Hindawi

Sleep Disorders
Volume 2020, Article ID 7302828, 5 pages
https://doi.org/10.1155/2020/7302828

Research Article
Prevalence of Restless Legs Syndrome among Medical Students of
Karachi: An Experience from a Developing Country

M. Ishaq, S. U. Riaz , N. Iqbal, S. Siddiqui, A. Moin, S. Sajjad, T. Ali, and S. Jamali

Jinnah Medical & Dental College, Pakistan

Correspondence should be addressed to S. U. Riaz; [email protected]

Received 26 July 2019; Revised 23 December 2019; Accepted 29 January 2020; Published 19 February 2020

Academic Editor: Yuan-Yang Lai

Copyright © 2020 M. Ishaq et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Restless legs syndrome (RLS) is a neurological disorder characterized by an uncomfortable sensation in the legs which
gets worse in the evening or night, relieved upon movement. The aim of this study was to specify the prevalence of RLS in the group
of young medical students and to assess the effect of RLS on sleep, as sleep disturbance is one of the chief complaints of RLS patients.
We also studied its association with smoking as it is considered an aggravating factor. Method. This was a cross-sectional study
conducted from June 2017 to July 2018 in Karachi. A total of 300 students (220 females and 80 males) participated and were
given questionnaires to detect RLS based on criteria proposed by the International Restless Legs Syndrome Study Group.
Subjects who were positive for RLS were further asked questions about sleep by using the Epworth Sleepiness Scale and severity
of RLS by using RLS Rating Scale. They were also asked about their smoking status. Results. The frequency of RLS is 8% among
young adults. Out of 300 medical students, 24 students were classified positive for RLS with a female preponderance (66.7%
were females and 33.3% were males). The severity of RLS was more rated to be mild to moderate. The effect of RLS on sleep was
in the mild range. The p value of smoking status comparing with gender came out to be <0.001, and p value of RLS is 0.773.
Conclusion. It is concluded that we found RLS to be present significantly in our population that is without comorbidities. Our
results showed female preponderance and a mild sleep disturbance in our study population. More attention is needed to
recognize RLS and to manage the aggravating factors of RLS.

1. Introduction are often unable to concentrate, have impaired memory, or

fail to accomplish daily tasks. It also can make traveling diffi-
Restless legs syndrome (RLS) is a neurological disease char- cult and can cause depression [1]. For 60-70% of patients
acterized by throbbing, pulling, creeping, or other unpleasant with RLS diagnosis, sleep disturbance is the chief cause lead-
sensations in the legs and an uncontrollable and sometimes ing them to seek treatment [4–6]. RLS has been associated
overwhelming urge to move them [1]. It was first described with dopaminergic dysregulation, several health conditions,
by Sir Thomas Willis, an English physician in 1672 [2]. Later and various lifestyle factors like consumption of alcohol,
in 1945, Ekbom classified it into a sensory form called as coffee, cigarettes, and some drugs [7].
asthenia crurum paraesthetica and a painful variant called RLS has also been found to substantially increase the risk
asthenia crurum dolorosa [3]. of major depressive disorder and anxiety disorders [8]. Rest-
The most distinctive aspect of the condition is that lying less legs syndrome is usually diagnosed according to the
down and trying to relax activates these symptoms. Most criteria proposed by International RLS Study Group
people with RLS have difficulty falling asleep or staying (IRLSSG) [4]. International Restless Legs Syndrome Study
asleep. Left untreated, the condition causes exhaustion and Group rating scale (IRLSS) is a valid instrument that has
daytime fatigue. Many people with RLS report that their shown high internal consistency, test-retest reliability, and
job, personal relations, and activities of daily living are clinical validity [9]. This is primarily a neurobehavioral
strongly affected as a result of their sleep deprivation. They disorder; hence, objectively, severity can only be assessed by
 3717, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2020/7302828 by INASP/HINARI - PAKISTAN, Wiley Online Library on [13/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 Sleep Disorders

