Is it restless legs syndrome or neuropathy?

Take the time to make the distinction between restless leg syndrome and neuropathy.
Take the time to make the distinction between restless leg syndrome and neuropathy.

 This week, a third patient came with a diagnosis of restless legs syndrome (RLS) when a more accurate diagnosis should have been neuropathy. Consequently, I thought I should try to clarify the difference between the two.

RLS is loosely defined as having pain in the extremities, especially during relaxation, that is eased by movement or walking. The symptoms are often characterized as "creepy crawling" or "jumpy legs" but are described as painful at times. However, there are more specific criteria that need to be met in order to make a diagnosis. (See below.)

Restless legs syndrome occurs in about 10% of the population and tends to run in families, so ask patients if anyone else in the family has similar symptoms or has been previously diagnosed with RLS.

The diagnostic criteria for RLS is defined in the International Classification of Sleep Disorders as follows:

  1. "The patient reports an urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs.
  2. The urge to move or the unpleasant sensations begin or worsen during periods of rest or worsen during periods of rest or inactivity such as lying or sitting.
  3. The urge to move or the unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity
  4. The urge to move or the unpleasant sensations are worse, or only occur, in the evening or night.
  5. The disorder is not better explained by another current sleep disorder, medical or neurological disorder, medication use, or substance use disorder."1

Neuropathy is described as burning, shooting, electrical, pins-and-needles type of pain in the extremities. This pain is usually not eased by walking, and many patients complain that movement makes the pain worse. This pain is generally present most of the time and does not change during particular times of the day.

What can make a diagnosis difficult is when a patient has neuropathy and RLS, as the two can occur together. RLS can also be seen in patients with kidney disease, Parkinson's disease, and iron deficiency. It is often seen in pregnancy and can be seen in patients taking antidepressants or antipsychotic drugs.

Besides the patient complaints, check a ferritin level in patients suspected of having RLS. Iron levels should be kept above 50 ng/mL in patients who have symptoms. Add iron if levels fall below. If this does not control symptoms, medications that can be helpful include ropinirole and pramipexole. I often try gabapentin for RLS, especially if there is a neuropathic component as this can help both.

The most important questions to ask your patients are:

  1. When does the pain occur?
  2. Does movement make the pain go away or feel better?

These questions will most likely help you with the diagnosis. In most cases, if the pain is occurring with inactivity, in the evening, and walking makes the pain feel better, then you are safe to assume it is RLS. If not, look for something else.

Have you had a difficult time distinguishing between RLS and neuropathy?

Sharon M. O'Brien, MPAS, PA-C, is a practicing clinician with an interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.

Reference

  1. American Academy of Sleep Medicine. International Classification of Sleep Disorders, 2nd edition, pocket version: Diagnostic and Coding Manual. Westchester, Illinois: American Academy of Sleep Medicine, 2006.
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