Restless legs syndrome - IAFP.com

RESTLESS LEGS SYNDROME:
Diagnosis and Treatment Strategies for the Primary Care Provider
Consensus Recommendations From an Expert Panel Vol 5(2): May 2004
CME Overview
Learning Objectives
Upon completion of this activity, participants should be able to:
✦ Elicit pertinent information that can aid in diagnosis of
restless legs syndrome (RLS) when taking a patient’s history.
✦ Diagnose RLS using the 4 essential diagnostic criteria.
✦ Appropriately prescribe and titrate pharmacologic agents
to treat RLS based on efficacy and tolerability profiles.
✦ Implement nonpharmacologic strategies to manage RLS.
✦ Seek referral to or consultation with a specialist in
appropriate RLS cases.
✦ Educate patients on RLS and provide sources for additional
information.
Credit Designation
Scienta Healthcare Education ® designates this educational activity for
a maximum of 1.5 category 1 credits toward the AMA Physician’s
Recognition Award. Each physician should claim only those credits that
he/she actually spent in the activity. Expiration: December 31, 2005.
This activity has been reviewed and is acceptable for up to 1.5
Prescribed credits by the American Academy of Family Physicians. 1.5 of
these credits conform to AAFP criteria for evidence-based CME clinical
content. Term of approval is for one year from beginning distribution date
of May 15, 2004 with option for yearly renewal. When reporting CME
credit, AAFP members should report total Prescribed and Elective credit
earned for this activity. It is not necessary for members to label credit as
evidence-based CME Prescribed or Elective for CME reporting purposes.
Accreditation
Scienta Healthcare Education ® is accredited by the Accreditation
Council for Continuing Medical Education (ACCME) to sponsor continuing
medical education for physicians.
Sponsorship
Cosponsored by the Illinois Academy of Family Physicians/Family
Practice Education Network and Scienta Healthcare Education ® .
EXPERT PANEL
Charles Adler, MD, PhD
Professor of Neurology
Chair, Division of Movement Disorders
Mayo Clinic College of Medicine and
Mayo Clinic, Scottsdale
Scottsdale, AZ
Richard Allen, PhD
Research Associate
Department of Neurology
Founder, Johns Hopkins Sleep
Disorders Center
Johns Hopkins Bayview Medical Center
Baltimore, MD
Introduction
W. Lane Edwards, Jr, MSN, ARNP, ANP
Nurse Practitioner, Internal Medicine
Lee Physician Group
Lee Memorial Health System
Fort Myers, FL
Mary P. Ettari, MPH, PA-C
Certified Physician Assistant
Medical Partners of Martin County
Stuart, FL
William G. Ondo, MD
Associate Professor
Department of Neurology
Baylor College of Medicine
Houston, TX
RLS is a clinically significant movement disorder that commonly
presents to the primary care provider as a sleep disturbance.
Although the disease was first characterized more than 60 years
ago, current understanding of the diagnosis and treatment of
RLS is based largely on research conducted within the past
decade. 1 The first clinical guidelines for treatment of RLS
were published by the American Academy of Sleep Medicine
in 1999. 2 In 2000, the National Center on Sleep Disorders
Research and Office of Prevention, Education, and Control of
the National Heart, Lung, and Blood Institute published
guidelines for the management of RLS in the primary care
Penny Tenzer, MD
Vice Chair and Residency Program Director
Department of Family Medicine and
Community Health
University of Miami School of Medicine
Miami, FL
Ray Watts, MD
Professor and Chair
Department of Neurology
University of Alabama School of Medicine
Birmingham, AL

setting. 3 The National Institutes of Health, in collaboration
with members of the International Restless Legs Syndrome
Study Group, updated RLS diagnostic criteria and established
standardized questions for epidemiological studies of RLS in
2003. 4 Furthermore, the Restless Legs Syndrome Foundation
(www.rls.org) has established an online updated medical
bulletin that covers relevant medical issues associated
with RLS.
Despite new guidelines and diagnostic criteria, however, RLS
is not foremost in the minds of most healthcare providers.