using a questionnaire. Restless legs syndrome affects the consent, study questionnaires, which were validated and
quality of sleep and causes daytime somnolence; this was were in the English language (all participants being medical
calculated by the Epworth Sleepiness Scale [10]. students know it), were then administered to the subjects,
RLS is one of the underdiagnosed conditions globally as and they were interviewed to rule out other conditions that
well as in Pakistan, and there is scarce local data related to mimic RLS.
the prevalence of RLS among the young population. The The study questionnaire was to be divided into four
purpose of our study is to find out the prevalence and to parts. The first part of the questionnaire was to gather
assess the severity of symptoms among medical students. demographic information including age, gender, and smok-
Also, its effect on sleep of students will be studied. This will ing status of the subject. The second part was to inquire
help create awareness about RLS among medical students. about the essential questions of the criteria of RLS specified
Also, any substantial issues found through our study will help by IRLSSG [4]:
lessen the burden of this disease and implement the strategies
necessary for treatment to bring about change. (1) An urge to move the legs, usually accompanied or
caused by uncomfortable and unpleasant sensations
2. Methodology in the legs. (Sometimes the urge to move is present
without the uncomfortable sensations, and some-
2.1. Study Design. It was a cross-sectional observational study. times the arms or other body parts are involved in
2.2. Study Setting. This study was conducted in different addition to the legs.)
medical colleges of Karachi, Pakistan, that included Jinnah (2) The urge to move or unpleasant sensations begin or
Medical and Dental College (JMDC), Karachi Medical and worsen during periods of rest or inactivity such as
Dental College (KMDC), Dow International Medical College lying or sitting
(DIMC), Liaquat College of Medicine and Dentistry
(LCMD), and Al-Tibri Medical College (ATMC). (3) The urge to move or unpleasant sensations are
partially or totally relieved by movement, such as
2.3. Inclusion and Exclusion Criteria. Our study population walking or stretching, at least as long as the activity
consisted of MBBS undergraduate students only. Individuals continues
aged 18-26 were included. Individuals who had impaired
sensation, neuropathies, pregnancy, morbid obesity, (4) The urge to move or unpleasant sensations are
decreased vitamin B 12, vegetarians, anemic, thyroid issues, worse in the evening or night than during the day
known comorbidities, history of trauma to the limbs, and or only occur in the evening or night. (When symp-
any febrile illnesses and pregnancy proven by biochemical toms are very severe, the worsening at night may
evidence were excluded. The study was approved by the not be noticeable but must have been previously
ethical committee of Jinnah Medical and Dental College, present.)
and individual consent was obtained through verbal and
If the answer to the questionnaire questions was yes and
implied consent on the questionnaire.
there is no known cause apart from RLS being responsible
2.4. Sampling Technique and Sample Size. The subjects were for these symptoms, so this was definitive for RLS. The third
selected through nonprobability convenience sampling. and fourth parts of the questionnaire relating to severity and
The sample size of the study was calculated by using the sleepiness were only administered to the RLS-positive indi-
formula: viduals. In the third part, questions regarding sleepiness were
asked using Epworth Sleepiness Scale [10]. This scale is
ðZ Þ2 Pð1‐PÞ important in clinics to measure the improvement with treat-
n= , ð1Þ ment as well as for the research purpose to measure the sever-
d2 ity of RLS. To know about its impact on sleep, the Epworth
Sleepiness Scale was used. This scale intended to measure
where n is the sample size, Z is the Z statistic for a level of
daytime sleepiness and is helpful in the diagnosis of sleep
confidence, P is the expected prevalence or proportion (if
disturbance among medical students.
the expected prevalence is 20%, then P = 0:2), and d is the
In the fourth part, the severity of RLS symptoms was
precision (If the precision is 5%, then d = 0:05).
explored by using the RLS Rating Scale. Different ques-
Assuming a prevalence of 23.6% (16), keeping the
tions regarding RLS symptoms were asked from the sub-
confidence level at 95% and accepting a 5% margin of
jects using this scale, and score was recorded. According
error, the estimated sample size was calculated to be
278. Further adding 10% for nonresponse, missing values, to the RLS Severity Rating Scale, a score of 1-10 denoted
and dropouts, we needed 300 subjects. For ease and diversity, mild severity, 11-20 was moderate, 21-30 was severe, and
we visited 4 different medical institutions and included the 31-40 was very severe. Statistical analysis was performed
sample size subjects. using the program Statistical Package for the Social Sciences
22.0 (SPSS). The qualitative variables were expressed as
2.5. Study Tool and Data Collection Method. Data was percentages, and quantitative variables were expressed as
collected from June 2017 to June 2018. After evaluating the mean ± standard deviation. A value < 0:05 was regarded as
patients’ eligibility to participate in the study and obtaining statistically significant.
 3717, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2020/7302828 by INASP/HINARI - PAKISTAN, Wiley Online Library on [13/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Sleep Disorders 3

