Restless leg syndrome : Causes, Symptoms, Treatment and Prevention

Overview

About Restless leg syndrome

Restless leg syndrome, or Willis-Ekbom disease, is a widespread neurological condition that involves an intense and uncontrollable urge to move the legs.

Restless Leg Syndrome (RLS) shows the presence of awful sensations in the legs, which present as an uncontrollable urge to move them.

The sensations are characterized as:

• Creeping
• Tingling
• Crawling
• Pulling

Usually, these sensations are experienced in the calf region, although they can also be felt in any area between the thigh and the ankle. Either one or both of your legs may be affected.

Symptoms typically manifest during the late afternoon or evening, with more severity observed at night during periods of rest.

Dual role of RLS

• RLS is both a sleep disorder as well as movement disorder. Restless Leg Syndrome (RLS) symptoms are triggered when individuals are at rest or attempting to sleep, making it a sleep disorder. Additionally, RLS is classified as a movement disorder, as individuals affected by RLS feel compelled to move their legs in order to reduce the symptoms.
• Restless legs syndrome (RLS) is a chronic condition which has no known cure. Nevertheless, there are available treatments to decrease symptoms.

Prevalence

Prevalence

• The prevalence of Restless Legs Syndrome (RLS) in the United States is estimated to be between 7-10% ³Prevalence| Researched based study from Nlm.nih.gov , and it can manifest at any age.
• The condition affects both genders, with a greater prevalence seen in females.
• The prevalence of severe symptoms tends to be higher among middle-aged and older individuals, and these symptoms generally increase in frequency and duration as individuals age.

Causes

Causes of RLS

The underlying causes of RLS can be:

• Genetic
• Calcium imbalance
• Anemia
• Vitamin D deficiency
• Genetic polymorphism.
• Reduced iron in the body
• Secondary restless leg syndrome ¹Causes| Researched based study from Nhs.uk

Genetic

• Autosomal dominant inheritance has been observed in several large families with restless legs syndrome, indicating the presence of various susceptibility loci. This implies a genetic etiology for the disease.

Calcium imbalance

• Uremic restless legs syndrome may involve calcium and phosphate imbalance, functional iron deficiency, anemia, and subclinical peripheral nerve abnormalities in its pathophysiology.

Vitamin D deficiency

• Vitamin D deficiency, disturbances in calcium metabolism, pre-eclampsia, familial predisposition, low serum iron and ferritin levels, as well as elevated estrogen levels, are potential factors that can influence pregnancy outcomes.

Genetic polymorphism

• Restless legs syndrome is linked to genetic polymorphisms in genes such as BTBD9 and MEIS1.

Reduced iron in the body

• Neuropathologic and imaging studies have demonstrated reduced iron levels in various brain regions, such as the substantia nigra and thalamus. These areas also exhibit a state of dopamine surplus.

Types

Types of RLS

The RLS can be classified into two main types:

• Primary RLS
• Secondary RLS

Primary Restless leg syndrome

• Primary RLS is classified as idiopathic when the underlying cause is genuinely unknown.
• A significant proportion (40.9 to 92%) of individuals with idiopathic Restless Legs Syndrome (RLS) have a family history of the condition, suggesting a significant influence of genetic factors in its development.

Secondary Restless leg syndrome

• The majority of secondary cases of restless leg syndrome (RLS) typically manifest after the age of 40.
• Secondary RLS refers to the type of restless legs syndrome that is linked to various disorders of the brain, iron deficiency, chronic kidney disease or pregnancy.

Secondary restless legs syndrome can develop if you have:

• The presence of iron deficiency anemia can result in decreased dopamine levels, triggering the development of restless legs syndrome.

• Chronic kidney disease, Parkinson’s disease, Diabetes, rheumatoid arthritis, fibromyalgia or an underactive thyroid are affected by long-term health conditions.

• Pregnant women, especially during the period from week 27 until delivery, commonly experience symptoms that typically go away within four weeks after giving birth.

Based on the age of onset, RLS can be:

• Early onset
• Late onset

Early onset

• Early-onset restless legs syndrome (RLS) refers to individuals who experience symptoms of RLS for the first time before the age of 45 years.

Late onset

• Late-onset restless legs syndrome (RLS) typically manifests in individuals aged 45 years and above.

Risk factors

Risk factors of RLS

Restless legs syndrome has been associated with various factors and can exhibit familial patterns. Some of these factors are:

Decrease in Dopamine Level

• Dopamine functions as a neurotransmitter facilitating communication between your brain and nervous system, therefore helping in the regulation and coordination of movement.

• Nerve cell damage leads to a decrease in brain dopamine levels, resulting in muscle spasms and involuntary movements.

• Restless legs syndrome symptoms tend to worsen in the evening and at night, possibly due to the natural decline in dopamine levels towards the end of the day.

