Dr. Rajesh Konnur
Restless Leg Syndrome (RLS) is a most common movement and neurological disorder with the complain of disturbed sleep. Non pharmacological management approaches alone can be appropriate with milder RLS but those with more severe levels of the disease require pharmacological measures.
If we go back to history, in the 19th century, this condition was called ‘impatience musculaire’ by the French and ‘anxietas tibiarum’ by the Germans and was believed to be a form of hysteria. The modern term, Restless Leg Syndrome (RLS) was coined in 1945 by the Swedish neurologist Karl Ekbom.
Restless Leg Syndrome is a disorder of the part of the nervous system that causes an urge to move the legs. Because it usually interferes with sleep, it is also considered a sleep disorder.
Epidemiological Concepts and Description:
RLS is a sensorimotor disorder clinically defined by:
- An urge to move the legs with or without unpleasant sensations.
- Improvement during movement.
- Worsening during sleep and rest.
- Worsening in the evening and night.
The four features are the essential diagnostic criteria for RLS listed by the International Restless Leg Syndrome Study Group (IRLSSG); other features, such as family history, are supportive features. Although it is called ‘restless leg syndrome’, the disorder may also involve arms and other body parts. Patients use various descriptive terms for the unpleasant sensations such as ‘crawling’, ‘searing’, ‘jittering’, ‘internal itch’, ‘burning’ & ‘tight feeling’ and mostly describe their sensations as painful.
Anyone can have restless leg syndrome, but it’s more common in older adults and women. Mild symptoms of RLS may start in early adulthood and then increase with age. After age of 50, RLS symptoms often increase in severity and significantly disrupt sleep. RLS is also common during pregnancy.
Restless Legs and Sleep Disruption:
Most patients with RLS complain of disturbed sleep. Most report difficulty falling asleep because the symptoms typically worsen in the evening and night and with immobility. Some, however, fall asleep rapidly but wake frequently with symptoms that force them to get up and wake around in an attempt to relieve the discomfort. As a group, patients with RLS have severe nocturnal sleep disruption compared with normal controls with reduced sleep time, reduced sleep efficiency and longer sleep latency. Disturbed sleep is the primary morbidity symptoms which needs treatment. RLS is also associated with periodic limb movements of sleep (PLMS) which may further disrupt sleep.
Etiology & Psychopath- Physiology:
Most cases of RLS occur as primary idiopathic disorder and 40-60% of these patients report a family history of the condition. Secondary RLS may also occur in association with a variety of medical disorders.
Primary RLS and Genetic Factors:
The exact neurological and pathogenesis of RLS is still debated. The most seen are in peripheral nerve conduction abnormalities, thalamic, basal ganglia and cerebellar activation defects, dopamergic and opiate receptor dysfunction and CNS iron deficiency is also noted. The reality is that the pathogenesis of RLS is probably multifactorial.
Genetic research findings shows that it is a complex multigenic disorder where carriers of susceptibility alleles are at increased risk of developing symptom and this risk is further modified by other genetic &/ or environmental factors, resulting in the heterogeneity of the disease spectrum seen clinically. In children, it is also associated with ADHD.
Secondary RLS:
Iron deficiency and Parkinson’s disease are closely related to RLS.
Diagnostic features:
- Detailed clinical history of collection & physical examination.
- Iron study and RFT.
- Polysonography
Medical Management:
Pharmacological Management:
The following medications are administered one to three hours before bedtime as guided during the onset of symptoms.
- Dopamine Precursors:
Levodopa with benserazide or Cabidopa.
- Dopamine Agonists:
Pramipexole & Ropinirole.
Bromocriptine, Cabergoline & Pergolide.
- Opiods:
Codeine, Methadone, Oxycodone & Tramadol.
- Benzodiazepines:
Clonazepam.
- Gabapentin:
800- 1800 mg/day.
- Non- Pharmacological Management:
The following measures help to manage RLS symptoms-
- Manage Stress:
The symptoms of RLS get worse when anxiety is more. Practice of relaxation techniques, such as meditation and deep breathing, Yoga and healing techniques may help. Cutting back or elimination of alcohol, stopping of over exercising, stopping of smoking/ consumption of other drugs, stopping of experimenting with caffeine, checking medicine cabinet and regular check – up for Iron and Vitamin deficiencies like Vitamin D, Magnesium and folic acid are expected to improve the situation.
- Daily Exercises:
Daily activity should include aerobic exercise and lower- body résistance training. Effort should be given to exercise for at least 30 minutes, not too close to bed time.
- Stretches for RLS:
Calf stretch, Front thigh stretch, high stretch etc. helps to stop the symptoms of RLS.
- Sleep hygiene:
Regular sleeping pattern has to be maintained. A warm bath and a massage are best cares.It has to be remembered that best care is self-care.
From above discussion, it can be concluded that there is no ‘cure’ for RLS and symptoms may worsen with age. However, a combination of good healthy life style choices plus medication (if necessary) may lessen the symptoms enough so that the concerned patient may be allowed to sleep.
References:
1. Medicine Today. 2018:12 (11)40-48.
2. Help Guide. June 2019.
3. Cleveland Clinic.org / sleep. 2019.
Concept Research Foundation 