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Counselling a patient with restless legs

Sixty-year-old Louise is complaining of feeling tired

all the time: 'But I can't sleep, because my legs are all jangly ­ they even wake me up in the night. I usually end up having to get up and walk round, or soak them in cold water.'

Dr Melanie Wynne-Jones discusses.

What are the causes of fatigue associated with restless sleep?

Any problem that seriously disturbs sleep can lead to daytime fatigue and irritability, as junior doctors and parents will readily confirm. External causes such as a poor sleeping environment (noise, light or other disturbance) or physical discomfort such as pain or jetlag can usually be readily identified.

Hyperthyroidism, sleep apnoea and nocturnal symptoms of systemic disease may be harder to pin down; insomnia occasionally appears to be idiopathic.

In general practice, anxiety and depression are two of the commonest causes of tiredness with insomnia, and must be excluded. Anxiety typically delays getting to sleep, whereas depression tends to cause early-morning wakening, but many patients have a combination of the two, and may lie awake worrying for hours.

Restless legs syndrome (RLS or Ekbom's syndrome, also related to periodic limb movement disorder of sleep) affects 5 to 10 per cent of adults. It may seem trivial, but it can cause great distress and there is sometimes a serious underlying cause.

What are the symptoms of RLS?

 · An unpleasant sensation in the legs (occasionally arms) described as creeping, crawling, burning, itching, cramping, twitching, tingling, jerking or painful, occurring every 10-60 seconds

 · An irresistible desire to move the legs or cool them down

 · Symptoms usually start when resting and are worse later in the day

Other features include:

 · Difficulty getting to or staying asleep, with daytime tiredness

 · Involuntary movements

 · Relief of symptoms by walking, stretching, massage, or applying heat or cold

 · Onset in early or middle adulthood, worsening with age (but growing pains and childhood hyperactivity may be early manifestations)

 · Worsening with caffeine or alcohol

 · Positive family history

 · Secondary depression

What clinical conditions are linked with RLS?

The following may be associated with RLS: iron deficiency, neuropathy (including diabetes and uraemia); rheumatoid arthritis; fibromyalgia; pregnancy (usually remits afterwards); Parkinson's disease and multiple sclerosis; pernicious anaemia; COPD; peripheral vascular disease and venous insufficiency.

Some drugs may also be linked with RLS, including phenothiazines, anti-emetics, calcium-channel blockers, phenytoin, and antidepressants (although antidepressants seem to relieve RLS in some people). Magnesium deficiency may possibly be linked with restless legs.

Investigations that may help are: FBC and serum ferritin, folate and B12; U&Es; blood glucose; ESR; C-reactive protein; rheumatoid factor; and trial without caffeine, alcohol or non-essential medication.

How can patients relieve RLS?

Many find their own solutions including:

 · Avoiding caffeine, nicotine or alcohol

 · Walking, stretching, knee-bends

 · Hot or cold packs/soaks or foot refresher sprays

 · Massage or vibration including TENS and acupressure

 · Relaxation techniques including yoga

 · Distraction ­ reading, watching TV

 · Sleep hygiene.

What medication can be tried?

Louise may be relieved if she does not have a serious illness, but distressed at the prospect of having to live with this condition, and may develop a depressive illness. She should be given details of the self-help group, and encouraged to return if simple measures do not work. Any vitamin or mineral deficiency should be corrected.

If Louise asks for medication, the pros and cons must be discussed fully. The following drugs have been successful in some but not all cases, but are not licensed for RLS so specialist advice must be sought:

 · Benzodiazepines, particularly clonazepam (potentially addictive)

 · Anticonvulsants such as carbamazepine and gabapentin (but some such as phenytoin may worsen RLS)

 · Levodopa with carbidopa in primary RLS and uraemia (but augmentation of symptoms may occur in 80 per cent of patients within a few months and they may have to stop levodopa)

 · Dopamine agonists such as pergolide and bromocriptine

 · Some opioids

 · Clonidine, especially in uraemia.

The lowest effective dose should be used, a couple of hours before bed.

 · Restless legs syndrome

is a common and often distressing condition that affects up to one person

in 10

 · Diagnosis is made on clinical grounds, but haematological and other curable causes should be excluded, especially iron deficiency and neuropathy

 · Deficiencies should be corrected

 · Self-treatment comprises excluding triggers such as caffeine and alcohol, and physical treatments such as heat, cold or stretches

 · Medication should not be prescribed without specialist advice

Useful resources

·Merck Manual of Diagnosis and Therapy

(available online at:

·Ekbom Support Group, 18 Rodbridge Drive, Thorpe Bay, Essex SS1 3DF (send SAE)

Tel 01702 582002

·Restless Legs Foundation

·Postgraduate Medicine

US National Heart Lung and Blood Institute

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