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Restless Legs Syndrome

Restless Leg Syndrome

Restless legs syndrome (Willis-Ekbom disease) is a neurological disorder characterized by an urge to move the limbs, paresthesias, motor restlessness and worsening of symptoms by relaxation. It most commonly affects the legs.


Presentation

Affected individuals complain of restlessness, feeling of unpleasant sensation in their legs and calf muscles. Restless legs syndrome presents with the following signs and symptoms:

Pain
  • Leg pain and discomfort are common complaints in any primary physician’s clinic. Two common causes of pain or discomfort in legs are nocturnal leg cramps (NLC) and restless leg syndrome (RLS).[doi.org]
  • Although the neurobiological mechanism in the development of pain remains unclear, a range of non-dopaminergic structures likely mediated pain processing in DLB in the present case based on neuropharmacological results.[ncbi.nlm.nih.gov]
  • Leg pain and discomfort are common complaints in any primary physician's clinic. Two common causes of pain or discomfort in legs are nocturnal leg cramps (NLC) and restless leg syndrome (RLS).[ncbi.nlm.nih.gov]
  • Severe RLS may cause painful feelings. However, the pain usually is more of an ache than a sharp, stabbing pain. Children may describe RLS symptoms differently than adults. In children, the condition may occur with hyperactivity.[web.archive.org]
  • We report a unique finding of a patient whose restless legs syndrome (RLS) symptoms abated after the placement of a spinal cord stimulator for chronic neuropathic pain.[ncbi.nlm.nih.gov]
Fatigue
  • Specific questionnaires were used in order to assess the health-related quality of life (HRQoL), fatigue levels, sleep quality, daily sleepiness, and depression symptoms of the patients.[ncbi.nlm.nih.gov]
  • These disruptive symptoms vary in severity and can result in difficulty staying or falling asleep, fatigue, and impaired daytime function resulting from loss of sleep.[books.google.de]
  • We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 13, 2019[patientslikeme.com]
  • Adults at risk for RLS also appeared to be more at risk for sleep apnea and insomnia and were more likely to report taking longer than 30 minutes to fall asleep, driving drowsy, and having daytime fatigue.[sciencedaily.com]
Nocturnal Leg Cramp
  • Two common causes of pain or discomfort in legs are nocturnal leg cramps (NLC) and restless leg syndrome (RLS). NLC present as painful and sudden contractions mostly in part of the calf.[doi.org]
  • Restless legs syndrome is different from kicking at night, periodic limb movements, and nocturnal leg cramps. Top 10 things to do if you have Restless Legs Syndrome.[sleepphones.com]
  • leg cramps outweigh any potential benefits.[web.archive.org]
  • Nocturnal leg cramps . Usually these are unilateral and require stretching of the muscle to ease the pain, rather than nonspecific movements. Parkinsonism . Venous insufficiency. Oedema or venous stasis.[patient.info]
Nocturnal Awakening
  • As a result, they have difficulty falling asleep, repeated nocturnal awakenings, or both. Symptoms may be worsened by stress.[merckmanuals.com]
  • Association of EDS, frequent nocturnal awakening, morning headache and transient memory or concentration disturbances (TMCD) with OSAS OR a 95% CI a P EDS No 1 b Yes 2.43 1.26–4.69 0.007 Frequent nocturnal awakening No 1 b Yes 1.61 1.01–2.72 0.04 Morning[doi.org]
  • Clinically, they decrease sleep latency and nocturnal awakenings. However, caution must be exercised when these drugs are prescribed for older patients.[doi.org]
Hyposmia
  • CONCLUSION: Our findings showed that neuro-cognitive co-morbidities such as parkinsonism, peripheral neuropathy, SCI, acting out dreams and hyposmia as well as cardio-metabolic risk factors and diseases were independent determinants of RLS.[ncbi.nlm.nih.gov]
Restless Legs Syndrome
  • Validation of the International Restless Legs Syndrome Study Group rating scale for restless legs syndrome. Sleep Med. 4, 121–132 (2003). 19. Trenkwalder, C. et al.[doi.org]
  • "RLS mimics"), proper diagnosis of Restless Legs Syndrome usually fails.[ncbi.nlm.nih.gov]
  • Restless legs syndrome is a common yet frequently undiagnosed sensorimotor disorder. In 1995, the International Restless Legs Syndrome Study Group developed standardized criteria for the diagnosis of restless legs syndrome.[ncbi.nlm.nih.gov]
  • Restless legs syndrome. Saunders 2009:272-275. Google Scholar 84. Matthews WB. Treatment of the restless legs syndrome with clonazepam. Br Med J 1979;1:751. PubMed Google Scholar 85. Akpinar S.[doi.org]
