Why the worsening at rest and worsening at night criteria for Restless Legs Syndrome are listed separately: review of the circadian literature on RLS and suggestions for future directions

Abstract

The field of circadian research on Restless Legs Syndrome (RLS) and periodic limb movements (PLMs) is reviewed in general. RLS has five obligatory criteria for diagnosis: (1) an urge to move the legs often accompanied by uncomfortable leg sensations; (2) symptoms are worse at rest, i.e., lying or sitting; (3) there is a least partial and temporary relief of symptoms by activity, e.g., walking or stretching or bending the legs; (4) symptoms are worse later in the day or at night; and (5) mimics of RLS such as leg cramps and positional discomfort should be excluded by history and physical. In addition, RLS is frequently accompanied by PLMs, either periodic limb movements of sleep (PLMS) as determined by polysomnography or periodic limb movements while awake (PLMW) as determined by the suggested immobilization test (SIT). Since the criteria for RLS were based upon clinical experience only, an early question after the development of the criteria was whether criteria 2 and 4 were the same or different phenomena. In other words, were RLS patients worse at night only because they were lying down, and were RLS patients worse lying down only because it was night? Early circadian studies performed during recumbency at different times of the day suggest that the uncomfortable sensations, PLMS, and PLMW as well as voluntary movement in response to leg discomfort follow a similar circadian pattern with worsening at night independent of body position and independent of sleep timing or duration. Other studies demonstrated that RLS patients get worse when sitting or lying down independent of the time of day. These studies as a whole suggest that the worsening at rest and the worsening at night criteria for RLS are related but separate phenomena and that criteria 2 and 4 for RLS should be kept separate based upon the circadian studies, as had been the case previously based upon clinical grounds alone. To more fully prove the circadian rhythmicity of RLS, studies should be conducted to see if bright light shifts the signs and symptoms of RLS to a different circadian time in concert with circadian markers.