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Year : 2022  |  Volume : 25  |  Issue : 3  |  Page : 507-510

Clinicians heuristic impression of the presentations of restless legs syndrome: A survey among medical graduate trainees in an academic hospital in India

Department of Neurology, National Institute of Mental Health And Neuroscience, Bangalore, Karnataka, India

Date of Submission16-Jul-2021
Date of Acceptance17-Sep-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
P R Srijithesh
Department of Neurology, NIMHANS, Bengaluru, Karnataka - 560 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aian.aian_655_21

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How to cite this article:
Raja P, Srijithesh P R, Mythirayee S, Yadav R. Clinicians heuristic impression of the presentations of restless legs syndrome: A survey among medical graduate trainees in an academic hospital in India. Ann Indian Acad Neurol 2022;25:507-10

How to cite this URL:
Raja P, Srijithesh P R, Mythirayee S, Yadav R. Clinicians heuristic impression of the presentations of restless legs syndrome: A survey among medical graduate trainees in an academic hospital in India. Ann Indian Acad Neurol [serial online] 2022 [cited 2022 Oct 3];25:507-10. Available from:


Restless legs syndrome (RLS) is a sensorimotor neurological disorder that is diagnosed based on clinical criteria.[1] The four essential criteria for diagnosis include an urge to move legs accompanied by or caused by an uncomfortable sensation in the legs, worsening of the symptoms with rest or inactivity, improvement of symptoms with movement, and symptoms worsening toward the evening or at night. The original diagnostic criteria were developed by the Delphi method.[2] The essential component of the original criteria was retained in all the subsequent modifications.[1]

The prevalence of the RLS is estimated to be about 10% in the North American and European populations where the diagnostic criteria have been validated.[3],[4] However, in studies from Asia, the prevalence is estimated to be 1%–3%.[5] This has been attributed to possible ethnic and racial differences. The prevalence of severe RLS is about 2.5%. Given the range of prevalence of RLS, it forms one of the most common neurological illnesses. However, in India, it is an uncommonly diagnosed entity. The reason for this could be multifactorial. It could be a case of genuine ethnic and racial differences. It could also be due to the poor discriminant capacity of the diagnostic criteria to characterize the condition in a linguistically diverse population. Another important factor could be the inability of clinicians to appreciate the nuances of diagnostic criteria and apply them to the local population.[5]

We did a survey to evaluate the heuristic impression of clinicians regarding the clinical profile and presentation of patients with RLS.

The survey was conducted from June 2018 to February 2020 in a large tertiary care hospital in south India. The institutional ethics review board approved the study. The study participants were postgraduate students in medicine, pediatrics, or neurology undergoing neurology posting as a part of the residency.

Participants were requested to respond to a survey questionnaire on RLS [Appendix]. The questionnaires consisted of polar questions, multiple response questions, and fill in the blank's questions.

The questionnaire explores the clinical detection rate and the clinical impression of doctors regarding RLS. It begins by inquiring about the number of patients with RLS that the participants have seen during their clinical careers. Thereafter, it enquires on the “clinical impressions of the participants concerning the presentation of RLS”. The questionnaire concludes with the question on the participant's impression of the population prevalence of RLS. The questionnaire takes 10–15 min to complete, and the response sheet was collected within 30 min of submission for the participant's response.

One hundred medical graduates participated in the survey. The mean age of the participants was 28.2 (SD: 2.5). The average years after graduation was 4.28 (SD: 2.4). Ninety-two (92%) participants were postgraduate (PG) students in general medicine or neurology. Five (5%) participants were undergoing postgraduation in psychiatry, and three (3%) in pediatrics.

