Restless legs syndrome
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3056 (Published 23 May 2012) Cite this as: BMJ 2012;344:e3056
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I read the review of restless legs syndrome(1) with interest as I had recent personal experience of this condition following withdrawal of tramadol hydrochloride. This drug was indeed mentioned as a possible treatment of restless legs but tramadol withdrawal was not mentioned as a cause of this syndrome, nor indeed was withdrawal of opiates.
Restless legs syndrome is a recognised symptom of opiate withdrawal(2), but may be less well known in association with tramadol withdrawal. My experience with tramadol started last year after insertion of a ureteric stent during an attempt to remove kidney stones. The stent was in place for three months. During this time I had intermittent loin pain of similar severity to that of renal colic, that was effectively relieved by taking tramadol 50mg two or three times a day. After a second stent was inserted, the pain was much less, I reduced the tramadol dosage to 50mg at night and then stopped it altogether. That night I had a very uncomfortable feeling in my legs making me writhe around, preventing sleep, and prompting me to take another 50mg of tramadol. This happily relieved the symptoms.
The next day I read the manufacturers leaflet which stated that you should not stop treatment early (whatever that means) because you may experience withdrawal effects, including difficulty sleeping. Tramadol is considered a weak opioid and unlikely to cause dependency(3) but there are a few published reports of withdrawal syndromes(4.5). I persevered with stopping treatment. Symptoms of malaise and restless legs were highly unpleasant for the following few nights, and the desire to take another tablet was strong! I have no other history of restless legs, drug abuse or dependency, and the dose taken was not considered to be excessive, but I did develop a physical dependency on tramadol.
1. Leschziner G, Gringras P. Restless legs syndrome. BMJ; 344:e3056
2. Scherbaum N, Stüper B, Bonnet U, Gastpar M. Transient restless legs-like syndrome as a complication of opiate withrawal. Pharmacopsychiatry 2003;36:70-2.
3. Desmeules JA. The tramadol option. Eur J Pain. 2000;4,SupplA:15-21.
4. Withdrawal syndrome and dependence: tramadol too. Prescrire Int 2003;12:99-100.
5. Pollice R, Casacchia M, Bianchini V, Mazza M, Conti CM, Roncone R. Severe tramadol addiction in a 61 year-old woman without a history of substance abuse. Int J Immunopathol Pharmacol 2008;21:475-6.
Competing interests: No competing interests
It was good to read the excellent review of Restless Legs Syndrome [RLS] in the current BMJ: a valuable resource for health professionals and sufferers. This condition is intriguing in that the main symptom taxes sufferers' powers of description: in over two hundred telephone interviews personally carried out in the last two years, when asked to describe their experience of sleep being disrupted by RLS most people preface any description by saying that “it's really difficult to describe”. Why should sensations, such as tingling, pain, crawling sensations under the skin, etc., that are common in RLS and are relieved by movement, be difficult to describe? On probing, the sufferer's difficulty is that the irrepressible urge to move that they eventually accede to seems to them out of proportion to the mere unpleasantness of the sensation. This urge may even be felt as a pure impulse without any actual abnormal sensations. It is as though the process whereby a voluntary decision to move progresses into the selection and production of a specific motor pattern, is high-jacked by an aberrant impulse that is interposed at the selection stage and makes movement inevitable but not stereotyped or involuntary. None of the various factors so far associated with RLS such as iron deficiency, specific genes, diabetes etc are invariably present and the pathogenesis remains mysterious.
To add to the puzzles RLS sets us, Douglas Longden, a medically qualified osteopath, discovered more than twenty years ago a specific manipulative treatment[1] that can control or even cure the condition in the majority of cases. Initially his finding was confirmed by a case series[2] which led to the London College of Osteopathic Medicine carrying out an RCT of this method which has confirmed Longden's findings. The trial report is at present in preparation for publication. Meanwhile the method is being developed for use as a self-treatment and entry into a study cohort is now open to sufferers.
References:
1. Peters T. Restless Legs. Osteopathy Today 2002; October : 12-13
2. Jones LH, Kusunose R, Goering E. “Jones Strain-Counterstrain” 1995. P 83
ISBN 0 – 9645135-4-4.
Competing interests: No competing interests
Restless legs are a redundancy. Our legs have large muscle groups, which are designed for movement. In my experience, restless legs respond well to aerobic exercise, such as walking, running, biking, dancing, and swimming. Please let’s not medicalize life with endless diagnoses that just create a pretext for more pharmaceuticals.
