Neuroleptic-induced “painful legs and moving toes” syndrome: successful treatment with clonazepam and baclofen

Abstract

The syndrome of "painful legs and moving toes" is characterised by spontaneous causalgic pain in the lower extremities associated with peculiar involuntary movements of the toes and feet. It has been observed after a variety of lesions affecting the posterior nerve roots, the spinal ganglia and the peripheral nerves. The pathophysiology of the syndrome is unknown. I report a patient who developed the syndrome during treatment for schizophrenia with the antipsychotic agent molindone hydrochloride. The patient's response to the combination of clonazepam and baclofen suggests that the pathophysiology of the "painful legs and moving toes" may be linked to impairment of spinal serotonergic and GABA functions.

Painless legs moving toes in a patient with Wilson's disease

“…PLMT syndrome has been shown to occur secondary to other neurological disorders (including spinal cord or cauda equina trauma, lumbar radiculopathy, peripheral neuropathy, traumatic lesions of the soft tissue and bone in the foot, during treatment with neuroleptics and herpes zoster infections). However, some cases are idiopathic 8–14. To date, only the latter have been associated with the “painless legs and moving toes” variant,6 which seems to fit our case.…”

Neuroleptics as a cause of painful legs and moving toes syndrome

“…The pathology behind PLMT syndrome remains obscure and, to date, cases induced by neuroleptics are seldom reported; Sandyk11 reported the first patient with PLMT syndrome precipitated by molindone in 1990, which was successfully treated with baclofen and clonazepam. Alvarez et al ,6 in his case series of 14 patients with PLMT syndrome, described two patients having the onset of abnormal movements after long-term intake of a neuroleptic; one patient was taking perphenazine and the other was taking ziprasidone.…”

Case series of painful legs and moving toes: Clinical and electrophysiologic observations

“…Whether isolated toe movements (with or without pain) associated with neuroleptic use can be lumped with the syndrome of PLMT remains to be determined. There has been only 1 other case report of possible neuroleptic‐induced PLMT in a patient who had toe movements and pain typical of PLMT from molindone 12…”

“…Quite rarely, it can be familial 5. The etiology is varied and includes nerve root lesions, peripheral trauma, neuropathy (e.g., polyneuropathy from alcoholism, hypertrophic mononeuritis, or tarsal tunnel syndrome), Wilson disease, herpes zoster myelitis, human immunodeficiency virus, neuroleptics, and chemotherapeutic agents 6–14…”