Introduction:

Restless Leg syndrome means an irresistible desire to move legs continuously mostly in evenings. It was a disorder of a part of nervous system. Since it interferes with sleep patterns it is also known as sleep disorder.

It is associated with involuntary jerking movements of legs and arms called periodic limb movements in sleep (PLMS).

  • It usually occurs at rest while sitting or while lying down.
  • The patient with this syndrome will experience discomfort and unpleasant sensations, twitchiness of his limbs.
  • It worsens with age and can cause disturbance with sleep(insomnia).
  • Restless leg syndrome is also known as Willis- Ekbom disease (RLS/WED).

Abnormal and unpleasant sensations in legs or feet. They usually occur on both sides, occasionally seen in arms.

Clinical symptoms of Restless Legs Syndrome:

The symptoms may range from mild to severe.

  • Urge to move legs.
  • Strange and unpleasant sensations in legs.
  • Aggravation from rest and ameliorated by moving about.
  • Symptoms worsen over evenings and nights.
  • Twitching of legs at night time.
  • Sensations may be itching, pins and needle sensations crawling, tingling, tugging, creeping, pulling, throbbing, aching, similar to electric shocks.
  • Affected people will complaint irresistible desire to move their limbs.
  • This discomfort can be relieved by moving the legs.
  • The symptoms worsen when the patient is at rest or inactive.

It may be due to mental problems or physical problems or adverse effects of some medications. Depending on the frequency and severity of the symptoms it can be classified as mild or severe.

Facts about restless legs syndrome (RLS):

  1. Chances of Restless Legs Syndrome are more in women during pregnancy.
  2. It may be caused by a combination of mental or physical factors. It will affect one in ten people at some time during their life.
  3. RLS can develop at any age mostly worsens with age.

Causes:

There are no known causes of this RLS/WED. Many researches have doubted that this condition may be caused by an imbalance in dopamine levels of the brain.

  • Heredity: This condition often runs in families especially if it occurs below 40years. Some sites on chromosomes were identified by researchers where genes for this RLS/WED were found.
  • Pregnancy: we observe hormonal changes during pregnancy that we’re responsible for worsening of the symptoms of this condition. Some women will experience the symptoms of RLS especially during her last trimester and it will improve over time that is after delivery she may become normal. Symptoms generally go away within a month after delivery.

  • Chronic diseases: Certain chronic diseases like diabetes, kidney failure, Parkinson’s disease, iron deficiency, peripheral neuropathy often include symptoms of RLS. Treating these conditions will often give relief from symptoms of RLS.
  • Medications: Certain medications were also Responsible for worsening of this condition like anti-emetics, anti-psychotics, anti-depressants, cold and allergy containing sedating antihistamines.

Dopamine is a neurotransmitter that sends impulses to control muscle movements.

Classification of RLS:

It may be primary or secondary.

Primary or idiopathic RLS: Idiopathic means cause is not known.

Primary restless leg syndrome is a neurological disorder. It is the most common type and has the following characteristics:

  • It begins before 40.
  • It is genetically related.
  • Changes in dopamine levels are associated with primary restless leg syndrome.
  • Dopamine is a neurotransmitter which is involved in controlling movements of muscles of our limbs.
  • Regulation of dopamine levels are useful to treat primary RLS / neurological RLS.

Secondary restless leg syndrome is more severe than primary and there is associated underlying conditions like diabetes anemia, folate deficiency, kidney disease, attention deficit disorder (ADD), attention deficit or hyperactivity disorder (ADHD) pregnancy, rheumatoid arthritis, Parkinson’s disease.

Restless leg syndrome during pregnancy:

About 1 in 5 pregnant women will experience the symptoms of RLS during the last trimester of pregnancy especially.

  • It can cause problems in women with pregnancy.
  • As the pregnancy term progresses the symptoms worsens further, especially in the third trimester. The exact cause behind the increased risk of RLS during pregnancy is unknown, but it was associated with the following factors:
  • Low vitamin and mineral levels like folate and iron.
  • Disruption of sleep due to changes in body and discomfort. Changes in hormones. Increased sensitivity of senses.
  • Behavioral treatments, such as mild exercise and healthy sleeping pattern are often recommended as a first-line treatment for women during pregnancy.
  • If low iron levels are thought to be caused by RLS, oral iron supplements are safe to prescribe during pregnancy. If the case is severe, higher concentrations may be administered intravenously (IV)through a drip.