  • Allen, Association of Restless Legs Syndrome Variants in Korean Patients with Restless Legs Syndrome, Sleep, 10.5665/sleep.3200, 36, 12, (1787-1791), (2013) ., (2013).[doi.org]
Leg Cramp
  • The similarity of restless leg syndrome (RLS) and leg cramps poses a dilemma in diagnosing and differentiating the two.[doi.org]
  • Two common causes of pain or discomfort in legs are nocturnal leg cramps (NLC) and restless leg syndrome (RLS). NLC present as painful and sudden contractions mostly in part of the calf.[ncbi.nlm.nih.gov]
  • The unpleasant feelings from RLS aren't the same as the leg cramps many people get at night. Leg cramps often are limited to certain muscle groups in the leg, which you can feel tightening.[web.archive.org]
  • PURPOSE OF REVIEW: This article provides an update on six sleep-related movement disorders: restless legs syndrome (RLS), periodic limb movement disorder, sleep-related leg cramps, bruxism, rhythmic movement disorder, and propriospinal myoclonus, with[ncbi.nlm.nih.gov]
  • A significant difference in clinical presentation in the study subjects was the high prevalence of leg cramps in the RLS-positive subjects (P 0.01).[ncbi.nlm.nih.gov]
Head Banging
  • Rhythmic movement disorder typically affects young children and is characterized by repetitive, stereotypic, rhythmic movements (eg, head banging, head rolling, body rolling, body rocking) that precede sleep onset and continue transiently into early light[enotes.tripod.com]
Paranoid Ideation
  • The following case presents a RLS patient who developed hallucinatory and delusional symptoms with paranoid ideation after pramipexole assumption; these symptoms gradually decreased after pramipexole suspension and treatment by an oral antipsychotic therapy[ncbi.nlm.nih.gov]
Insomnia
  • Herein, we describe 7 patients with isolated insomnia in whom insomnia responded to low dose levo-dopa. Six of them had a family history of RLS.[ncbi.nlm.nih.gov]
  • KEYWORDS: Clinical; Gender; Insomnia; Restless legs; Review; Sleep apnoea[ncbi.nlm.nih.gov]
  • Depression, anxiety, daytime sleepiness, insomnia and sleep quality were evaluated in detail. RESULTS: The mean age of obese patients was 40.52 years and that of non-obese patients was 39.76 years.[ncbi.nlm.nih.gov]
  • In fact, it was due to a routine workup in a sleep clinic, where the patient was referred because of a coincident chronic insomnia (Restless Legs Syndrome is a known and important cause of insomnia/chronic insomnia), which resulted in a proper diagnosis[ncbi.nlm.nih.gov]
  • Because of the concomitant insomnia, this drug was applied in our patient.[ncbi.nlm.nih.gov]
Somnolence
  • Placebo comparisons showed a significantly higher incidence of nausea for pramipexole (p 0.01), whereas nausea, vomiting, dizziness, and somnolence were significantly higher for ropinirole (all p 0.01).[ncbi.nlm.nih.gov]
  • The main side effects were dizziness, somnolence, headache, and irritability. CONCLUSION: These preliminary results suggest that perampanel has significant therapeutic effects on both sensory and motor symptoms.[ncbi.nlm.nih.gov]
  • Dizziness and somnolence are the most common adverse effects. However, use of this drug to treat RLS has not been extensively studied.[merckmanuals.com]
  • Somnolence and fatigue (ostensibly, the real target of the drug) were also higher in the ropinirole versus the placebo group (12% versus 6%; 8% versus 4%, respectively).[ncbi.nlm.nih.gov]
Agitation
  • Greater awareness of potential causes of RLS, and its differentiation from akathisia and illness related agitation might help in reducing the distress associated with it and improving patient compliance in patients using atypical antipsychotic agents.[doi.org]
  • These might include dizziness, visual disturbances, agitation, seizures, mental clouding, depression, euphoria and other reactions.[consumerreports.org]
  • Stress often plays a role in agitating RLS, so any treatments that help reduce stress can help alleviate your symptoms. Relaxation techniques, such as breathing and meditation, can help reduce your stress level.[healthline.com]
  • Camomile contains an enzyme that agitates the tendons in the extremities. St. John ’ s wort is better applied directly to the skin. Evening Primrose causes constipation, which aggravates RLS .[nymag.com]
Trichotillomania
  • The case report describes a 39-year-old woman with restless legs syndrome (RLS) and trichotillomania (TTM). She was treated with venlafaxine and clonazepam with partial remission of RLS and no response for TTM.[ncbi.nlm.nih.gov]
  • Kokaçya, Improvement of restless legs syndrome and trichotillomania with aripiprazole, Journal of Clinical Pharmacy and Therapeutics, 34, 6, (723-725), (2009). K. Ekbom and J.[doi.org]