Thirty-nine percent of the participants have not seen patients with RLS in their clinical careers. A total of 82% of participants had read about RLS, whereas 48% have been taught about the illness. Of the participants who responded to have seen patients with RLS, 72.1% reported that they have seen less than five patients in their career. Fourteen participants claimed to have seen 5–10 patients, whereas only four participants claimed to have seen 11–50 patients [Table 1].
Table 1: Clinical and Academic Encounter of RLS Patients among Medical Graduates Surveyed (n=100)

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More than half of the participants (59%) considered RLS as a “movement disorder” [Figure 1]a. Of the participants who responded to the question on the most impressive clinical feature of RLS, the most common symptoms described were the “urge to move limbs” (50%). The other symptoms considered as the most common symptoms were restlessness and unpleasant sensation. A minority of respondents considered “improvement of symptoms on movement” and “symptoms present at night/sleep” as the most impressive clinical feature.
Figure 1: Clinical manifestation of RLS according to the trainees (a) Most impressive clinical feature of RLS according to the trainees. (b) Topography of symptoms in RLS according to the trainees

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The majority of the doctors were either not aware or did not agree on the topography of the presentation of RLS: 37% were not aware or did not agree on bilateral presentation of RLS, whereas 46% were not aware or did not agree of the unilateral presentation of the condition. A total of 73% were not aware or did not agree on the upper-limb presentation of RLS [Figure 1]b.

Of the participants who responded to the question to guess the population prevalence of RLS (n = 73), 27 (37%) responded that it was 1%–2%, 32 (44%) mentioned it as 0.1%–1%, and 14 (19.1%) considered the prevalence to be less than 0.1%.

The knowledge about RLS was compared between neurology trainees and trainees in general medicine, pediatrics, and psychiatry trainees. It was found that neurology trainees have better knowledge of RLS. However, even neurology trainee was not proficient in the entire range of symptomology of RLS [Table 2].
Table 2: Comparision of Knowledge of RLS between Neurology Trainees and Non-Neurology Trainees*

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This survey demonstrates the low rate of clinical detection of RLS. Although prevalence studies from Asia have found a prevalence of 1%–3%,[6] it is still substantial to have not been recognized as a common clinical problem by the trainee doctors. A prevalence of 1%–3% of the illness would make it as common as epilepsy in medical and neurological clinical practice. In the present survey, only 60% of the doctors had seen a case of RLS, and 72% of the respondents had seen only less than five patients in their clinical tenure. This is a dismally low detection rate, as RLS is a common disorder associated with many common medical disorders such as anemia, peripheral neuropathy, and renal failure. It is possible that patients may not consider RLS as a condition needing medical attention, and is, therefore, underreported to medical practitioners in India.

The survey demonstrates the lack of a clear “heuristic” impression among the young doctors regarding the clinical presentation of RLS. There is a widespread misunderstanding of RLS as a movement disorder. This appears to be compounded by the textbook description of the condition under hyperkinetic movement disorder.[7] This is bound to create a heuristic mismatch when clinicians see patients with RLS. It is likely that RLS is underdiagnosed in India due to a host of reasons including the ability of clinicians to elicit the cardinal symptoms of the illness in a linguistically diverse population.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Earley CJ. Clinical practice. Restless legs syndrome. N Engl J Med 2003;348:2103-9.  Back to cited text no. 1
Walters AS, Aldrich MS, Allen R, Ancoli-Israel S, Buchholz D, Chokroverty S, et al. Toward a better definition of the restless legs syndrome. The International Restless Legs Syndrome Study Group. Mov Disord 1995;10:634-42.  Back to cited text no. 2
Allen RP, Picchietti D, Hening WA, Trenkwalder C, Walters AS, Montplaisi J, et al. Restless legs syndrome: Diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Med 2003;4:101-19.  Back to cited text no. 3
Tison F, Crochard A, Léger D, Bouée S, Lainey E, Hasnaoui AE. Epidemiology of restless legs syndrome in French adults: A nationwide survey: The INSTANT Study. Neurology 2005;65:239-46.  Back to cited text no. 4
Tan EK, Seah A, See SJ, Lim E, Wong MC, Koh KK. Restless legs syndrome in an Asian population: A study in Singapore. Mov Disord 2001;16:577-9.  Back to cited text no. 5
Rangarajan S, Rangarajan S, D'Souza GA. Restless legs syndrome in an Indian urban population. Sleep Med 2007;9:88-93.  Back to cited text no. 6
Fahn S, Jankovic, J. Hallett, M. Principles and Practice of Movement Disorders. China: Elsevier; 2011.  Back to cited text no. 7


  [Figure 1]

  [Table 1], [Table 2]


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