Triggers

Several triggers can exacerbate symptoms of restless legs syndrome, although they do not directly cause the condition, Like:

Medicines

• Antidepressants
• Certain antipsychotic medications
• Lithium is a medication commonly prescribed for the management of bipolar disorder
• Antihistamines
• Beta blockers

Additional potential triggers include

• Excessive consumption of caffeine or alcohol.
• Smoking
• Experiencing excess weight or obesity
• Nicotine
• Lumbosacral radiculopathy
• Stress
• Diabetes mellitus
• Rheumatic disease
• Amyloidosis
• Fibromyalgia
• Inadequate sleep ²Risk factors| Researched based study from Sleepfoundation.org
• Coeliac disease
• Medications used for the treatment of nausea, allergies, cold and mental health disorders.
• Prolonged sitting, such as during extended train journeys, may cause RLS.

Symptoms

Symptoms of RLS

The sensation of RLS can also extend to the arms, chest, and face. The intensity of these unpleasant sensations can vary from mild to severe, with a tendency to worsen in the evening and at night. Leg discomfort can be relieved through leg movement or rubbing.

Symptoms may vary in frequency, with some individuals experiencing them intermittently and others experiencing them on a daily basis.

It has been characterized as:

• Symptoms may include tingling, burning, itching, or throbbing sensations.
• Experiencing a sensation like moving of small insects or spiders on the skin, accompanied by a sensation of fluid running within the blood vessels of the legs.
• Distressing cramping sensation in the legs, specifically in the calf muscles.

Periodic limb movements (PLM)

• Patients with periodic limb movement disorder (PLM) may experience involuntary leg jerking or twitching, commonly occurring during nocturnal sleep. The movements are characterized by brevity and repetition, occurring at intervals of 20 to 40 seconds. PLM can cause disruptions in sleep.

Insomnia

• Restless Leg Syndrome (RLS) often hinders individuals from falling asleep and maintaining sleep due to the urge to move their legs.
• Symptoms begin shortly after you go to bed at night.
• People affected with RLS may feel an irresistible urge to rise from bed and engage in leg movements such as kicking, stretching, or massaging.
• RLS frequently leads to fatigue and excessive sleepiness during the day because of sleep disturbances.
• Sleep deficiency is commonly linked to restless leg syndrome (RLS), depression, anxiety, heart disease, and obesity.
• The primary motivation for individuals with RLS to seek medical attention is their sleep-related concerns.

Diagnosis

Diagnosis of Restless leg syndrome

Medical professionals use four primary criteria (4) times a to confirm a diagnosis. They are:

• Strong compulsion to move the legs, often accompanied by unpleasant sensations such as itching or tingling.
• Symptoms manifest or exacerbate during periods of rest or inactivity.
• Symptoms are alleviated through leg movement or stretching.
• Symptoms exacerbate in the evening or nocturnal hours.

Diagnostic tests for restless legs syndrome are primarily used to exclude other potential underlying causes rather than directly diagnose the condition.

Hematological analysis

• Blood tests are conducted to exclude alternative factors.

Electromyography (EMG) and nerve conduction studies

• They are commonly used diagnostic techniques in the field of neurophysiology. Radiculopathy or neuropathy should be suspected if you observe symptoms of RLS.

Polysomnography

• Leg movements are frequently quantified and sleep patterns are characterized through this process. It is a diagnostic test used to evaluate sleep disorders.

Iron studies

• RLS screening should be conducted in all symptomatic patients. Proper iron studies, including serum iron, ferritin, transferrin saturation, and total iron-binding capacity, should be conducted. If a complete iron test is not possible, measuring ferritin levels should be considered as a minimum requirement.

Sleep study

• Sleep study is usually not required for diagnosing the majority of cases of RLS. However, it may be advisable to conduct a sleep study if you suspect of periodic leg movement disorder (PLMD), other sleep disorders or sleep apnea.

Nerve conduction study

• This test assesses the speed of electric signals in nerves and can be utilized for diagnosing or excluding peripheral neuropathy.
• Nerve conduction studies and electromyography (EMG) should be considered for patients with suspected radiculopathy or neuropathy, even if their neurological examination yields normal results.

If there is suspicion of a secondary cause, additional laboratory tests should be conducted, including a complete blood count (CBC) and an assessment of levels of the following:

• Blood urea nitrogen (BUN): It is a commonly used clinical test to measure the amount of urea nitrogen in the blood.
• Fasting blood glucose refers to the measurement of glucose levels in the bloodstream after an individual has abstained from consuming food or beverages for sometime
• Creatinine levels.
• Thyroid-stimulating hormone (TSH)
• Magnesium
• Vitamin B-12: It is a micronutrient that plays a vital role in various physiological processes.
• Folate.

Differential diagnosis of Restless leg syndrome

These are the medical issues to be considered while you make the diagnosis of restless legs syndrome:

• Tardive dyskinesia
• Leg cramps
• Akathisia
• Vascular disease
• Radiculopathy
• Muscle spasms⁵Diagnosis| Researched based study from Nlm.nih.gov

Treatment

Restless leg syndrome Treatment

Restless leg syndrome can be treated by:

Sleep improvement device

• In 2014, the US Food and Drug Administration (FDA) approved a sleep improvement device for commercial use in patients with RLS. The device counter employs vibrations to stimulate the patient’s legs. The approval was granted based on two randomized studies that demonstrated the device’s superiority in improving sleep compared to a placebo padding.