Competing interests: No competing interests
Dear Sir, Leschziner & Gringras article1 is timely and highlights several problems related to the recognition and treatment of restless legs syndrome. Augmentation syndrome is an increasing problem, perhaps because dopamine agonists are now more widely prescribed, and diagnostic criteria defined2. However all increase in symptoms is not augmentation syndrome: patients should also be aware that symptoms of restless legs fluctuate over time, and 6% of patients taking placebo present augmentation like symptoms over a period of 6 months3. Tolerance to dopamine agonists also occurs and leads to a gradual increase of doses over time without the appearance of the classic symptoms of augmentation4. However it seems likely that in certain cases, tolerance precedes augmentation. As stated by Leschziner & Gringras, augmentation is frequent (60% at 11 months) with L-dopa5, but studies show rates of up to 10% annually with dopamine agonists5-8. Symptoms appear progressively, but once present, patients can be exhausted by their constant presence and the consequent sleep deprivation. As symptoms are temporarily improved by an increase in dopamine agonist dose, if clinicians are not aware of the existence of augmentation syndrome, it is assumed that the increase in symptoms represents the natural progression of the disease, and patients can end up taking very high doses. Treatment of severe augmentation syndrome requires cessation of dopamine agonists, which patients are reluctant to try. Careful monitoring of symptoms, regular therapeutic windows and in some patients the rotation of treatment using different therapeutic approaches as suggested by Kurlan et al is advisable9.
Management of restless legs syndrome can be complicated. However it is further complicated in France by the fact that no dopamine agonists are currently reimbursed by the French health authority, because they are considered as a non essential treatment, simply increasing patient comfort. As a result paying for dopamine agonists is a source of considerable expense to patients who are often very handicapped by their symptoms and for whom dopamine agonists are very effective. We would like to highlight the need to coordinate at a European level in order to harmonise management and access to treatment.
1. Leschziner G, Gringras P. Restless legs syndrome. BMJ 2012;344:e3056
2. Garcia-Borreguero D, Allen RP, Kohnen R et al. Diagnostic standards for dopaminergic augmentation of restless legs syndrome: report from a World Association of Sleep Medicine-International Restless Legs Syndrome Study Group consensus conference at the Max Planck Institute. Sleep Med. 2007;8(5):520-530.
3. Hogl B, Garcia-Borreguero D, Trenkwalder C et al. Efficacy and augmentation during 6 months of double-blind pramipexole for restless legs syndrome. Sleep Med. 2011;12(4):351-360.
4. Ondo W, Romanyshyn J, Vuong KD, Lai D. Long-term treatment of restless legs syndrome with dopamine agonists. Arch Neurol. 2004;61(9):1393-1397.
5. Hogl B, Garcia-Borreguero D, Kohnen R et al. Progressive development of augmentation during long-term treatment with levodopa in restless legs syndrome: results of a prospective multi-center study. J Neurol. 2010;257(2):230-237.
6. Silver N, Allen RP, Senerth J, Earley CJ. A 10-year, longitudinal assessment of dopamine agonists and methadone in the treatment of restless legs syndrome. Sleep Med. 2011;12(5):440-444.
7. Allen RP, Ondo WG, Ball E et al. Restless legs syndrome (RLS) augmentation associated with dopamine agonist and levodopa usage in a community sample. Sleep Med. 2011;12(5):431- 439
8. Inoue Y, Kuroda K, Hirata K, Uchimura N, Kagimura T, Shimizu T. Long-term open-label study of pramipexole in patients with primary restless legs syndrome. J Neurol Sci. 2010;294(1-2):62-66.
9. Kurlan R, Richard IH, Deeley C. Medication tolerance and augmentation in restless legs syndrome: the need for drug class rotation. J Gen Intern Med. 2006;21(12):C1-4.
Competing interests: No competing interests
Re: Restless legs syndrome
I am a septuagenarian with a long past history of L5/S1 and L4/L5 disc problems which have resulted in limited flexion of my lumbar spine. If I sit in a low chair I begin to get the clssic symptoms of Restless Legs Syndrome. Prolonged sitting, even in a fairly reasonable posture - say of an evening with TV - is likely to be followed by the symptoms on going to bed. I assume mechanical irritation of my spinal cord (rather perhaps than of nerve roots because the sensation is felt in lumbar spine as well as - often symmetrically - in the legs) is to blame.
May I suggest a little investigation along these lines in a group of sufferers, and a trial of improved seating postures. Many, especially older, sufferers possibly have orthopaedic causes for this condition.
Competing interests: No competing interests