoms into other body regions such as the arms, shorter duration
between rest and symptoms and also earlier onset of symptoms into the daytime. Some medications are worse at doing this than
others, particularly Levo-Dopa. This is why it is no longer a first choice
treatment. The combined task force of the RLS-Foundation,
European RLS Studdy Group and the International RLS Study Group have produced their management
recommendations in 2016. You can find a link to the whole guidance
in the link below. But briefly 1. Non-dopamine medications such as Gabapentin
Enacarbil, also called Horizant, should be trialled first which should avoid the risk
of Augmentation. However, it is not yet universally licensed
as a first line medication. 2. When dopaminergic medications are utilised
these should be at the lowest possible doses e.g. Pramipexole, Ropinirol or Rotigotine
and the aim should be to reduce symptoms to the point where quality of life isn’t impaired
but not their complete eradication. 3. If augmentation does occur then anything exacerbating
factors should be addressed such as iron replacement if they have low Iron stores or avoidance
of medications that can exacerbate augmentation such as Anti-depressants and Anti-histamines
should be reduced or avoided and any lifestyle factors such as sleep deprivation addressed. 4. Other medications may need to be added at
this point such as Horizant or even switching. 5. Opioids such as Oxycodone do have a place
as treatment but are reserved for those with severe augmentation symptoms not responding
to all other means. I hope that you found this video useful, and
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