Medications for RLS:

Medication is given based on individual symptoms

  1. Iron supplementation: Useful in people with low iron levels.
  2. Alpha 2 antagonists: effective in cases of primary restless leg syndrome, but they will not have any effect on periodic limb movement during sleep.
  3. Pain killers like ibuprofen, a non-steroidal anti-inflammatory drug (NSAID) may help to relieve mild symptoms.
  4. Anti – Convulsants: These treat pain, muscle spasms, day time symptoms, neuropathy.

Ex: Neurontin, gabapentin

  1. Benzodiazepines: These are the sedatives, help people with sleep problems associated with RLS.

Ex: Restoril, temazepam, Xanax, alprazolam, Klonopin, clonazepam.

  1. Dopaminergic agents: These will increase the dopamine levels (neurotransmitters) in the brain. They can treat the unpleasant sensations of limbs associated with RLS.

Ex: levodopa, carbidopa are common dopaminergic agents.

  1. Dopamine agonists: These will also raise the dopamine levels in the brain and also treat unpleasant leg sensations. They are known to cause some side effects, especially in order people. More side effects are seen with levodopa.
  2. Opiates: These will treat pain and help to relieve RLS symptoms. These were prescribed by the doctor when other medications have failed.

Low dose opiates examples: Codeine, Propoxyphene.

High dose opiates examples: Oxycodone hydrochloride, Methadone hydrochloride, levorphanol tartrate are the common high dose opiates.

Parkinson’s disease and epileptic drugs are sometimes used for the RLS because they can reduce involuntary movements.

If certain underlying conditions are responsible for RLS such as iron deficiency anemia, peripheral neuropathy treating those underlying conditions can relieve the symptoms of RLS.

Risk factors:

  • It can develop at any age, even during childhood.
  • Incidence is found to be more in women than men.
  • Risk increases with the increase of age.
  • Alcohol use, sleep deprivation may worsen the symptoms of RLS or they may act as triggers.
  • Most of the people who are affected severely are middle-aged/old people.

It sometimes accompanies other conditions like:

  • Peripheral neuropathy – Damage to the nerves of your hand and feet is due to Chronic diseases like diabetes and alcoholism.
  • Iron deficiency: Deficiency of iron can worsen this RLS even without anemia.
  • Some of the causes of iron deficiency are: bleeding from the bowels, heavy menstrual bleeding, donating blood many times.
  • Kidney failure: It may be associated with iron deficiency anemia. In the case of kidney failure kidneys don’t function properly this may lead to decreased iron reserve in the blood. Hence RLS may worsen.
  • Lessons of spinal cord: It may also worsen the symptoms of RLS/WED. Giving spinal anesthesia (spinal block) also increases the risk of this RLS.

Complications:

The main complications associated with this RLS is sleep problems, they find it difficult to fall asleep. It can impair the quality of life and it may lead to depression. Insomnia (sleeplessness) may lead to excessive drowsiness during day time.

Treatment:

It was a case which was most often misdiagnosed or it is unrecognized mostly if the symptoms are mild or intermittent. It can be treated successfully when once this condition is diagnosed correctly. There are no direct medical tests done to diagnose this condition. Physician may advise blood tests for underlying conditions, Diagnosis of RLS/WED is based on symptoms and inquiry of the patient that is asking about family history of the patient( whether any of his / her parent complained of similar symptoms previously) physician should rule out other possible medical conditions or other chronic diseases like diabetes, kidney failure , iron deficiency etc; presence of sleep-related problems; like (sleepiness during day time) ,any medication use previously.

Drugs that are used in the treatment of RLS are:

Dopaminergic drugs – These drugs will act on neurotransmitter dopamine in our brain.

Mirapex, Neupro, Requip, are approved by the Food and Drug Administration for treating moderate to severe RLS, others like levodopa may also be suggested.

Benzodiazepines, a class of sedatives can also be prescribed if there is a problem with nighttime sleep but they cause side effects like day time drowsiness.

If the pain is severe narcotic pain killers are prescribed.

Anti-Convulsant, antiseizure drugs can also be prescribed.

There is no complete cure for Restless leg syndrome however we can improve the condition by decreasing the Symptoms and improving the sleep of an affected individual.

Management:

Mild and moderate symptoms are easy to manage. We should advise exercises, lifestyle changes, reduce intake of stimulants like alcohol, caffeine, tobacco. The conditions associated with this should be aimed first and treated in order to relieve these symptoms of RLS.

Massaging the affected legs, applying ice packs, hot baths, heat pads to legs, adapting to good sleeping habits in regular patterns, using vibrating pads known as relaxes.

References

  1. https://www.frontiersin.org/articles/10.3389/fnagi.2017.00171/full
  2. https://onlinelibrary.wiley.com/doi/abs/10.1002/mds.27260

 

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