Restless Legs Syndrome

Restless Leg Syndrome (RLS): What you Need to Know

Restless legs syndrome (RLS) is a condition in which your legs feel extremely uncomfortable, typically in the evenings while you’re sitting or lying down. It makes you feel like getting up and moving around. RLS can begin at any age and generally worsens as you age. Restless legs syndrome can disrupt sleep — leading to daytime drowsiness — and make traveling difficult. Moving the legs reduces and may relieve the discomfort. The constant need to move the legs disturbs sleep and can lead to impairment of function in daily life.

Restless legs syndrome – RLS – Lat. asthenia crurum paraesthetica, anxietas tibiarum, has been described as early as in XVII century by an English physician Thomas Willis – known as the "Father of Neuroscience" and was a Founder Fellow of the prestigious Royal Society. The condition was first suggested to be associated with venous insufficiency Dr. Karl A Ekbom in 1944. Doctors who treat varicose veins have long heard from their patients descriptions of throbbing, buzzing, creepy-crawly, pains in the lower extremities–symptoms that sound very similar to those of RLS. Restless legs syndrome has long been accepted as a symptom of venous insufficiency by phlebologists. When RLS co-exists with venous insufficiency, treating the venous insufficiency can provide substantial improvement in symptoms and subsequently the quality of life. RLS is also called Willis-Ekbom Disorder (WED).

Restless legs syndrome affects approximately 10 percent of adults in the United States. RLS may begin at any age, including childhood, and affects approximately twice as many women as men. 80% of those affected by RLS also experience Periodic Limb Movement Disorder (PLMD) during sleep, in which the patient has brief "jerks" of the legs or arms while sleeping.

PLMD causes you to involuntarily flex and extend your legs while sleeping — without being aware you’re doing it. Hundreds of these twitching or kicking movements may occur throughout the night. If you have severe RLS, these involuntary kicking movements may also occur while you’re awake. PLMD is common in older adults; 4 out of 5 people with RLS also experience PLMD.

Venous insufficiency not only causes varicose veins, it can be the underlying cause for a multiple conditions, including lower extremity cellulitis, leg cramps and restless legs syndrome. When patients present with venous insufficiency symptoms, physicians often only check some of the obvious explanations and do not delve deeper to look for the possibility of venous reflux as an underlying cause. Unfortunately, there is a large percentage of people walking around with venous problems who aren’t getting the evaluation or treatment they need. Symptoms of restless legs syndrome may vary from person to person but often include burning, tingling, creeping sensations and the uncontrollable urge to move the legs. This is generally worse at night when laying down and is usually relieved by movement or walking. The symptoms of venous insufficiency and restless leg syndrome are almost interchangeable and many patients with documented severe superficial venous insufficiency and restless leg syndrome will have resolution of their restless leg syndrome after successful vein treatment.

Treating the cause, not just the symptoms

Studies show that the treatment of venous insufficiency can relieve symptoms of restless leg syndrome. According to a study in the journal Phlebology, in patients with restless leg syndrome and venous insufficiency, 98% of patients experienced relief from restless legs syndrome symptoms by treating their venous insufficiency, and 80% had long-term relief.

Given the results of the recent studies, it is recommended that, before patients start taking prescription medication for restless leg syndrome, they request a consult by a qualified vein specialist who can perform ultrasound evaluation to identify whether there is significant underlying venous insufficiency which may be causing or contributing to their problem. There is no downside to getting an ultrasound – there is no radiation involved, no needles, no pain, and it is a physiologic test which reveals which veins are leaking and how much they are leaking. Venous ultrasound for insufficiency is conservative, noninvasive, and it accurately identifies which patients are most likely to benefit from treatment.

Diagnosis

RLS diagnosis is based on thoroughly collected medical history. RLS/WED symptoms vary considerably in frequency from less than once a month or year to daily, and severity from mildly annoying to disabling. Symptoms may also remit for various periods of time. RLS/WED is diagnosed by ascertaining symptom patterns that meet the following five essential criteria.

