Am Fam Physician. 2000;62(1):51-52
My experience with the Restless Legs Syndrome (RLS) Working Group, which produced the document published in this issue of American Family Physician,1 reminded me of how much we can learn from our colleagues. Despite the recent focus on evidence-based medicine, we should not overlook the value of clinical experience and dialogue. After countless hours of discussion and revision, the authors of this collaborative review were careful to produce meticulously formulated definitions, as well as practical, solid recommendations. Although many treatments were discussed, they were omitted from the report if the group agreed that the supportive evidence was weak. Because of the lack of scientific support for lifestyle modification and nonpharmacologic therapies, no suggestions relating to these measures were included in this document.2 Only established facts found their way into the final draft, whereas any information without solid foundation was eliminated. Given the limitations of our medical knowledge and our fallibility in the real practice of medicine, a consensus among practitioners can be a powerful resource. It suggests that we do not know everything, but given what we know we can agree on a standard of care.
In addition to the valuable summary that the Working Group document provides, this review enhances our awareness of a condition that we may have tended to underdiagnose.3 Some illnesses elude diagnosis because they are not common in a given practice or because the symptoms are minor and are not brought to the physician's attention. Although RLS is the fourth leading cause of insomnia, its prevalence ranges from 2 to 15 percent and, therefore, its incidence may vary according to practice. Thus, either of the aforementioned possibilities may come into play.4 Awareness is important because RLS is diagnosed almost exclusively by history. In this sense, it stands to reason that the Working Group should have devoted a substantial portion of its energies to the definition of RLS, a syndrome that is often called “indescribable.”3 In terms of differential diagnosis, however, few conditions resemble it. Nocturnal leg cramps, with their sudden, severe muscle contraction and relatively rapid resolution, are nothing like the almost mental, irritating discomfort of RLS. Remembering its place among sleep disturbances may be all that is required to identify it in susceptible patients.
Another reason that RLS may elude our attention is that none of the medications used in its treatment are primarily indicated for RLS. RLS is essentially a stepchild of other neurologic disorders such as Parkinsonism and anxiety, conditions to which it is unrelated but whose pharmacologic treatments it has inherited. In addition, many common conditions, including pregnancy and iron deficiency anemia, may be associated with RLS. In our routine management of these familiar scenarios, we could easily fail to consider the possibility of RLS.
All of this leads to a final point, which is that RLS can be treated effectively by primary care physicians. First, as previously mentioned, it is diagnosed almost exclusively by history. Second, the differential diagnosis is, for the most part, limited to a few common, easily recognized conditions. Third, the treatment options include medications that family physicians often prescribe for other illnesses, except that lower dosages are used in RLS. Thus, the Working Group has provided an important service to patients suffering from this potentially debilitating condition. It also provides a service to family physicians by adding to the repertoire of ailments we can treat successfully on our own, without sub-specialty consultation or unnecessary diagnostic testing.