Restless legs syndrome (RLS) characterized by unpleasant sensations in the limbs, usually the legs that occur at rest or before sleep and find relief by activity such as walking. These sensations felt deep within the legs are described as creeping, crawling, aching, or fidgety.
Restless legs syndrome, also known as Ekbom syndrome, Wittmaack-Ekbom syndrome, anxieties tibiarum, or anxieties tibialis, affects up to 10-15% of the population. Some studies show that RLS is more common among elderly people. Almost half of patients over age 60 who complain of insomnia are diagnosed with RLS. In some cases, the patient has another medical condition with which RLS is associated. In idiopathic RLS, no cause has been found. In familial cases, RLS may be inherited from a close relative, most likely a parent.
Causes and symptoms
Most people experience mild symptoms. They may lie down to rest at the end of the day and, just before sleep, will experience discomfort in their legs that prompts them to stand up, massage the leg, or walk briefly. Eighty-five percent of RLS patients have either difficulty falling asleep or wake several times during the night, and almost half experience daytime fatigue or sleepiness. It is common for the symptoms to be intermittent. They may disappear for several months and then return for no apparent reason. Two-thirds of patients report that their symptoms become worse with time. Some older patients claim to have had symptoms since they were in their early 20s, but were not diagnosed until their 50s. Suspected under-diagnosis of RLS may be attributed to the difficulty experienced by patients in describing their symptoms.
More than 80% of patients with RLS experience periodic limb movements in sleep (PLMS). These random movements of arms or legs may result in further sleep disturbance and daytime fatigue. Most patients have restless feelings in both legs, but only one leg may be affected. Arms may be affected in nearly half of patients.
There is no known cause for the disorder, but recent research has focused on several key areas. These include:
• Central nervous system (CNS) abnormalities. Several types of drugs have been found to reduce the symptoms of RLS. Based on an understanding of how these drugs work, theories have been developed to explain the cause of the disorder. Levodopa and other drugs that correct problems with signal transmission within the central nervous system (CNS) can reduce the symptoms of RLS. It is therefore suspected that the source of RLS is a problem related to signal transmission systems in the CNS.
• Iron deficiency. The body stores iron in the form of ferritin. There is a relationship between low levels of iron (as ferritin) stored in the body and the occurrence of RLS. Studies have shown that older people with RLS often have low levels of ferritin. Supplements of iron sulfate have shown to significantly reduce RLS symptoms for these patients.
A careful history enables the physician to distinguish RLS from similar types of disorders that cause nighttime discomfort in the limbs, such as muscle cramps, burning feet syndrome, and damage to nerves that detect sensations or cause movement (polyneuropathy).
The most important tool the doctor has in diagnosis is the history obtained from the patient. Several common medical conditions are known either to cause or to be closely associated with RLS. The doctor may link the patient's symptoms to one of these conditions, which include anemia, diabetes, disease of the spinal nerve roots (lumbosacral radiculopathy), Parkinson's disease, late-stage pregnancy, kidney failure (uremia), and complications of stomach surgery. In order to identify or eliminate such a primary cause, blood tests taken to determine the presence of serum iron, ferritin, folate, vitamin B12, creatinine, and thyroid-stimulating hormones. The physician may also ask if symptoms are present in any close family members, since it is common for RLS to run in families and this type is sometimes more difficult to treat.
In some cases, sleep studies such as polysomnography help identify the presence of PLMS that are reported to affect 70-80% of people who suffer from RLS. The patient is often unaware of these movements, since they may not cause him to wake. However, the presence of PLMS with RLS can leave the person more tired, because it interferes with deep sleep. A patient who also displays evidence of some neurologic disease may undergo electromyography (EMG). During EMG, a very small, thin needle is inserted into the muscle and electrical activity of the muscle is recorded. A doctor or technician usually performs this test at a hospital outpatient department.
RLS usually does not indicate the onset of other neurological disease. It may remain static, although two-thirds of patients get worse with time. The symptoms usually progress gradually. Treatment with Levodopa is effective in moderate to severe cases that may include significant PLMS. However, this drug produces significant side effects, and continued successful treatment may depend on carefully monitored use of combination drug therapy. The prognosis is usually best if RLS symptoms are recent and traced to another treatable condition that is associated with RLS. Some associated conditions are not treatable. In these cases, such as for rheumatoid arthritis, alternative therapies such as acupuncture may be helpful.
Diet is important in preventing RLS. A preventive diet will include an adequate intake of iron and the B vitamins, especially B12 and folic acid. Strict vegetarians should take vitamin supplements to obtain sufficient vitamin B12. Ferrous gluconate may be easier on the digestive system than ferrous sulfate, if iron supplements are prescribed. Some medications may cause symptoms of RLS. Patients should check with their doctor about these possible side effects, especially if symptoms first occur after starting a new medication. Caffeine, alcohol, and nicotine use should be minimized or eliminated. Even a hot bath before bed has been shown to prevent symptoms for some sufferers.
