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Table 3 Differential diagnosis

From: Algorithms for the diagnosis and treatment of restless legs syndrome in primary care

Meeting Criteria Comment   Disorder
Urge to move & unpleasant sensations in the legs
Symptoms begin/worsen during periods of rest or inactivity.
Symptoms relieved with movement
Symptoms worse in the evening/night
Definite RLS Awake symptom diagnosis made by clinical history; uncomfortable urge to move with or without deep creepy-crawling sensation brought on at time of inactivity or rest (sitting or lying); immediate relief either complete or partial with movement; symptomatic relief is persistent as long as movement continues; presence of circadian pattern with peak around midnight and nadir in the morning RLS
Urge to move -
Symptoms begin/worsen during periods of rest or inactivity.
Symptoms relieved with movement
Orthostatic hypotension
Neurological disorder with "urge to move" Feeling of restlessness which may be localized in legs, brought on by sitting still; should not occur while lying down but might be relieved by movement; occurs in patients with orthostatic hypotension Hypotensive akathisia
Unpleasant sensations in the legs
Symptoms relieved with movement
Symptoms worse in the evening/night
No positive response to dopaminergic drugs
Pain Disorder Dysesthesias and pain in the legs, frequently one-sided, often radicular arrangement of sensory symptoms, atrophic changes of musculature, no urge to move the legs, symptoms can be initiated by sitting and lying and improve by movement, usually neurological and neurophysiological deficits, does not respond to dopaminergic therapy Radiculopathy
Unpleasant sensations in the legs
Symptoms relieved with movement
Symptoms worse in the evening/night -
Vascular Disorder Dysesthesias and pain in the legs. May appear to occur with or after rest but is associated with or occurs after periods of standing/walking; ntensity increased by movement and usually relieved by prolonging rest often best in a lying position, no urge to move, no circadian pattern, usually no sleep disturbances, frequently associated with skin alterations and edemas. Often associated with vascular disease, circadian pattern if any relates more to activity levels Vascular claudication, neurogenic claudication
Urge to move
Symptoms begin/worsen during periods of rest or inactivity
Periodic limb movements
History of neuroleptics
Neurological disorder with "urge to move" Looks like very severe RLS affecting the whole body -but usually without any sensations of pain reported by RLS patients often no relief with movement;, should have a history of specific medication exposure Neuroleptic-induced akathisia
Unpleasant sensations in the legs
Symptoms begin/worsen during periods of rest or inactivity
No positive response to dopaminergic drugs
Pain Disorder Sensory symptoms commonly reported as numbness, burning, and pain; not as common in RLS; numbness is rare in RLS, no urge to move; sensory symptoms usually present throughout the day, less frequent at night, complete and persistent relief is not obtained while walking or during sustained movement Neuropathy
No periodic limb movements    
Unpleasant sensations in the legs
Symptoms begin/worsen during periods of rest or inactivity.
Pain Disorder Patients after surgeries frequently do not remember the origin of their complaints. They almost always report symptoms in the legs or in the back, when lying or sitting or during movement. Chronic pain syndrome (lumbal, cervical)
Unpleasant sensations in the legs
Symptoms relieved with movement
Disorders without "urge to move" Often comes on with prolonged sitting or lying in the same position but usually relieved by a simple change in position, unlike RLS, which often returns when change of position, movement, or walking is not continued, no circadian pattern Positional discomfort
Symptoms relieved with movement
Symptoms worse in the evening/night
Neurological disorder with "urge to move" Leg cramps or charley horse cramps can come on at night and are relieved with stretching or walking; no urge to move; experienced as a usually painful muscular contraction, often involving the calf muscles, unlike RLS sensations; sudden onset, occurs not regularly, short duration, usually palpable contractions Nocturnal leg cramps
Unpleasant sensations in the legs
Symptoms worse in the evening/night
Sleep disturbance
Sleep-related Disorders Involuntary muscle (myoclonic) twitch which occurs during falling asleep, described as an electric shock or falling sensation which can cause movements of legs and arms. Occurring once or twice per night, frequent in the population. Hypnic jerks
Unpleasant sensations in the legs
Symptoms worse in the evening/night
Sleep disturbance
Psychiatric Disorders Depressive disorder with somatic symptoms like psychomotor agitation and diverse somatic complaints, circadian pattern with early awakening in the morning, daytime sleepiness. Depression, various forms with somatic syndrome
Urge to move
No positive response to dopaminergic drugs
No sleep disturbance
Neurological disorder with "urge to move" Occurs in subjects who fidget, especially when bored or anxious, but usually do not experience associated sensory symptoms, discomfort, or conscious urge to move; symptoms do not bother the subject, usually lacks a circadian pattern, more of a type of psychic restlessness, less sleep disturbances, no response to dopaminergic medication Volitional movements, foot tapping, leg rocking
Urge to move
No positive response to dopaminergic drugs
No periodic limb movements
Disorders without "urge to move" Discomfort centered more in joints, may not have prominent circadian pattern as seen in RLS, increase of symptoms during movement .does not respond to dopaminergics, usually no PLMs Arthritis, lower limb
Urge to move
Sleep disturbance
Disorders without "urge to move" Multiple, alternating, multiform complaints in muscle groups and joints; sometimes leg-accentuated but mostly whole body affected; frequent sleep disorders, no circadian pattern, no relief by movement, no dopaminergic response Fibromyalgia
Urge to move Vascular Disorder Discomfort in legs, some relief with massage or inactivity Varicose veins