Restless Legs Syndrome (RLS)

What is Restless Legs Syndrome (RLS)

Restless Legs Syndrome also known as Willis Ekbom disease, is a chronic neurological disorder manifested by an urge or a need to move the limbs to stop unpleasant sensations in the evening or while at rest.

Periodic limb movements of sleep are seen in over 80% to 90% of Restless Legs Syndrome patients.

Primary Restless Legs Syndrome is characterized by high familial aggregation suggesting a genetic component.

Approximately 63% of patients report having at least one first-degree relative with the condition.

Restless legs syndrome is a condition that causes uncomfortable feelings or sensations in the legs, especially while sitting or lying down.

The sensations usually cause an overwhelming urge to move the legs.

The arms can also sometimes be affected.

The condition can range from mild to severe.

The symptoms often interfere with a person’s ability to sleep.

What are the causes?

The cause of this condition is not known.

What increases the risk of Restless legs syndrome?

The following factors may make you more likely to develop this condition:

• Being older than 50.
• Pregnancy.
• Being a woman. In general, the condition is more common in women than in men.
• A family history of the condition.
• Having iron deficiency.
• Overuse of caffeine, nicotine, or alcohol.
• Certain medical conditions, such as kidney disease, Parkinson’s disease, or nerve damage.
• Certain medicines, such as those for high blood pressure, nausea, colds, allergies, depression, and some heart conditions.

What is the pathogenesis of RLS? 

Brain iron dysregulation is considered to play a key role in the pathogenesis of Restless Legs Syndrome.

There is dysregulation of iron transport across the blood–brain barrier, which is considered the chief mechanism of the low brain iron.

The circadian change in brain iron status also plays an important role in Restless Legs Syndrome.

What are the symptoms of Restless legs syndrome?

The main symptom of this condition is uncomfortable sensations in the legs, such as:

• Pulling.
• Tingling.
• Prickling.
• Throbbing.
• Crawling.
• Burning.

Usually, the sensations:

• Affect both sides of the body.
• Are worse when you sit or lie down.
• Are worse at night. These may wake you up or make it difficult to fall asleep.
• Make you have a strong urge to move your legs.
• Are temporarily relieved by moving your legs.

The arms can also be affected, but this is rare. People who have this condition often have tiredness during the day because of their lack of sleep at night.

How is this diagnosed?

This condition may be diagnosed based on:

• Your symptoms.
• Blood tests.

In some cases, you may be monitored in a sleep lab by a specialist (a sleep study). This can detect any disruptions in your sleep.

The diagnosis is clinical and is based on the

The 2012 revised International Restless Legs Syndrome Study Group diagnostic criteria

Compared to 2003 criteria, the 2012 version includes a fifth criterion to rule out RLS mimickers, and in addition, all the essential diagnostic criteria have to be met:

• (1) the urge to move the legs, usually but not always accompanied by or felt to be caused by uncomfortable and unpleasant sensations in the legs;
• (2) the urge to move the legs and any accompanying unpleasant sensations begin or worsen during periods of rest or inactivity such as lying down or sitting;
• (3) the urge to move the legs and any accompanying unpleasant sensations are partially or totally relived by movement, such as walking or stretching, at least as long as the activity continues;
• (4) the urge to move and any accompanying unpleasant sensations during rest or inactivity only occur or are worse in the evening or night than during the day; and
• (5) the above features are not solely accounted for by other medical or behavioral conditions, such as myalgias, venous stasis, leg edema, arthritis, leg cramps, positional discomfort, habitual foot tapping, and other nocturnal sensory-motor symptoms.

What treatment options are available for Restless legs syndrome? 

Several categories of medications are used in the management of Restless legs syndrome, such as calcium channel alpha-2-delta ligands, which include

• gabapentin,
• gabapentin enacarbil,
• and pregabalin, and
• dopamine agonists, which include ropinirole, pramipexole, and rotigotine.

Opioids also help. If the serum ferritin is <75 ng/mL, iron replacement therapy is recommended.

This condition is treated by managing the symptoms. This may include:

• Lifestyle changes, such as exercising, using relaxation techniques, and avoiding caffeine, alcohol, or tobacco.
• Medicines. Anti-seizure medicines may be tried first.

Therapy related complication of Restless legs syndrome

Augmentation

Augmentation is an important therapy-related complication of Restless legs syndrome seen in those patients chronically treated with dopaminergic drugs, such as dopamine agonist and carbidopa/levodopa.

Augmentation is characterized by progressively earlier onset of Restless legs syndrome symptoms associated with increased intensity of symptoms, shorter latency after rest, an expansion of symptoms to the upper limbs and the trunk, and a shorter duration of the effect of the medication.

Patients with augmentation typically describe their Restless legs syndrome symptoms as being worse than those before treatment.

A US community-based study estimated prevalence of augmentation in all patients treated with a dopaminergic medication to be 76%, with a yearly growth rate of 8%.

Follow these instructions at home:

General instructions

• Take over-the-counter and prescription medicines only as told by your health care provider.
• Use methods to help relieve the uncomfortable sensations, such as:
  • Massaging your legs.
  • Walking or stretching.
  • Taking a cold or hot bath.
• Keep all follow-up visits as told by your health care provider. This is important.

Lifestyle

• Practice good sleep habits. For example, go to bed and get up at the same time every day. Most adults should get 7–9 hours of sleep each night.
• Exercise regularly. Try to get at least 30 minutes of exercise most days of the week.
• Practice ways of relaxing, such as yoga or meditation.
• Avoid caffeine and alcohol.
• Do not use any products that contain nicotine or tobacco, such as cigarettes and e-cigarettes. If you need help quitting, ask your health care provider.

Contact a health care provider if:

• Your symptoms get worse or they do not improve with treatment.

Summary

• Restless legs syndrome is a condition that causes uncomfortable feelings or sensations in the legs, especially while sitting or lying down.
• The symptoms often interfere with a person’s ability to sleep.
• This condition is treated by managing the symptoms. You may need to make lifestyle changes or take medicines.