The Essential Diagnostic Criteria of RLS (WED) (all must be met) are:

1. An urge to move the legs, usually accompanied by an uncomfortable sensation(s)
2. The uncomfortable sensation(s) begins or worsens during periods of rest
3. The unpleasant sensations are partially or totally relieved by walking/movement
4. The urge to move is greater in the evening or night than during the day
5. The disorder cannot be accounted for as symptoms primary to another medical or behavioural condition

Specifier for Clinical Significance of RLS

The symptoms of RLS cause significant distress or impairment in social, occupational, educational or other important areas of functioning by the impact on sleep, energy/vitality, daily activities, behavior, cognition or mood.

RLS is a condition that mainly occurs with various diseases including iron deficiency anaemia, multiple sclerosis, polyneuropathy, Parkinson’s disease, as well as common chronic diseases such as arterial hypertension, headache, or conditions such as inflammation, and pregnancy. Over time a differentiation of RLS into "primary, idiopathic" and "secondary, symptomatic" has been established without clear criteria for differentiating both. Although available evidence now encompasses a broad spectrum of pathophysiological, populationbased (cross-sectional or longitudinal) studies, the question whether RLS is more a primary disorder or a comorbidity, remains unresolved. It is even likely that a cumulative number of diseases within a single patient increases the risk of the additional manifestation of RLS symptoms on the background of the genetic risk load, or vice versa.

The above criteria help differentiate RLS (WED) from other disorders that mimic the symptoms of RLS (WED). Following has to be taken into consideration in differential diagnose of RLS (WED):

  • Leg cramps
  • Peripheral neuropathy
  • Radiculopathy
  • Arthritic diseases
  • Multiple sclerosis

Treatment

Lifestyle and home remedies

Making simple lifestyle changes can help alleviate symptoms of RLS/WED. This applies mostly to the so called sleep hygiene. This has been presented in the section → sleep disoredrs. This also includes warm bath and massage, applying warm or cool compresses, avoiding caffene, getting light moderate exercise.

Associated Disorders Treatment

The prevalence of RLS increases with age, and is also often associated with one or even several other conditions. Most of these, such as diabetes, arterial hypertension, multiple sclerosis, or neurodegenerative diseases cannot be cured, and for some, such as spino-cerebellar ataxias, there is no treatment available at all. RLS in uraemic patients is a frequent complaint in dialysis centres. Between 20-30% of patients on haemodialysis need a specific treatment for frequently severe RLS.

Patients with low ferritin, either with or without anaemia, should first be treated with iron formulations before starting any dopaminergic therapy. Iron deficiency is obviously also a major contributing factor to RLS in pregnancy.

Dopaminergic therapy in RLS

This therapty increases dopamine levels, important chemical messenger, in your brain. Ropinirole (Requip), rotigotine (Neupro) and pramipexole (Mirapex) are approved by the Food and Drug Administration for the treatment of moderate to severe RLS/WED. Short-term side effects of these medications are usually mild and include nausea, lightheadedness and fatigue. However, they can also cause impulse control disorders, such as compulsive gambling, and daytime sleepiness.

Alpha-2-delta-ligands

This therapy affects calcium channels. Certain medications, such as gabapentin (Neurontin) and pregabalin (Lyrica), work for some people with RLS/WED.

Opioids

Narcotic medications can relieve mild to severe symptoms, but they may be addicting if used in high doses. Some examples include codeine, oxycodone (OxyContin, Roxicodone), combined oxycodone and acetaminophen (Percocet, Roxicet), and combined hydrocodone and acetaminophen (Norco, Vicodin), also have risk of creation medicine dependency are not suitable for longterm therapy.

Muscle relaxants and sleep medication

Known as benzodiazepines, these drugs help you sleep better at night, but they don't eliminate the leg sensations, and they may cause daytime drowsiness. A commonly used sedative for RLS/WED is clonazepam (Klonopin). These drugs are generally only used if no other treatment provides relief, and have substantial risk of creation medicine dependency and are not suitable for longterm therapy.

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