Restless legs syndrome

International classification of sleep disorders - third edition, text revision (ICSD-3-TR)[7]American Academy of Sleep Medicine. The AASM international classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023​ [internet publication]. https://aasm.org/clinical-resources/international-classification-sleep-disorders

Criteria A-C must be met for a diagnosis of restless legs syndrome (RLS):

1. A complaint of the urge to move the legs, usually accompanied by or thought to be caused by uncomfortable and unpleasant sensations in the legs. These symptoms must:

   1. Begin or worsen during periods of rest or inactivity such as lying down or sitting

   2. Be partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues; and

   3. Occur exclusively or predominantly in the evening or night rather than during the day.

2. The above features are not solely accounted for a condition that mimics RLS (e.g., leg cramps, positional discomfort, myalgia, venous stasis, leg edema, arthritis, habitual foot tapping).

3. The symptoms of RLS cause concern, distress, sleep disturbance, or impairment in mental, physical, social, occupational, educational, behavioral, or other important areas of functioning.

International Restless Legs Syndrome Study Group (IRLSSG) criteria[1]Allen RP, Picchietti DL, Garcia-Borreguero D, et al; International Restless Legs Syndrome Study Group. Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria - history, rationale, description, and significance. Sleep Med. 2014 Aug;15(8):860-73. http://www.ncbi.nlm.nih.gov/pubmed/25023924?tool=bestpractice.com

All 5 of the following are needed for a clinical diagnosis of RLS:

1. An urge to move the legs usually, but not always, accompanied by, or felt to be caused by, uncomfortable and unpleasant sensations in the legs.

2. The urge to move the legs and any accompanying unpleasant sensations begin or worsen during periods of rest or inactivity, such as lying down or sitting.

3. The urge to move the legs and any accompanying unpleasant sensations are partially or totally relieved by movement such as walking or stretching, at least as long as the activity continues.

4. The urge to move the legs and any accompanying unpleasant sensations during rest or inactivity only occur or are worse in the evening or night than they are during the day.

5. The occurrence of the above features is not solely accounted for as symptoms primary to another medical or a behavioral condition (e.g., myalgia, venous stasis, leg edema, arthritis, leg cramps, positional discomfort, habitual foot tapping).

The following clinical specifiers are added where appropriate:

Specifiers for clinical course of RLS

• Chronic-persistent: symptoms when not treated would occur on average at least twice weekly for the past year

• Intermittent: symptoms when not treated would occur on average less than twice a week for the past year, with at least five lifetime events.

Specifier for clinical significance of RLS

• The symptoms cause significant distress or impairment to social, occupational, educational, or other important areas of functioning by their impact on sleep, energy/vitality, daily activities, behavior, cognition, or mood.

10-question rating scale of the International Restless Legs Syndrome Study Group[31]Walters AS, LeBrocq C, Dhar A, et al. Validation of the International Restless Legs Syndrome Study Group rating scale for restless legs syndrome. Sleep Med. 2003 Mar;4(2):121-32. http://www.ncbi.nlm.nih.gov/pubmed/14592342?tool=bestpractice.com

The scale is used to assess the severity of RLS and is predominantly used in therapeutic trials. It has the following 10 questions:

1. Overall, how would you rate the RLS discomfort in your legs or arms?

2. Overall, how would you rate the need to move around because of your RLS symptoms?

3. Overall, how much relief of your RLS arm or leg discomfort do you get from moving around?

4. Overall, how severe is your sleep disturbance from your RLS symptoms?

5. How severe is your tiredness or sleepiness from your RLS symptoms?

6. Overall, how severe is your RLS as a whole?

7. How often do you get RLS symptoms?

8. When you have RLS symptoms, how severe are they on an average day?

9. Overall, how severe is the impact of your RLS symptoms on your ability to carry out your daily affairs: for example, carrying on a satisfactory family, home, social, school, or work life?

10. How severe is your mood disturbance from your RLS symptoms: for example, angry, depressed, sad, anxious, or irritable?

All questions (apart from number 3) are scored with the following: very severe (4 points), severe (3 points), mild (1 point), none (0 points). Question 3 is scored by: no relief (4 points), slight relief (3 points), moderate relief (2 points), either complete or almost complete relief (1 point), no RLS symptoms and therefore question does not apply (0 points).

The score is calculated with the following categories:

• Mild: 1 to 10 points

• Moderate: 11 to 20 points

• Severe: 21 to 30 points

• Very severe: 31 to 40 points.

Johns Hopkins restless legs severity scale[22]Allen RP, Earley CJ. Restless legs syndrome: a review of clinical and pathophysiologic features. J Clin Neurophysiol. 2001 Mar;18(2):128-47. http://www.ncbi.nlm.nih.gov/pubmed/11435804?tool=bestpractice.com [32]Allen RP, Earley CJ. Validation of the Johns Hopkins restless legs severity scale. Sleep Med. 2001 May;2(3):239-42. http://www.ncbi.nlm.nih.gov/pubmed/11311687?tool=bestpractice.com

This scale was the first validated severity scale for RLS. It asks about the usual time of onset of RLS symptoms for at least 50% of days. Patients are asked, "At what time of day do these feelings usually start?" It is described as a rating from 0 to 3, with higher numbers identifying more severe symptoms.

• 0 = no symptoms

• 1 = bedtime only symptoms (symptoms starting no earlier than 60 minutes before bedtime)

• 2 = evening and bedtime symptoms (symptoms starting no earlier than 6 p.m. [adjustment needed if atypical bedtimes and/or afternoon siesta])

• 3 = day and night symptoms (symptoms before 6 p.m. or all day).