Workup

Diagnosis of restless legs syndrome primarily begins with a detailed history of sleep pattern of the affected individuals. In addition, individuals with such a syndrome must meet the following criteria given by International Restless Legs Syndrome Study Group:

  • Individuals have a very strong desire to move the legs due to uncomfortable sensations. The sensations that cause compulsive movement of the legs include tingling, itching, gnawing, creeping and crawling.
  • The symptoms tend to worsen when the individual is either taking rest or sitting; in other words when the legs are in resting position, the symptoms get severe.
  • Symptoms generally are relieved by carrying out activities such as walking, moving or stretching.

In addition, to the above mentioned criteria, certain blood tests like ferritin levels may also be carried out to rule out organic other causes [8]. Nerve conduction and electromyographic studies may prove to be useful even with a normal neurologic exam [9].

Free Erythrocyte Protoporphyrin
  • Hemogram was done in all participants, and free erythrocyte protoporphyrin (FEP) and total iron binding capacity (TIBC) in anemic patients. RLS symptoms were present in 6.25% of healthy participants and 34.37% of anemic patients (p 0.001).[ncbi.nlm.nih.gov]
White Matter Lesions
  • Restless legs syndrome was more common in migraine patients with and without aura and in those with nonspecific white matter lesions in the cranial MRI.[ncbi.nlm.nih.gov]

Treatment

Treating underlying conditions can in majority of the cases correct the condition. However, when restless legs syndrome presents as a sole problem then the treatment regime involves medications along with changes in lifestyle factors. For mild symptoms the doctors may advice some light exercises clubbed with massage and certain relaxation techniques. These methods in a great way help effectively manage the mild symptoms of RLS.

In case of severe symptoms, medications are prescribed to help individuals sleep comfortably and manage other symptoms. The commonly prescribed medications include ropinirole, gabapentin, opioids and clonazepam [10].

Prognosis

If left untreated, RLS can lead to severe mental and physical exhaustion. Numerous people with this condition describe serious consequences in their daily lives, including job difficulties, relationship problems, and a lack of mental acuity. Additionally, others have reported difficulty concentrating, poor memory, and an inability to perform simple activities of daily living. Untreated RLS may also cause problems while traveling and can result in depression.

Complications

Restless legs syndrome seldom causes any serious life threatening conditions. However, the symptoms often get severe during the night hours making life miserable for the affected individuals. Many individuals complain of sleep disturbances during night time, which in turn causes drowsiness during the day. But, development of nausea during the day often prevents the individuals from taking a short nap.

Sleep disturbance also gravely affects the concentration of the individuals and when experienced for long periods, can cause psychiatric disturbances as well.

Etiology

In many situations, the cause of RLS is unidentified. There may be a genetic basis for it, however, since it is often noted to run in families when the symptoms are first noted before age 40. Research has also shown that a cerebral iron deficiency may have in influence on RLS [2]. Additionally, there is substantial support from scientific studies that seems to indicate a connection between dysfunction in the brain’s basal ganglia circuits and RLS. Interference in these neural conduits often leads to uncontrolled movements.

Research has shown that patients who suffer from Parkinson’s disease, which is also characterized by dysfunction in the basal ganglia, frequently have restless legs syndrome. Although scientists do not know conclusively if these components actually cause RLS, there appears to be a definite connection between these issues and RLS: Chronic diseases such as peripheral neuropathy, diabetes, and renal failure, the use of certain antipsychotic, antidepressant, antihistamine, and anti-nausea medications or being in the last trimester of pregnancy. Lack of restorative sleep and alcohol use may also cause RLS symptoms in some patients.