3. Results this is the only initiative taken among medical students with
respect to this topic in Pakistan.
Around 390 students were approached in medical colleges, Mahmood et al. made attempts to see the prevalence of
and the data of 300 subjects were included in the final analy- RLS in the general population of Karachi. Their results,
sis. The data was collected from different medical colleges although much higher than ours at 8% compared to theirs
(LCMD, JMDC, DIMC, KMDC, and Al-Tibri) of Karachi. at 23.6%, confirmed female preponderance. There was no
Overall, there were 220 (73.3%) females and 80 (26.6%) specified age group defined, and they took patients with
males. Out of 300 students, 33 (11%) were smokers and 267 comorbidities. Our study was in healthy individuals, so the
(89%) were nonsmokers. The mean age was calculated to be impact is foreseen to be higher with advanced age and
21.3 (SD = 1:68). Demographic characteristics of the sample comorbidities [11]. Both studies go on to prove a ratio of
population are summarized in Table 1. 2 : 1 of female to male suffering from this condition. A similar
Out of 80 male students, 21 (26.25%) were smokers and study was carried out among medical students in Egypt
the rest were nonsmokers. In female students, 12 (5.45%) showing a prevalence of 11.8% with a female preponderance.
out of 220 were smokers and 208 (94.54%) were nonsmokers Most had idiopathic variety [12, 13].
(Figure 1). Our study reemphasizes the fact that RLS is more of a
Out of 300 individuals, 24 (8%) were classified as RLS disease in the female gender than in the male gender, a point
positive based on criteria defined by IRLSSG shown in highlighted by the previous studies. We have four such
Figure 2. The prevalence of RLS was found to be 8.6% and studies to confirm our conclusions [4, 5, 14, 15]. Since our
9.3% among females and males, respectively. sample was of a university-going age group, the severity of
Out of 300 students, 21 (7%) males were smokers and 59 the symptoms was of mild category. It also can be because
(19.6%) were nonsmokers and 12 (4%) females were smokers the students were suffering from no comorbidities and were
and 208 (69.33) were nonsmoker. In those smoker males, 7 young and healthy [16, 17]. All these studies concluded, much
were RLS positive and 73 were negative whereas 17 smoker like ours, that patients suffering from RLS were subject to
females were found to be RLS positive and 203 were negative, some or to the other sort of sleep disturbance. [5, 15, 18, 19].
respectively. The p value of smoking status comparing with A study published in Sleep Medicine in 2015 stated that
gender came out to be <0.001, and p value of RLS is 0.773 students self-diagnosed themselves with restless legs syn-
in Table 2. drome and were not aware of the term Willis-Ekbom Disease
The mean (SD) value of RLS in males is 11.57 (5.798) [20]. A study with a higher subject participation was con-
compared with the mean (SD) value of RLS females which ducted in Iran where patients with all sort of comorbid factors
is 10.86 (4.384). The mean (SD) value of severity of sleepiness were investigated, and it concluded that smoking or any
of RLS in males is 9.71 (3.039) as compared to the severity of neurodegenerative comorbidity played a significant role in
sleepiness of RLS in females which is 6.866 (3.020). The p the incidence [21]. A study in Turkey showed a general low
value calculated was 0.754 comparing between gender and incidence, but people living at high altitudes were at a greater
RLS severity score mean. The p value was 0.053 comparing risk to develop this disorder, so more studies can be done to
between gender and sleepiness severity score in Table 3. probe into this topic in the future. This study also went on to
The students diagnosed with RLS were 24, out of which reiterate the role that smoking plays in acquiring RLS [22].
only 21 solved the questionnaire part for assessing severity Various meta-analysis has been stating the causes of rest-
based upon the RLS Rating Scale. Out of those 21 students, less legs syndrome and showed iron deficiency, uremia, diabe-
9 (42.85%) students had mild and 12 (57.14%) students had tes, and certain drugs play a role in increased incidence [23, 24].
moderate severity of RLS symptoms. One of the strengths of this study is that diagnosis was made
Out of them as shown in Table 4, 3% were males and 6% according to the criteria set by IRLSSG for diagnosing RLS.
were females who had mild RLS severity and 4% males and
8% females had moderate RLS severity. In Sleepiness severity 5. Conclusion
scale, 6 females reported no daytime sleepiness. Among
students, 4 males and 8 females reported mild severity. Only It has been concluded that the prevalence of RLS among
1 male and 1 female had moderate sleepiness severity. Two the young population of Karachi cannot be underestimated.
males had severe daytime sleepiness. There were no males It is also an underdiagnosed condition as most people did
or females with very severe sleep symptoms. not know the condition responsible for their symptoms in
our research.