Needs assessment data reveal that many primary care
providers remain uninformed about RLS and its treatment. In
2004, the Family Practice Education Network (FPEN), coordinated
by the Illinois Academy of Family Physicians (IAFP) and
Scienta Healthcare Education ® , assembled
a panel of experts in the management
of RLS. After reviewing established
guidelines, the current medical
literature, and their own clinical
experiences, the panel formulated
recommendations for primary
care providers regarding RLS
diagnosis and treatment.
Although RLS is commonly
encountered in the primary
care setting, it is generally not
a first-line consideration in the
differential diagnosis for sleep
complaints. Thus, it is often inadequately
diagnosed. In some cases, patients
with symptoms of RLS are misdiagnosed with
insomnia or anxiety, resulting in ineffective treatments.
In other cases, RLS patients remain undiagnosed and are
inappropriately referred to a variety of specialists. Accurate
diagnosis and treatment of RLS is further confounded by the
fact that RLS symptoms are difficult to articulate.
Because most RLS sufferers will initially consult a primary
care provider for their symptoms, the primary care provider
has a central role in the diagnosis and treatment of RLS. For
most patients, RLS can be managed effectively in the primary
care setting. Primary care providers’ long-term relationships
with their patients and familiarity in managing multiple
aspects of healthcare uniquely position them to offer unparalleled
patient education and support. These consensus recommendations
will review the current RLS literature, highlight
diagnostic approaches and treatment options, and discuss
how to educate and support RLS patients in the
primary care setting. This guideline offers the healthcare
provider a succinct, stepwise, and proactive strategy to
manage RLS.
2
RLS Epidemiology and Impact
on Quality of Life
Despite being a common movement disorder and a cause of
sleep loss, RLS is often underdiagnosed. 1,2,5 RLS is the second
or third most common sleep disorder; although estimates
vary, recent surveys suggest that RLS may affect 10% to
15% of the general population. 5,6 Standardized epidemiological
data are currently incomplete, but preliminary surveys indicate
that prevalence increases with age 7 and appears to be higher
among women than men. 7-9 Onset of symptoms can occur at
any age. However, the phenotype in children may differ from
that seen in adults and may be confused with attention
deficit disorder or “growing pains.” RLS is a progressive
disorder, and severity usually increases with age, 10 although
remissions may occur. Diagnosis often occurs during middle
age, when symptoms have progressed sufficiently for
the patient to seek medical advice. Patients whose
symptoms appear before age 45 are more
likely to exhibit a family history of
RLS and experience a more indolent
onset. Those with onset
beyond age 50 often have a
more rapid progression with
age and are less likely to
demonstrate a family history of
the condition. 10
Sleep disturbance is a major
comorbidity of RLS and is
often the primary reason that
the patient seeks medical attention.
When severe, RLS produces the
most extreme chronic sleep loss of any
sleep disorder, and severely affected RLS
patients routinely sleep only a few hours per night.
While the severity of symptoms varies widely, RLS may
impact quality of life dramatically, for both patients and their
bed partners. In addition to disrupting sleep, RLS may contribute
to daytime and evening discomfort and an inability to
sit still, thereby affecting activities such as meetings and
airplane rides. Moreover, people with RLS suffer the consequences
of sleep loss, including difficulties with attention
and cognitive focus. Thus, RLS may affect work, social, and
leisure activities.
Primary and Secondary Causes of RLS
Primary Causes. Genetic predisposition appears to be a factor,
particularly for patients with an onset of RLS symptoms
early in life (eg, before age 45). 10-12 Slightly more than half of
reported cases of RLS indicate a familial occurrence of the

disorder, 4 with the presentation following an autosomal dominant
pattern. 13 Several possible loci, including chromosomes
12q 14 and 14q, 13 have been linked to RLS. Analysis of available
studies suggests that a person with RLS is 3 to 6 times more
likely to have a family history of the disorder than a person
who does not have RLS. 4 Environmental factors may also
play a role.
