Many patients who have sleep disruptions, irritable bowel syndrome and chronic pain also suffer from restless legs.
Restless legs syndrome (RLS) is one of the most common neurological disorders in general practice (1). Although the condition is relatively easy to diagnose, RLS is probably both under-diagnosed and under-treated.
Bjorvatn et al. are currently in the process of publishing a survey of how many of the patients at a sample of GP offices in Western and Southern Norway met the criteria for RLS (2). The patients were asked to complete a questionnaire on symptoms while waiting for their appointment. Unsurprisingly, the researchers found a high prevalence of RLS in the study population. While many reported frequent and fairly severe discomfort, few used medications. This concurs with the literature (1) and my own experience, and indicates that knowledge of RLS in general practice is inadequate.
RLS may lead to pronounced discomfort affecting quality of life and level of functioning in daily life. In addition to prickling in the legs, patients find the reduced quality of sleep particularly troublesome. The majority of patients with RLS suffer from sleep problems (3), and these are often the reason for the patient consulting the GP. Patients frequently experience periodic leg movements at night associated with micro-awakenings and poor sleep quality. If there is doubt about the diagnosis and especially when considering whether RLS is the cause of the sleep problem, polysomnography is recommended (4).
The patients in Bjorvatn et al.'s study from general practice were also asked about irritable bowel syndrome, chronic fatigue and chronic muscle and back pain symptoms. Such symptoms are common among patients who consult their GP. The percentage reporting RLS was considerably higher among patients who also had these diagnoses, The findings are interesting but not surprising. Earlier studies have shown high comorbidity between RLS and, for example, chronic pain and irritable bowel syndrome (5, 6). In my own experience as a specialist in neurology, RLS is often comorbid with musculoskeletal pain, as well as with migraine. All these conditions demonstrate an increased prevalence of sleep problems and mental disorders. In the case of migraine, it is important to reduce trigger factors, for example sleep disruptions. Several patients have told me that the RLS treatment has led to the alleviation of their migraine.
All these conditions demonstrate an increased prevalence of sleep problems and mental disorders
The high prevalence of RLS found by Bjorvatn et al. (15 %) may possibly arise from selection bias, as the authors also point out. In unselected material, the prevalence is shown to be 5–10 % (3). Only those with frequent and severe discomfort need treatment. In accordance with more recent guidelines, Alpha-2-delta calcium channel ligands (gabapentin and pregabalin) should be preferred over dopamine agonists (ropinirole, pramipexole and rotigotine), because the latter may cause an exacerbation of the condition (7). The lowest possible effective dose should be prescribed, and maximum recommended doses should not be exceeded. In treatment-resistant cases, opioids may be an option, either alone or in the form of combination therapy. In Norway, the combination oxycodone + naloxone is approved for treatment of RLS. Iron supplement is recommended when ferritin levels fall below 50–75µg/L (7).
Most people find living with RLS tolerable and only a small number need treatment. However, it is important to identify the condition and if necessary, treat those who are experiencing considerable discomfort. In my experience, many patients receive a delayed diagnosis and only receive treatment after a prolonged period of discomfort. A recent large European study of the socioeconomic impact of RLS concludes that improved diagnostics and treatment may not only reduce suffering but also result in major socioeconomic savings (1). Bjorvatn et al. thus provide an important assessment of the scope of this public health problem. GPs should be vigilant for the condition, especially in patients with sleep problems and/or other common conditions such as chronic pain, irritable bowel syndrome and chronic fatigue. We also need more studies that can give us a better understanding of the pathophysiology and the degree to which the treatment of RLS can also improve comorbid conditions and vice versa.