Restless legs syndrome

Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a common neurological sensorimotor disorder characterised by an irresistible urge to move the legs — and sometimes the arms — typically caused by uncomfortable sensations felt inside the limbs. It can start at any age and generally worsens over time.

RLS significantly disrupts sleep by preventing the stillness needed to fall asleep or stay asleep, leading to chronic sleep deprivation, daytime fatigue, and impaired quality of life. In severe cases it contributes to anxiety and depression.

**Symptoms and their characteristic features:** - An overwhelming, irresistible urge to move the legs - Uncomfortable sensations inside the limb (not on the skin) — described as crawling, creeping, pulling, tugging, throbbing, aching, itching, or electric - Symptoms are triggered or worsened by rest (sitting or lying down) - Symptoms are temporarily relieved by movement — walking, stretching, or pacing - Symptoms worsen in the evening and are worst at night - Periodic limb movements of sleep (PLMS) — involuntary, repetitive leg jerks every 20–40 seconds during sleep — frequently co-occur - Symptoms fluctuate in severity; periods of remission are common

**Causes and risk factors:**

In many patients no underlying cause is identified (idiopathic RLS), which appears to involve a dopaminergic imbalance in the basal ganglia-spinal cord pathways. When an underlying cause is present, it is called secondary RLS: - **Iron deficiency** — even without anaemia; iron is essential for dopamine synthesis - **Renal failure / dialysis** — dialysis patients have high rates of RLS - **Peripheral neuropathy** — from diabetes, alcoholism, or other causes - **Spinal cord disease** — lesions or prior spinal anaesthesia - **Pregnancy** — especially the third trimester; usually resolves post-partum - **Medications** — antihistamines, antidopaminergic antipsychotics, SSRIs, and some anticonvulsants can trigger or worsen RLS

**Genetics:** RLS runs in families, particularly when onset is before age 40. Several genetic loci have been identified.

**Complications:** Chronic sleep disruption, daytime sleepiness, anxiety, and depression. RLS can be debilitating in severe cases.

**Treatment:** 1. Treat any identified secondary cause (iron supplementation for low ferritin, dialysis optimisation, medication review) 2. Sleep hygiene and lifestyle: regular exercise, avoiding caffeine and alcohol, warm baths, massage 3. Pharmacological: dopamine agonists (pramipexole, ropinirole, rotigotine), pregabalin or gabapentin, low-dose opioids for severe refractory cases 4. Non-pharmacological interventions: rTMS, tDCS, acupuncture, and pulsed radiofrequency for cases where medications are inadequate or not tolerated