Secondary Causes. Symptoms of RLS may be associated
with or exacerbated by medications 15 or by several secondary
conditions, including iron deficiency, 16,17 pregnancy, 18 end-stage
renal disease, 19 and peripheral neuropathy 20 (see treatment
section for details). Secondary RLS often remits when the
specific secondary condition is resolved, such as through
childbirth 18 or renal transplant. 21
Diagnosing RLS: The 4 Essential Criteria
RLS is characterized by an urge to move the legs that is
partially or totally relieved by movement and is often associated
with a series of unpleasant sensory features. Patients with
RLS will often speak of sensations deep within the leg
muscles, described variously as “creepy,” “crawly,” “like
worms or bugs crawling in the muscle,” or “soda bubbling in
the veins.” 4 Although these descriptions may vary, they will
usually be associated with an urge to move. While this
discomfort usually affects both legs simultaneously, it may be
unilateral, alternate between the legs, or include the arms. 22
Although RLS symptoms vary widely in severity and
frequency (eg, from occasionally to daily), most RLS patients
who seek treatment experience daily or nearly daily symptoms.
Four criteria are essential to diagnose RLS (Table 1). 4 Each
criterion is subsequently described in more detail.
Table 1. The 4 Essential Diagnostic Criteria for RLS*
✓ An urge to move the limbs that is often accompanied
or caused by uncomfortable or unpleasant sensations
in the legs
✓ The urge to move or unpleasant sensations begin
or worsen during periods of rest or inactivity
✓ Symptoms may be partially or totally relieved by
movement (eg, walking or stretching), at least for
the duration of the activity
✓ Symptoms either occur exclusively or worsen
during the evening or night
* All must be present for diagnosis.
An urge to move the legs, usually accompanied or caused by
uncomfortable or unpleasant sensations in the legs. This is
the key feature of RLS. The urge to move the legs may be
present without any clearly identified sensation and may
include the arms. However, RLS is not to be confused with
fidgeting or habitual repetitive movement, such as foot tapping.
The urge to move begins or worsens during periods of rest
or inactivity. Two aspects of rest, physical immobility and
decreased central nervous system activity that supports
alertness, may be implicated in the onset of symptoms. 23 RLS
is not triggered by a specific body position during rest.
However, more restful positions and a longer duration of rest
increase the likelihood of symptoms.
Symptoms may be partially or totally relieved by movement
(eg, walking or stretching), at least for the duration of the
activity. Patients with RLS often describe a rapid relief of
symptoms as a result of movement, although the relief may or
may not be complete. As the disease progresses, the amount
of relief obtained through movement may diminish; more
movement may be required for relief of severe RLS.
Symptoms either occur exclusively or worsen during the
evening or night. Several studies have demonstrated a peak
in RLS restlessness in the hours immediately after
midnight and a nadir in the late morning hours. 24,25 In cases of
severe RLS, discomfort may occur continuously, although
patients will recall nocturnal severity as a feature of an
earlier stage of disease development.
Diagnosing RLS: Asking the Right Questions
Because of the relatively unusual sensations associated with
RLS, many patients have difficulty expressing their symptoms
accurately. As a result of this suboptimal communication,
there is a tendency to diagnose RLS via a process of exclusion,
ie, RLS is diagnosed only after other possibilities have been
disproved. However, this diagnosis-of-exclusion approach
should be abandoned, and the primary care provider must
seek an unequivocal and clear diagnosis of RLS by completing
a sleep review (Appendix A) with all patients who present with
a sleep complaint. If RLS is suspected, it is essential to ask the
right questions as they apply to the 4 essential RLS diagnostic
criteria (Table 2). Sleep studies are not necessary to diagnose
RLS; patients who answer “yes” to the 4 questions in Table 2
are likely to have RLS. An algorithm for the diagnosis of RLS is
provided in Figure 1.
To assess the severity of RLS, the primary care provider
should consider the frequency and overall severity of the
symptoms. These 2 factors will guide treatment decisions.
It may also be useful to use the International Restless
Legs Syndrome Study Group Rating Scale 26 prior to and
3

4
Figure 1. Diagnosis Algorithm
Difficulty sleeping and/or daytime sleepiness
Unusual sensations in legs relieved
by movement
Painful sensations in legs at night
Take history
Take history
Take history
Conduct a sleep review of symptoms to
assess cause (see Appendix A)
Conduct neurologic exam
Are responses suggestive of RLS?