4. Discussion 5.1. Limitations. One lack of our study was that the sample
size was too small for whom severity and effect on sleep were
We went through various research articles, and to the best of studied. Nevertheless, for assessing severity and effect on
our knowledge, this was the first attempt to categorize RLS sleep, we had used internationally established scales which
among the young generation in Pakistan in an attempt to had test-retest ability. This study cannot be generalized as it
find out its repercussions and aftermath on sleeping habits was done in young and healthy subjects, and there is a need
of students who suffer from this neurological disorder. Since for further probing into the topic keeping in mind the popu-
pain in legs is a common complaint in all age groups, the data lation with comorbidities. We also noted that the diagnostic
in our population supporting is scarce. As far as we know, questions asked in the questionnaires administered to the
 3717, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2020/7302828 by INASP/HINARI - PAKISTAN, Wiley Online Library on [13/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 Sleep Disorders

Table 1: Baseline characteristics of study respondents (n = 300). Table 3: Comparison of RLS rating score and sleepiness severity
score among gender (n = 21).
Variables Mean (SD) n (%)
Females Males
Age (year) 21.3 (1.68) Variable p valuea
Mean (SD) Mean (SD)
Gender
RLS score (rating score) 10.86 (4.348) 11.57 (5.798) 0.754
Male 80 (26.6)
Sleepiness severity score 6.866 (3.020) 9.71 (3.039) 0.053
Female 220 (73.3)
a
Smoker p value calculated by using an independent sample t-test.

Yes 267 (89)

No 33 (11) Table 4: Distribution of RLS and sleepiness scale severity among
SD: standard deviation. gender.

Females Males
Variable
250 n (%) n (%)
RLS severity
12
200 Mild (1-10) 6 (66.7) 3 (33.3)
Moderate (11-20) 8 (66.7) 4 (33.3)
150 Sleepiness scale severity (total score)
Normal (0-5) 6 (100) 0 (0)
100 208
Mild (6-10) 8 (66.7) 4 (33.3)
21
Moderate (11-12) 1 (50) 1 (50)
50
59 Severe (13-15) 0 (0) 2 (100)
0 Very severe (16-24) 0 (0) 0 (0)
Male Female

Smoker students were answered based on self-judgment instead of a

Non-smoker complete clinical interview and examination.

Figure 1: Bar graph showing the frequency of smokers and 5.2. Recommendations. Patients with RLS should be advised
nonsmokers among male and female students.
to see the physician for early recognition and treatment,
and further research is warranted to improve and recognize
the condition in patients of our population. Therefore,
24 awareness needs to be spread about RLS. As it also affects
the sleep of students, thus, more extensive studies are
required to be done about the etiologies behind these symp-
toms so that they can be addressed then.
276
Data Availability
Will be provided upon request.

No RLS
RLS Conflicts of Interest
Figure 2: Frequency of RLS among medical students. The authors declare that they have no conflicts of interest.

References
Table 2: Association of gender with smoking and RLS (n = 300).
[1] Bethesda, Restless Legs Syndrome Fact Sheet, NINDS, 2010,
Females Males NIH Publication No. 10-4847.
Variable p value
n (%) n (%)
[2] S. B. Venkateshiah and O. C. Ioachimescu, “Restless legs syn-
Smoking status drome,” Critical Care Clinics, vol. 31, no. 3, pp. 459–472, 2015.
Smoker 12 (36.4) 21 (63.6) <0.001 [3] K. A. Ekbom, “Restless legs syndrome,” Acta Medica Scandi-
Nonsmoker 208 (77.9) 59 (22.1) navica, vol. 158, pp. 4–122, 1945.
RLS [4] R. P. Allen, D. Picchietti, W. A. Hening et al., “Restless legs
syndrome: diagnostic criteria, special considerations, and
Yes 17 (70.8) 7 (29.2) 0.773
epidemiology: A report from the restless legs syndrome diag-
No 203 (73.6) 73 (26.4) nosis and epidemiology workshop at the National Institutes
p value calculated by using the chi-squared test. of Health,” Sleep Medicine, vol. 4, no. 2, pp. 101–119, 2003.
 3717, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1155/2020/7302828 by INASP/HINARI - PAKISTAN, Wiley Online Library on [13/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Sleep Disorders 5