Restless legs syndrome (RLS) or Wittmaack–Ekbom syndrome is a neurological disorder characterized by an irresistible urge to move one's body to stop uncomfortable or odd sensations. It most commonly affects the legs, but can affect the arms, torso, and even phantom limbs. Moving the affected body part modulates the sensations, providing temporary relief.
RLS sensations can most closely be compared to an itching or tickling in the muscles, like "an itch you can't scratch" or an unpleasant "tickle that won't stop.” The sensations typically begin or intensify during quiet wakefulness, such as when relaxing, reading, studying, or trying to sleep. In addition, most individuals with RLS have limb jerking during sleep, which is an objective physiologic marker of the disorder and is associated with sleep disruption. Some controversy surrounds the marketing of drug treatments for RLS. It is a "spectrum" disease with some people experiencing only a minor annoyance and others experiencing major disruption of sleep and significant impairments in quality of life.
In 2003, a National Institutes of Health (NIH) panel modified their criteria to include the following:
1. An urge to move the limbs with or without sensations.
2. Improvement with activity. Many patients find relief when moving and the relief continues while they are moving. In more severe RLS, this relief of symptoms may not be complete or the symptoms may reappear when the movement ceases.
3. Worsening at rest. Patients may describe being the most affected when sitting for a long period, such as when traveling in a car or airplane, attending a meeting, or watching a performance. An increased level of mental awareness may help reduce these symptoms.
4. Getting worse in the evening or night. Patients with mild or moderate RLS show a clear circadian rhythm to their symptoms, with an increase in sensory symptoms and restlessness in the evening and into the night.
RLS is either primary or secondary.
The most commonly associated medical condition is iron deficiency (specifically blood ferritin below 50 µg/L), which accounts for 20% of all cases of RLS. A study published in 2007 noted that RLS features were observed in 34% of patients having iron deficiency as against 6% of controls. Conversely, 75% of individuals with RLS symptoms may have increased iron stores. Other associated conditions include varicose vein or venous reflux, folate deficiency, magnesium deficiency, fibromyalgia, sleep apnea, uremia, diabetes, thyroid disease, peripheral neuropathy, Parkinson's disease and certain auto-immune disorders such as Sjögren's syndrome, celiac disease, and rheumatoid arthritis. RLS can also worsen in pregnancy. In a 2007 study, RLS detected in 36% of patients attending a phlebology (vein disease) clinic, compared to 18% in a control group.
Certain medications may cause or worsen RLS,
Hypoglycemia worsens RLS symptoms.
Opioid detoxification has been associated with provocation of RLS-like symptoms during withdrawal.
Both primary and secondary RLS are worsened by surgery of any kind; however, back surgery or injury can be associated with causing RLS.
Some experts believe RLS and periodic limb movement disorder are strongly associated with ADHD. Dopamine appears to factor into both conditions and medications for the treatment of both conditions affect dopamine levels in the brain.
The cause vs. effect of certain conditions and behaviors observed in some patients (ex. excess weight, lack of exercise, depression or other mental illnesses) is not well established. Loss of sleep due to RLS could cause the conditions, or medication used to treat a condition could cause RLS.
More than 60% of cases of RLS are familial and inherited in an autosomal dominant fashion.
No one knows the exact cause of RLS. Research and brain autopsies have implicated both dopaminergic system and iron insufficiency in the substantia nigra. Iron is an essential cofactor for the formation of L-dopa, the precursor of dopamine.
Three genes, MEIS1, BTBD9 and MAP2K5, were found to be associated to RLS. Their role in RLS pathogenesis is still unclear. More recently, a fourth gene, PTPRD was found to be associated to RLS
There is also some evidence that periodic limb movements in sleep (PLMS) are associated with BTBD9 on chromosome 6p21.2. The presence of a positive family history suggests that there may be a genetic involvement in the etiology of RLS
Other than preventing the underlying causes, no method of preventing RLS has been established or studied.
Pharmacotherapy involves dopamine agonists as first line drugs for daily restless legs syndrome; gabapentin (Horizant and opioids for treatment of resistant cases.
Stretching the leg muscles can bring relief lasting from seconds to days. Walking around brings relief also. Tiredness can be a factor and some sufferers may find going to bed usually stops the discomfort. Bouncing or shaking the legs/feet in an up and down motion, with the ball of the foot on the floor when sitting down may bring temporary relief.
There is also strong anecdotal evidence that medical marijuana alleviates RLS, although studies are lacking because of governmental restrictions.
For those who experience RLS infrequently and do not need or want to try medication, in addition to lifestyle changes they can try:
• some form of exercise for several minutes such as walking, stretching, meditation, yoga, etc. at bedtime
• heat or cold, such as a hot or cold bath, a heating pad, or a fan
• soaking one's feet in hot water just prior to going to sleep
• engrossing the mind in a game, the computer, or figuring something out
• wearing compression stockings, tight pantyhose, or wrapping the legs in ace bandages
• placing a pillow between the knees or upper-legs while lying in bed
• hot green tea can relieve symptoms
• vigorous, deep breathing for one or two minutes
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