Ask 4 key RLS questions
No Yes
Is there evidence of neuropathy?
No
Yes
Consider other sleep disorders: sleep deprivation,
insomnia, drug-induced insomnia, obstructive
sleep apnea, or circadian rhythm disorder
Did patient answer “yes” to all 4 questions?
Evaluate and treat neuropathy
and ask 4 key RLS questions
Yes
Diagnose RLS and treat using
treatment algorithm

Figure 2. Suggested Treatment Algorithm
Patient diagnosed with RLS
Symptom Profile
Nightly 3-5 times/week

during treatment to evaluate treatment benefit. This wellvalidated
scale has been used in treatment studies, 27 and
up-dated versions of the scale are available online from the
MAPI Research Institute (www.mapi-research-inst.com).
RLS and Periodic Limb Movements in Sleep
(PLMS) and Waking (PLMW)
Many RLS patients also experience periodic limb movement
disorder (PLMD), which may be manifested as periodic limb
movements in sleep (PLMS) and in waking (PLMW). 1
Approximately 85% of RLS patients also experience PLMS, 4
and the finding of PLMS supports a diagnosis of RLS. PLMS,
however, also commonly occurs independently, especially in
the elderly. Characteristics of PLMS include the following:
6
Table 2. Key Questions for Patients
Who May Have RLS
✦ Do you feel an urge to move your legs, usually
accompanied or caused by uncomfortable and
unpleasant sensations in the legs?
✦ Does this urge to move begin or worsen when you
lie down, rest, or are inactive?
✦ Is the urge to move partially or totally relieved by walking
or stretching, as long as the movement continues?
✦ Are your symptoms worse in the evening or at night,
or do they only occur during the evening or the night?
✦ Involuntary, stereotypic, slow leg and hip movements
(0.5 to 5 seconds in duration) while asleep
✦ Movements occur periodically (usually every 20 to
40 seconds)
✦ Movements can be associated with awakenings
and arousal
✦ PLMS are nonspecific and may occur in isolation
or with narcolepsy, REM (rapid eye movement)
sleep behavior disorder, or sleep apnea
PLMW may also occur for RLS patients. These movements
are less common for elderly patients and are therefore more
specific for the diagnosis of RLS. However, the sensitivity of this
measure is not known. PLMW may occur during the night, when
the patient lies awake in bed, or in the evening, when the patient
is lying down or seated with legs outstretched.
Treatment Options
Iron Supplementation. Patients with RLS often have a
decreased level of ferritin and an elevated level of transferrin
in their cerebrospinal fluid. 17 Furthermore, a low serum
ferritin level (

These dopaminergic agents may be recognized by primary
care providers as the gold standard for treatment of
Parkinson’s disease, in which relatively large doses are
administered to control motor abnormalities caused by loss
of nigrostriatal dopaminergic neurons. In contrast, relatively
small doses of these agents are used to treat RLS, thus minimizing
the side effects. It is therefore important that primary
care providers not base their decisions to use these agents
for RLS solely on their prior experience using them for
Parkinson’s disease.
Long-term use of levodopa, and possibly the dopamine agonists,
promotes augmentation of RLS symptoms. With augmentation,
symptoms begin to appear progressively earlier in
the day and may become more severe. Augmentation has
been reported in approximately 80% of patients who take levodopa,
31 although the process appears to be associated
much less frequently with dopamine agonists. 27, 32-34 It must be
noted, however, that the dopamine agonists have not been
investigated as fully as levodopa in long-term clinical trials.
Table 3. Drugs Used to Treat RLS 28
Levodopa’s rapid onset of action (15 to 20 minutes) makes it
ideal for intermittent usage when symptoms occur only
occasionally, as augmentation is unlikely in this scenario. For
patients with daily symptoms, however, a dopamine agonist
is suggested as first-line treatment.
Sedative-Hypnotic Agents. This class of drugs represents an
option if dopaminergic agents are unsuitable. However, at
present, there are few data to evaluate the efficacy of these
agents for RLS. Sedative-hypnotic agents may be used in combination
with the aforementioned agents if sleep initiation
remains problematic despite relief of the sensory symptoms of
RLS. It must be noted that these agents mask the symptoms
of RLS but do not treat the underlying causes of the disease.
