Introductory Remarks

Restless leg syndrome (RLS), also called Willis-Ekbom disease is a neurological and sleep condition that causes overwhelming, almost irresistible urge to move legs. It is partly relieved by moving them. Although it is a nervous system disorder, medical practitioners consider RLS as a sleep disorder because it happens during sleep or rest.

This condition is hard to diagnose in the pediatric population because children cannot describe their symptoms properly. In children, it might look like ADHD (attention-deficit hyperactivity disorder).

The main symptom of RLS is an overpowering urge to move legs.

 

 Statistics & Facts

What are the statistics and facts that surround RLS?

• In the US, about 10% of the population suffer from RLS.
• Racially, it is common among whites.
• It also affects women and people assigned female at birth (AFAB) more.
• Aging is a risk factor. It commonly affects individuals who are over 50 years. Middle-aged persons are highly likely to have severe symptoms.
• It is estimated that almost 8 out of 10 people with RLS also suffer from periodic limb movement disorder (PLMD)  or periodic limb movement of sleep (PLMS).

 

 Risk Factors

• Genetics. Research has found out that specific genes are related to RLS and under such circumstances, symptoms develop before 40 years.
• Ethnicity. It is common among white people.
• Age. It commonly affects individuals who are over 50 years.

 

 Causes & Triggers

The cause of RLS is not completely comprehended.

The basal ganglia part of the brain, which controls movement, uses dopamine to regulate how the body moves. Therefore, with little dopamine to stimulate it, it becomes unable to function efficiently, leading to symptoms of RLS.

 

Conditions that can cause RLS are:

Chronic conditions and diseases;

• Anemia.
• Diabetes.
• Parkinsonism.
• Peripheral nerve damage (neuropathy).
• Renal disease.
• Iron deficiency in the body; for some individuals, lower levels of iron may be a factor.

 

Medications

• These do not cause RLS, but they worsen symptoms. They are:

 

1. Metoclopramide.
2. Calcium channel blockers.
3.  Anti-nausea medications.
4. Anti-histamines.
5. Anti-psychotics.

The above listed conditions can happen in addition to RLS.

 

What  factors can trigger RLS?

• Likely trigger factors  which can worsen RLS symptoms are:

1. Alcohol.
2. Smoking.
3. Obesity.
4. Stress.
5. Not performing physical exercises.
6. Caffeine.
7. Nicotine.
8. Lack of sleep or sleep disorders such as sleep apnea.

 

Types

What are the types of RLS?

Two forms of RLS which are known based on onset/timing  are early onset and late onset RLS.

Early onset RLS:

•  Diagnosis occurs before 45 years of age.
•  It runs in families.
•  It is characterized by slow progression.

 

Late onset RLS:

•  Diagnosis occurs past 45 years of age.
•  It progresses faster.

 

Besides this classification, another one is:

•  Primary or idiopathic RLS.
•  Secondary RLS.

 

Primary RLS

• Majority of the cases of RLS are primary or idiopathic (unknown cause).
• Some scientists propose that it may be due to a problem affecting the basal ganglia region of the brain. This part utilizes dopamine, which is a chemical neurotransmitter, to regulate muscle movement.
• The quantity of dopamine in the brain becomes decreased when there is damage on the cells of the basal ganglia. This leads to muscle spasms and involuntary movements.
• Normally, levels of dopamine lower as the day ends and this may be the reason behind worsening of symptoms in the evening and at night.

 

Secondary RLS

• This type happens as a complication of another medical condition. Individuals are likely to develop secondary RLS if they have:

1. Diabetes.
2. Parkinsonism.
3. Rheumatoid arthritis.
4. Hypothyroidism.
5. Fibromyalgia.
6. Iron deficiency anaemia.
7. Chronic kidney disease.

 

 Signs & Symptoms

What are the manifestations of RLS?

• Uncomfortable sensations in the legs which lead to urges of moving them.
• Worsening of sensations during rest or inactivity.
• Jerking of the legs during sleep or in the evening.
• Temporary relief of discomfort on leg movement.

 

RLS feels like:

• Pulling.
• Aching.
• Itching.
• Burning.

Sensations can affected one body side, but mostly they affect both sides (both legs).

 

 Diagnostic Procedures & Tests

• There is no single diagnostic tool that can pinpoint RLS.
• Diagnosis of RLS involves:

1.  Physical examination.
2.  History-taking (anamnesis). A whole personal  medical and family medical histories are taken by the health-care provider.
3. Other procedures can be performed to rule out other conditions or establish causes of the symptoms. These include:

• Neurological examination.
• Blood tests.
• Polysomnography (overnight sleep study) is conducted to evaluate other likely sleep conditions. However, RLS does not need sleep testing.

 

The following criteria are looked for for proper confirmation of an RLS diagnosis:

Five basic criteria for diagnosing a patient with RLS;

1.  An overwhelming urge to move legs which happens alongside uncomfortable sensations such as pain or unusual feelings.
2. Symptoms start to present during moments of rest or they worsen during inactivity.
3. Feeling relieved when stretching the legs or walking. When you move, the urge goes away either partially or totally.
4. Occurrence  or worsening of symptoms at night or in the evening.
5. Confirmation that another medical condition did not result in the presenting symptoms.

 

 Treatment & Management

RLS medication:

• These medications relieve symptoms of RLS. They are:

1. Anti-seizure drugs such as pregabalin and gabapentin.
2. Iron supplements, which are taken alongside Vitamin C.
3. Dopamine precursors such as levodopa.
4. Dopamine agonists such as pramipexole and ropinirole.

Note that drugs which raise dopamine levels can lead to worsening of RLS symptoms (augmentation). Therefore,  they should be closely monitored.

If all other forms of treatment fail, the following categories may be helpful in severe cases:

1. Benzodiazepines such as clonazepam.
2. Opiods such as methadone.
3. Hypnotics such as zolpidem.

At-home RLS therapies:

1. Perform regular physical exercises such as bike-riding. Avoid  intense exercising a few moments before sleeping time.
2. Embrace good sleep habits such as not using mobile phones in bed.
3. Do not drink caffeine before sleep time.

 Complications

What are the complications of RLS?

• Complications of RLS include:

1.  Difficulty concentrating.
2. Behavioral changes.
3. Daytime sleepiness.
4. Urge to stretch lower limbs.

 

 Prevention Strategies

What are the methods of preventing RLS?

• To reduce the risk associated with development of RLS:

1.  Treat underlying health conditions, if any, such as rheumatoid arthritis and diabetes.
2. Avoid triggers such as alcohol and smoking.