Epidemiology

Restless legs syndrome is a rather common disorder, approximately one in ten people suffer from restless legs syndrome. Various studies regarding the prevalence of RLS in women versus men have been inconclusive.

Sex distribution
Age distribution

Pathophysiology

About 25-30% of individuals with anemia, renal failure, or late-stage pregnancy that exhibit some form of impairment of iron hemostasis are likely to develop restless legs syndrome [3]. Patients who are pregnant or have renal failure may not necessarily also have anemia. The diminished state of serotonin ferritin transporters in the brainstem may give rise to RLS [4].

However, intravenous and oral iron therapy may significantly relieve RLS symptoms in many of these individuals, whether there is substantiated anemia or not. Anemia, particularly cerebrospinal anemia, has been assumed a substantially causal factor in RLS symptoms for over half a century. Although the exact pathogenesis of the disorder remains elusive till this date [5].

Prevention

The exact etiology behind the development of RLS is not very well understood and therefore, no guidelines have been postulated to prevent the development of such a syndrome. Researchers however state that making certain lifestyle changes can in a great way help manage the symptoms effectively.

Summary

Restless legs syndrome (RLS) is a neurological condition described as aching, crawling, cramping, or other unpleasant feelings in the lower extremities frequently accompanied by an overpowering compulsion to move one’s legs [1]. These symptomsare usually more prominent when someone is resting and may become more severe at night. As reported by patients, paresthesia and/or dysesthesia may range in severity from slightly unpleasant to extremely agonizing.

Patient Information

Definition

Restless legs syndrome (RLS), a neurological disorder is characterized by development of unpleasant sensations in the legs and calf muscles. The sensations include feeling of creeping, tingling, tugging and pain. These symptoms are known to get worse when the legs are in resting position. Also, the condition gets severe during the night hours disrupting the sleep of the affected individuals.

Cause

The exact cause behind the development of RLS is not yet known. However, the RLS can accompany certain disease conditions such as anemia, Parkinson’s disease, peripheral neuropathy and other chronic disease conditions.

Symptoms

Symptoms of RLS include creeping, gnawing, crawling, tugging, tingling and pain in the legs and calf muscles. The symptoms tend to get severe during the night hours when the individual is at rest.

Diagnosis

Diagnosis of RLS comprises of gathering a detailed history of the symptoms experienced by the patient. In addition, information about the sleep pattern is also gathered. Blood tests are done to rule out underlying conditions. 

Treatment

Treatment of RLS is geared towards making certain life style changes to cope with the mild symptoms. Severe forms of symptoms are managed with medications and lifestyle changes.

References

Article

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th. Arlington, VA: American Psychiatric Association; 2013:410-3.
  2. Restless legs syndrome. Detection and management in primary care. National Heart, Lung, and Blood Institute Working Group on Restless Legs Syndrome. Am Fam Phys. Jul 1 2000; 62(1):108-14.
  3. Winkelman JW. Considering the causes of RLS. Eur J Neurol. Oct 2006; 13 Suppl 3:8-14.
  4. Jhoo JH, Yoon IY, Kim YK, Chung S, Kim JM, Lee SB. Availability of brain serotonin transporters in patients with restless legs syndrome. Neurology. Feb 9 2010; 74(6):513-8.
  5. Takaki J, Nishi T, Nangaku M, et al. Clinical and psychological aspects of restless legs syndrome in uremic patients on hemodialysis. Am J Kidney Dis. Apr 2003; 41(4):833-9.
  6. Krueger BR. Restless legs syndrome and periodic movements of sleep. Mayo Clin Proc. Jul 1990; 65(7):999-1006.
  7. Restless legs syndrome. Detection and management in primary care. National Heart, Lung, and Blood Institute Working Group on Restless Legs Syndrome. Am Fam Phys. Jul 1 2000; 62(1):108-14.
  8. Hening WA. Restless Legs Syndrome. Curr Treat Options Neurol. Sep 1999; 1(4):309-319.
  9. Ferreri F, Rossini PM. Neurophysiological investigations in restless legs syndrome and other disorders of movement during sleep. Sleep Med. Jul 2004; 5(4):397-9.
  10. Bogan RK, Bornemann MA, Kushida CA, Trân PV, Barrett RW. Long-term maintenance treatment of restless legs syndrome with gabapentin enacarbil: a randomized controlled study. Mayo Clin Proc. Jun 2010; 85(6):512-21.

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Last updated: 2019-07-11 20:48