There are no data available that demonstrate augmentation
with sedative-hypnotic agents, although tolerance may
develop. The potential for abuse, morning drowsiness, and an
increased risk of falls during the night should be considered
when prescribing these medications for RLS.
Agent Initial Dose Recommended Maximum Daily Dose Serum Half-life Common Side Effects
(at levels indicated for
Parkinson’s Disease)
Dopaminergic Agents
Levodopa (Dopar ® ,
Larodopa ® )
Ropinirole*
(Requip ® )
Pergolide*
(Permax ® )
Pramipexole*
(Mirapex ® )
Sedative-Hypnotic Agents
Clonazepam
(Klonopin ® )
Oxazepam
(Serax ® )
Zaleplon
(Sonata ® )
Zolpidem
(Ambien ® )
Triazolam
(Halcion ® )
50 mg
0.25 mg
0.025 mg
0.125 mg
0.25 mg
10 mg
5 mg
5 mg
0.125 mg
200 mg at bedtime
4 mg in divided doses (evening and
bedtime)
0.5 mg in divided doses (evening and
bedtime)
1.5 mg in divided doses (evening and
bedtime)
2 mg at bedtime
40 mg at bedtime
20 mg at bedtime
20 mg at bedtime
0.5 mg at bedtime
1.5-2 h
6-8 h †
2-16 h
8-10 h ‡
30-40 h
5-10 h
1 h †
1.6 h †
2-4 h
Nausea, vomiting, augmentation
of symptoms, sedation
Same as for levodopa, plus
nasal congestion and fluid
retention
Same as for ropinirole
Same as for ropinirole
Tolerance, sedation
Tolerance, sedation
Tolerance, sedation
Tolerance, sedation
Tolerance, sedation
7

Anticonvulsants. Two agents, carbamazepine 35 and
gabapentin, 36 have shown efficacy for RLS treatment.
Although gabapentin has not been evaluated for long-term
complications such as augmentation, the Expert Panel recommends
it as the preferred anticonvulsant agent for its tolerability
and safety. The Expert Panel also concurred that
gabapentin is a suitable choice for second- or third-line therapy
and can be considered as a first-line agent for patients
who report pain as a major symptom of RLS.
Opioids. Opioids are effective second- or third-line agents for
RLS patients who report frequent or nightly symptoms. They
can also be considered as a first-line treatment for patients
who report pain as a symptom of their RLS. Dependence and
8
Table 3. Drugs Used to Treat RLS 28 (cont)
tolerance may occur with opiate use, but there are no data
available that demonstrate augmentation with these agents.
Nonpharmacologic Strategies. In contrast to most other
sleep disorders, RLS does not respond to typical sleep
hygiene. Instead, the condition may be resolved, at least temporarily,
by intense tactile stimulation or mental activity.
Lifestyle patterns that promote engrossing mental or physical
activity during daytime hours may reduce the need for medicine
until late evening. Other strategies, such as leg vibration,
massage, and hot baths, may also help alleviate symptoms.
In some cases, the avoidance of caffeine and alcohol
may also help to reduce symptoms.
Agent
Anticonvulsants
Initial Dose Recommended Maximum Daily Dose Serum Half-life Common Side Effects
(at levels indicated for
Parkinson’s Disease)
Gabapentin
(Neurontin ® )
Carbamazepine §
(Tegretol ® )
Opioids
Propoxyphene
(Darvon ® )
Hydrocodone
(Vicodin ® )
Codeine
Tramadol
(Ultram ® )
Oxycodone
(OxyContin ® )
Oxycodone-XR
Methadone*
(Dolophine ® ,
Methadose ® )
Morphine
Sulphate-XR
(RoxanolTM )
100-300 mg §
200 mg
100-200 mg
5 mg
30 mg
50 mg
5 mg
10 mg
2.5 mg
15 mg
3600 mg in 2-3 divided doses §
800 mg in 2-3 divided doses
600 mg in 2-3 divided doses
20-30 mg in 2-3 divided doses
180 mg in 2-3 divided doses
300 mg in 2-3 divided doses
20-30 mg in 2-3 divided doses
20-30 mg in 2-3 divided doses
20 mg in 2 divided doses
30-45 mg in 2-3 divided doses
* Administer at least 2 h before bedtime or anticipated onset of symptoms.
