As featured in the April issue of MedForum magazine.
Restless legs syndrome (RLS) is a poorly understood but relatively common condition that increases in prevalence with age (5–15% incidence). RLS typically causes an uncontrollable urge to move the legs to reduce uncomfortable sensations. Symptoms most commonly appear shortly after laying down/resting at night.
Patients often have difficulty describing the unpleasant sensations associated with RLS. Terms used include creeping, crawling, pulling, throbbing, aching, itching, ‘electric shocks’, night cramps, twitching, or uncomfortable legs. Symptoms usually occur in both legs but can be worse in one and may also involve the upper limbs/body.
Moving the legs temporarily eases the unpleasant feeling but the restlessness can disrupt sleep, not only for the RLS sufferer but also their sleeping partner. This often leads to fatigue and daytime sleepiness, poor concentration, reduced work performance, and relationship conflicts. Sleep deficiency is also associated with increased depression, anxiety, heart disease, and obesity.
RLS is frequently neglected by patients and usually goes undiagnosed by doctors. The international RLS (IRLS) rating scale is a validated screening tool that can be used in clinical practice to diagnose RLS and monitor response to treatment.
Untreated RLS can lead to significant impairment in quality of life, especially if severe.
Reported negative outcomes versus control patients include:
- Tired (35% vs. 20%),
- Pessimistic (16% vs. 10%),
- Prefer to be alone (34% vs. 22%),
- Stressed (37% vs. 21%)
- Angry (15% vs. 6%) during a typical day.
Whilst many doctors are familiar with the need to order iron studies (mostly normal), very few are aware of the need to order CVI studies (frequently abnormal).
Despite several published studies showing a strong association between RLS and CVI, this knowledge remains largely unknown outside the phlebology and vascular surgery communities. In one study, 89% of patients reported significant improvement in RLS symptoms post-CVI treatment and 31% had complete symptom relief. Another study found that 40% of CVI patients suffered from RLS and that >80% of these patients had symptoms improve following treatment.
40% of our own CVI patients presenting for treatment have RLS. Often this is first diagnosed on completing the IRLS rating scale. Over 90% of our patients experience significant RLS improvement following treatment, often going from the severe to mild category.
The majority of RLS sufferers in the community go undiagnosed and untreated, only 2.5% having symptoms severe enough to prompt them to peruse medical assessment/ intervention. Unfortunately, very few RLS sufferers get investigated for CVI, denying them a chance of a potential drug free cure for their RLS by treating underlying venous reflux (CVI) if present.
Simple lifestyle changes may provide relief for mild-to-moderate RLS; maintaining good sleep hygiene, regular exercise, leg massage, warm baths, and magnesium supplements. Drug therapy is not always effective and not without potentially serious side effects; for this reason, is best reserved following negative investigations and failure of conservative measures mentioned above.
The Vein Clinic has provided significant relief to hundreds of RLS sufferers using a combination of minimally invasive treatments including endovenous laser ablation, ambulatory phlebectomy, and ultrasound-guided foam sclerotherapy. We are undertaking ongoing research in this area and look forward to contributing to the scientific literature to further recognition of the importance of treatable CVI as a cause of RLS in the medical and wider community.
In summary, RLS is a common condition that is usually neglected and remains undiagnosed and untreated leading to avoidable impairment in quality of life for many people.
Medical doctors in general and especially those involved in primary care, respiratory medicine, and psychiatry should display increased vigilance for RLS and utilise the IRLS rating scale. CVI ultrasound is now the primary first line investigation prior to deciding on treatment.
The Vein Clinic is proud to be at the forefront of increasing this awareness and looks forward to helping relieve the avoidable suffering of RLS in our community.
References available on request.