[5] W. Hening, A. S. Walters, R. P. Allen, J. Montplaisir, A. Myers, [20] K. Carlos, L. B. F. Prado, L. B. C. Carvalho, and G. F. Prado,
and L. Ferini-Strambi, “Impact, diagnosis and treatment of “Willis-Ekbom Disease or Restless Legs Syndrome?,” Sleep
restless legs syndrome (RLS) in a primary care population: Medicine, vol. 16, no. 9, pp. 1156–1159, 2015.
the REST (RLS Epidemiology, Symptoms, and Treatment) [21] S.-M. Fereshtehnejad, A. Rahmani, M. Shafieesabet et al.,
primary care study,” Sleep Medicine, vol. 5, no. 3, pp. 237– “Prevalence and associated comorbidities of restless legs
246, 2004. syndrome (RLS): data from a large population-based door-
[6] R. Rijsman, A. K. Neven, W. Graffelman, B. Kemp, and A. de to-door survey on 19176 adults in Tehran, Iran,” PLoS One,
Weerd, “Epidemiology of restless legs in the Netherlands,” vol. 12, no. 2, article e0172593, 2017.
European Journal of Neurology, vol. 11, no. 9, pp. 607–611, [22] S. Sevim, O. Dogu, H. Camdeviren et al., “Unexpectedly low
2004. prevalence and unusual characteristics of RLS in Mersin, Tur-
[7] S. Virolainen, “Restless Legs Syndrome - prevalence and asso- key,” Neurology, vol. 61, no. 11, pp. 1562–1569, 2003.
ciated factors among university students in Estonia,” Sleep [23] B. Einollahi and N. Izadianmehr, “Restless leg syndrome: a
Medicine, vol. 14, article e299, Supplement 1, 2013. neglected diagnosis,” Nephro-Urology Monthly, vol. 6, no. 5,
[8] S. J. Cho, J. P. Hong, B. J. Hahm et al., “Restless legs syndrome article e22009, 2014.
in a community sample of Korean adults: prevalence, impact [24] F. M. Haggstram, A. V. Bigolin, A. S. Assoni et al., “Restless
on quality of life, and association with DSM-IV psychiatric legs syndrome: study of prevalence among medical school
disorders,” Sleep, vol. 32, no. 8, pp. 1069–1076, 2009. faculty members,” Arquivos de Neuro-Psiquiatria, vol. 67,
[9] A. S. Walters, C. LeBrocq, A. Dhar et al., “Validation of the no. 3b, pp. 822–826, 2009.
international restless legs syndrome study group rating scale
for restless legs syndrome,” Sleep Medicine, vol. 4, no. 2,
pp. 121–132, 2003.
[10] M. W. Johns, “A new method for measuring daytime Sleepi-
ness: The Epworth Sleepiness Scale,” Sleep, vol. 14, no. 6,
pp. 540–545, 1991.
[11] K. Mahmood, R. Farhan, A. Surani, A. A. Surani, and S. Surani,
“Restless legs syndrome among Pakistani population: a cross-
sectional study,” International Scholarly Research Notices,
vol. 2015, Article ID 762045, 5 pages, 2015.
[12] A. S. Shalash, H. H. Elrassas, M. M. Monzem, H. H. Salem,
A. Abdel Moneim, and R. R. Moustafa, “Restless legs
syndrome in Egyptian medical students using a validated Ara-
bic version of the restless legs syndrome rating scale,” Sleep
Medicine, vol. 16, no. 12, pp. 1528–1531, 2015.
[13] D. Picchietti, R. P. Allen, A. S. Walters, J. E. Davidson,
A. Myers, and L. Ferini-Strambi, “Restless legs syndrome:
prevalence and impact in children and adolescents—the Peds
REST study,” Pediatrics, vol. 120, no. 2, pp. 253–266, 2007.
[14] A. Fasih, K. N. Abdullah, and S. Iqbal, “Obstetric restless legs
syndrome in industrialized area of Pakistan,” The Journal of
Bahria University Medical and Dental College, vol. 5, no. 2,
pp. 69–72, 2015.
[15] R. P. Allen, A. S. Walters, J. Montplaisir et al., “Restless legs
syndrome Prevalence and Impact,” Archives of Internal Medi-
cine, vol. 165, no. 11, pp. 1286–1292, 2005.
[16] S. Rangarajan, S. Rangarajan, and G. A. D’Souza, “Restless legs
syndrome in an Indian urban population,” Sleep Medicine,
vol. 9, no. 1, pp. 88–93, 2007.
[17] S. O. Wali and B. Abaalkhail, “Prevalence of restless legs syn-
drome and associated risk factors among middle-aged Saudi
population,” Annals of Thoracic Medicine, vol. 10, no. 3,
pp. 193–198, 2015.
[18] J. Ulfberg, B. Nyström, N. Carter, and C. Edling, “Restless legs
syndrome among working-aged women,” European Neurol-
ogy, vol. 46, no. 1, pp. 17–19, 2001.
[19] B. Saletu, P. Anderer, M. Saletu, C. Hauer, L. Lindeck-Pozza,
and G. Saletu-Zyhlarz, “EEG mapping, psychometric, and
polysomnographic studies in restless legs syndrome (RLS)
and periodic limb movement disorder (PLMD) patients as
compared with normal controls,” Sleep Medicine, vol. 3,
pp. S35–S42, 2002.