† Possibly longer with hepatic dysfunction.
‡ Possibly longer with renal dysfunction.
§ Expert Panel recommendation.
Adapted with permission in 2004 from Earley CJ. Clinical practice: restless legs syndrome. N Engl J Med. 2003;348:2103-2109.
Copyright © 2003, Massachusetts Medical Society. All rights reserved.
5-7 h ‡
6 h
6-12 h †
3 h †
2.5-3 h †
5-8 h †‡
3 h ‡
12 h ‡
16-22 h †
4 h †
Sedation, dizziness, fatigue,
ataxia, somnolence
Hyponatremia, sedation, liver
function test abnormalities
Sedation, pruritis, constipation,
nausea, dry mouth,
dependence
Same as for propoxyphene
Same as for propoxyphene
Same as for propoxyphene
and augmentation
Same as for propoxyphene
Same as for propoxyphene
Same as for propoxyphene
Same as for propoxyphene

Medications That Exacerbate RLS. Dopamine antagonists
(eg, antipsychotics, emetics, gastric-motility agents) and
several common over-the-counter medications may exacerbate
RLS symptoms. A list of medications that may cause or
exacerbate RLS is provided in Table 4.
Table 4. Medications That May Cause or
Exacerbate RLS
✦ Antihistamines
✦ Dopamine antagonists (including nausea medications)
✦ Tricyclic antidepressants
✦ Lithium
✦ Selective serotonin reuptake inhibitors
Dosing and Titrating Drugs for RLS
Because there are few formal data and no published titration
guidelines for RLS medications, the primary care
provider must design an individual treatment regimen for
each RLS patient. However, a few guiding principles can be
employed. Symptoms should be treated as necessary, eg,
nightly symptoms may require daily treatment, whereas
intermittent symptoms should be treated as often as is necessary.
Dosing should commence 1 to 2 hours before the
anticipated onset of symptoms. Timing of subsequent doses
to ensure coverage throughout the night should be based on
the half-life of the selected agent. Beginning with the initial
dose (Table 3), a medication should be titrated until symp-
toms remit or the maximum daily dose is reached. The
effects of these drugs on RLS are almost immediate, so the
efficacy of a dosing regimen can usually be evaluated within
several days. Gradual upward titration of the dose will
therefore allow the primary care provider to assess
response. The International Restless Legs Syndrome Study
Group Rating Scale may be used to establish the relative
success of a dosing schedule.
Medications should be rotated in patients who do not
respond to the first-line agent at its maximal daily dose. If
monotherapy is not completely successful, the healthcare
provider can also consider combining drugs from the different
classes of agents. Any patient whose symptoms do not
remit after several agents have been administered at their
maximal daily doses should be referred to a neurologist.
Educating Patients About RLS
Because of the unusual symptoms of RLS and potential fears
of Parkinson’s disease, many patients with RLS feel uneasy
when seeking treatment. As a result, the healthcare provider
should educate the patient about the etiology of RLS. The
Expert Panel recommends that healthcare providers discuss
the following principles with RLS patients:
✦ RLS and Parkinson’s disease are distinct disorders,
although they have common treatment modalities
✦ RLS is not a precursor to Parkinson’s disease, and
RLS patients do not have increased risk for
Parkinson’s disease
✦ RLS is a manageable condition
✦ Difficulty in articulating symptoms is common for
RLS patients
✦ RLS is a physical condition, not a mental disorder
Several online resources are available to inform and educate
providers and patients who wish to learn more about RLS. A
list of organizations and their resources is provided in Table 5.
In addition to serving as a patient support group for RLS sufferers,
the Restless Legs Syndrome Foundation provides an
annually updated RLS medical bulletin and a regular online
newsletter for persons with RLS.