Dopamine agonists

• Dopamine agonists may be prescribed for people with frequent restless legs syndrome symptoms.
• Possible recommended dopamine agonists include: The medications ropinirole, pramipexole, and rotigotine skin patch are commonly used for the treatment of Parkinson’s disease.
• These drugs function by increasing dopamine levels.
• These medications may cause drowsiness, nausea, vomiting, dizziness and Impulse control disorder (ICD) can occur as a rare adverse effect of dopamine agonists.

Painkillers

• Codeine, a mild painkiller derived from opiates, may be prescribed to alleviate pain related to restless legs syndrome.

• Gabapentin and pregabalin are occasionally prescribed for reducing the painful symptoms. Common adverse effects of these medications include dizziness, fatigue, and headaches.

Sleep medications

• In cases where restless legs syndrome significantly impairs sleep, a temporary medication regimen may be advised to facilitate improved sleep quality.

• These medications, namely zopiclone and zolpidem are hypnotics. Hypnotics are prescribed for short-term use, usually not exceeding one week. You may experience drowsiness or a hangover-like sensation upon waking after medication administration.

Iron supplements

• They can be dietary supplements that contain iron. They are commonly used to treat or prevent iron deficiency anemia. Drug form of iron comes in Ferric carboxymaltose (1000 mg) effectively treats moderate to severe RLS.

Anti-seizure drugs

• Anti-seizure medications are commonly prescribed as the initial treatment for individuals suffering from Restless Legs Syndrome (RLS).

• Gabapentin enacarbil has been recently approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe restless legs syndrome (RLS).

• Anti-seizure medications and pregabalin can reduce nerve pain and sensory disturbances.

Opioids

• Methadone, codeine, hydrocodone, and oxycodone are occasionally prescribed for individuals with severe restless leg syndrome (RLS) symptoms that do not improve with other medications.

Benzodiazepines

• Clonazepam and lorazepam are commonly prescribed medications for the treatment of anxiety, muscle spasms, and insomnia, with the potential to improve the quality of sleep.⁴Treatment| Researched based study from Nlm.nih.gov

Prevention

Prevention & Restless Legs Syndrome Home Care Tips

These approaches can reduce RLS symptoms and can be used with medication in severe cases:

Sleep hygiene

• Good sleep hygiene generally means creating a clean bedroom and sticking to a consistent daily routine. Avoid alcohol and caffeine to prevent worsening of symptoms.

Exercise

• Exercise may help relieve RLS symptoms caused by physical inactivity. RLS patients who exercised for six weeks experienced a 39% reduction in symptom severity, while those who did not exercise only had an 8% reduction.

Pneumatic pressure therapy

• Pneumatic compression equipment increases blood flow to the legs. After one month of daily usage, compared to a control group, researchers discovered that the device reduced RLS symptoms, quality of life, and tiredness.

Massage and hot baths

• Massage and hot baths are commonly recommended for stimulating the legs in RLS, but there is limited scientific evidence that promotes their effectiveness.

Use heat or cold compressions

• Apply a heating pad or ice pack on your legs and arms for 20 minutes. This relieves pain and muscle cramps.

Massaging the affected area

• Massage limbs or take a hot Epsom salt bath. This can relax muscles, ease pain, and reduce discomfort.

Supplement addition

• Supplements like iron, magnesium and vitamin B12 can decrease symptoms of RLS and improve the nervous system. Medication such as anticonvulsants, opioids or dopaminergic drugs will also help.

Diet adjustment

• Consuming iron, magnesium, and vitamin B12, C, D and E rich foods can enhance nervous system function and alleviate symptoms. Avoid caffeine and nicotine.

Stretch

• Stretch before bedtime. This prevents muscle tightness and restless legs or arms.

Use OTC medication

• Pain relievers, anti-inflammatories, and muscle relaxants can relieve restless legs and arms.

Pharmacological treatments

• Lifestyle changes can also be effective, in addition to medication. Dopamine agonists are prescribed for restless leg syndrome. Consult a doctor for treatment of restless leg syndrome symptoms.

Complications

Complications of RLS

Restless legs syndrome may worsen in people with other medical conditions if appropriate treatment is not given:

• The disease primarily affects quality of life through sleep disturbances and fatigue. The symptoms worsen over time and have a substantial impact on the patient’s quality of life.

• The majority of individuals diagnosed with restless legs syndrome experience the “idiopathic” variant. For such variants, There is no risk of RLS progressing into a more severe condition, such as Parkinson’s disease.

RLS will let you experience:

• Changes in the mood
• Difficulty in concentrating
• Memory loss
• Depression and anxiety
• Exhaustion
• Daytime sleepiness
• Decreased productivity

Takeaway

Takeaway

You know that feeling when you’re finally ready for a good night’s sleep, but all of a sudden your arms or legs start moving around uncontrollably? Restless legs syndrome (RLS) is a condition that disrupts sleep quality. However, effective treatment and home remedies can be employed to reduce symptoms of RLS. You must follow proper medication regimen and try out home remedies to get rid of restless leg syndrome.