9

Conclusion
RLS is a common, but often inadequately diagnosed and
treated, movement disorder that can usually be well managed
in the primary care setting. Diagnosis of RLS and selection
of the appropriate treatment depend on the primary care
provider’s asking the correct questions regarding the characteristics,
frequency, and quality of a patient’s symptoms.
By doing so, the healthcare provider can design an individualized
treatment regimen to combat this disturbing disorder,
thereby enhancing the RLS patient’s quality of life, both during
sleeping and waking hours.
10
Table 5. Online RLS Resources for Patients and Providers
Organization Contact Information Resources
Restless Legs Syndrome Foundation
Worldwide Education & Awareness for
Movement Disorders (WE MOVE)
National Institute of Neurological Disorders
and Stroke (NINDS), National Institutes of
Health
www.rls.org
(507-287-6465)
www.wemove.org
(800-437-6682)
www.ninds.nih.gov
(800-352-9424)
Appendix A. Suggested Questions Following a Sleep Complaint 37
✦ When did the problem begin?
(To determine acute versus chronic insomnia)
✦ Does the patient have a psychiatric or medical condition
that may cause insomnia?
✦ Is the sleep environment conducive to sleep?
(Relates to noise, interruptions, temperature, light)
✦ Does the patient report “creeping,” “crawling,” or
“uncomfortable, difficult-to-describe feelings” in the
legs or arms that are relieved by movement?
(Relates to RLS)
✦ Does the bed partner report that the patient's legs or
arms jerk during sleep?
(Relates to periodic limb movements of sleep)
Acknowledgements
The Illinois Academy of Family Physicians and Scienta
Healthcare Education ® developed this program for the Family
Practice Education Network. The Academy thanks
GlaxoSmithKline Pharmaceuticals for providing an educational
grant for this program. We also thank Charles A.
Goldthwaite, Jr, PhD, for his writing and editorial expertise in
developing this document.
✦ Patient support services
✦ Annual medical bulletin
✦ Quarterly newsletter
✦Case studies and online
courses
✦ Information about RLS and
movement disorders for
patients, caregivers, and
healthcare professionals
✦ Publications
✦ Current research
✦ Does the patient snore loudly, gasp, choke, or stop
breathing during sleep?
(Relates to obstructive sleep apnea)
✦ Is the patient a shift worker? What are the work hours?
(Relates to circadian sleep disorders/sleep deprivation)
✦ At what times does the patient go to bed and get up on
weekdays and weekends?
(Relates to poor sleep hygiene and sleep deprivation)
✦ Does the patient use caffeine, tobacco, or alcohol? Does
the patient take over-the-counter or prescription medications,
such as stimulating antidepressants, steroids,
decongestants, or beta-blockers?
(Relates to substance-induced insomnia)
Portions reprinted with permission from Table 1. Restless legs syndrome: detection and management in primary care. Am Fam Physician. 2000;62(1):108-114.
Copyright AAFP. All rights reserved.

Faculty Disclosures
The Illinois Academy of Family Physicians adheres to the
conflict-of-interest policy of the American Academy of
Family Physicians as well as to the guidelines of the
Accreditation Council for Continuing Medical Education and
the AMA. Current guidelines state that participants in CME
activities should be made aware of any affiliation or financial
interest that may affect an author’s article. The members of
this Expert Panel have completed conflict-of-interest statements.
Disclosures do not suggest bias, but provide readers
with information relevant to evaluation of contents of these
guidelines.
Charles Adler, MD, PhD, serves as a consultant for and has
received research support from GlaxoSmithKline, Pharmacia
Corporation, and Elan Pharmaceuticals, Inc. Richard Allen,
PhD, has received travel support from and has served as a
consultant for GlaxoSmithKline, Pfizer, and Boehringer
Ingleheim. Mary P. Ettari, MPH, PA-C, is a consultant for and
serves on the speakers bureau for GlaxoSmithKline. William
G. Ondo, MD, has received grant support from
GlaxoSmithKline within the previous 12 months. Raymond
Watts, MD, serves as a consultant for and has received
research support from GlaxoSmithKline and Pfizer. W. Lane
Edwards, Jr, MSN, ARNP, ANP, and Penny Tenzer, MD, report
no conflicts of interest.
11

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