Restless Legs Syndrome

What Is Restless Legs Syndrome?

Restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED), is a common neurological disorder that is characterized by an uncontrollable urge to move the legs. It is also associated with the feeling of unpleasant and sometimes painful sensations in the legs[1]

Individuals who suffer from RLS will experience an urge to move the legs in order to relieve the uncomfortable sensations that are felt. The symptoms of RLS are most prominent during the evening or at night – usually when the individual is trying to sleep.

RLS is most commonly associated with iron deficiency (ID), pregnancy, and uremia. Prevalence levels increase with increasing age. Furthermore, RLS is more commonly found in women compared to men[7]

Symptoms of RLS were first described by Thomas Willis in 1685, and then published by Karl-Axel Ekbom in 1960. Even though RLS has been recognized for many years it is still a relatively unknown disorder[7]

RLS can have a serious impact on an individual’s quality-of-life, which is why it is important to have a good understanding of the disorder so you can look to manage it properly.

Symptoms

The severity of the symptoms associated with RLS range from being slightly bothersome and infrequent, to being severe and common.

Symptoms of RLS may include:

  • Discomfort in the legs
  • An urge to move the legs in order to relieve discomfort
  • Restlessness

The most obvious symptom associated with RLS is the strong urge to move the legs in order to satisfy an unpleasant sensation. This is not just limited to just the legs though, as it can also occur in the arms too[3]

Other symptoms may also include:

  • Difficulty in falling/staying asleep
  • Daytime fatigue

When patients seek out medical attention they will often complain about a difficulty in falling or staying asleep, along with daytime fatigue[3]

Interestingly enough, RLS has a circadian pattern, which explains why the symptoms associated with RLS will worsen during the evening or at night. These symptoms will usually reach their lowest levels in the morning, and peak at their highest levels at night between 11 PM to 4 AM. [3]

Causes

Unfortunately, the cause of RLS is still relatively unknown.

Past research has suggested that RLS is related to an issue involving the basal ganglia, which is a group of nuclei found in the brain. The basal ganglia are responsible for motor control and facilitating movement. Dopamine is an important neurotransmitter associated with the basal ganglia, and is necessary for muscle activity and movement.

Symptoms of RLS have been shown to improve with the use of dopaminergic medications at low doses, and worsen when exposed to dopamine antagonists. [7]

RLS is also a hereditary condition, which has been seen in families that have symptoms of RLS occurring before they are 40 years old.

Pregnant women may experience hormonal changes that cause RLS to occur. Usually this is only temporary as symptoms tend to subside after delivery. Studies have shown that around 15-20% of pregnant women in Western countries have RLS. [7] If you are a woman then you are more prone to RLS compared to men. [6]

Conditions that cause a drop in iron levels also increase the risk of developing RLS, such as iron-deficiency anaemia, and coeliac disease. [4] Several studies have shown that roughly 25% of RLS patients had been suffering from iron deficiency. [7]

Certain drugs may cause or increase the severity of RLS symptoms. A study revealed the strongest evidence related to these specific drugs: escitalopram, fluoxetine, L-dopa/carbidopa and pergolide, L-thyroxine, mianserin, mirtazapine, olanzapine, and tramadol. [7]

This YouTube video by Dr Eric Burg suggests that lactic acidosis or an electrolyte imbalance may be a cause of RLS. He suggests that you can treat the condition with either vitamin B1 or potassium supplements.

Diagnosis

The diagnosis of RLS is based off of a patient’s clinical history, and also through a neurological examination. [1]

The International Classification of Sleep Disorders (ICSD-3) has established a number of criteria that are to be met for the proper diagnosis of RLS. [2]

Please note that ALL criteria A-C must be met:

  1. An urge to move the legs, usually accompanied by or thought to be caused by uncomfortable and unpleasant sensations in the legs. These symptoms must:
    1. Begin or worsen during periods of rest or inactivity such as lying down or sitting;
    2. Be partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues; and
    3. Occur exclusively or predominantly in the evening or night rather than during the day
  2. The above features are not solely accounted for as symptoms of another medical or behavioural condition (e.g. leg cramps, positional discomfort, myalgia, venous stasis, leg oedema, arthritis, habitual foot-tapping)
  3. The symptoms of RLS cause concern, distress, sleep disturbance or impairment in mental, physical, social, occupational, educational, behavioural or other important areas of functioning

Classification

RLS can be classified into two different groups: primary RLS, and secondary RLS. [7] It is important to recognise the difference between the two as treatment options may vary between them.

It should be noted that certain types of medication may also contribute to RLS. Psycotropics (i.e. antidepressants, neuroleptics) and dopaminergic drugs may cause or worsen the symptoms associated with RLS. [7]

Primary RLS (Idiopathic RLS)

Primary RLS is idiopathic, which means that it occurs spontaneously, and the direct cause of it is unknown. Primary RLS is commonly associated with a family history of RLS, which indicates that there is a strong genetic component involved with the disorder. [7]

Note: primary RLS may also be referred to as hereditary/familial RLS.

Secondary RLS

A majority of Secondary RLS patients experience the onset of RLS after 40 years of age. Secondary RLS is associated with a condition, such as: [7]

  • Neurological disorders
  • Iron Deficiency
  • Pregnancy
  • Chronic renal failure
  • Environmental factors (i.e. stress, lack of sleep)

If you experience any of these conditions, along with RLS, then you are classified as having secondary RLS.

Treatment

There are a number of treatment options available for individuals who suffer from RLS. The current focus of RLS therapy is to try and help relieve the symptoms associated with the disorder. [3]

The best treatment option will be based on the severity of the symptoms, along with the impact they have on the individual.

Lifestyle Changes

Lifestyle changes, such as decreasing or stopping the use of alcohol and cigarettes may help with RLS symptoms. You may also want to consider adjusting your sleep pattern, exercising more, massaging your legs, taking a warm bath, and using ice packs to help ease the discomfort.

Medication

Typically the first line of treatment for treating RLS is with the use of dopaminergic drugs [7]. These drugs include:

  • Pramipexole
  • Ropinirole

Other dopaminergic drugs such as pergolide and cabergoline are not recommended due to an increased association with valvular heart disease. [7]

Iron

Iron supplementation has been used in the past to help relieve patients of the symptoms associated with RLS.

Regardless of whether or not you have RLS, it is ALWAYS a good idea to go and have a blood test done. A blood test will be able to reveal how much iron you have, and you can identify whether or not you have an iron deficiency.

When Ekborn first described RLS he found that many patients were suffering from iron deficiency. Using this information Ekborn was able to successfully treat 21 out of 22 patients using large doses of intravenous (IV) iron. [4]

Vitamin D

A study performed in 2014 looked at the effect of vitamin D supplementation on the severity of RLS symptoms. The study found that vitamin D did in fact show a significant improvement to the severity of the symptoms associated with RLS. Furthermore, it also helped establish a possible link of vitamin D deficiency to RLS patients. [6]

It should be noted that a larger study is necessary in order to confirm these findings. [6]

Prevalence

Studies suggest that between 7.2-11.5% of the general population suffer from RLS. Furthermore, approx. 3% of the general population are said to experience symptoms that are severe enough to require medical assistance. [3]

The prevalence of RLS increases with an increasing age. [3]

Most cases of RLS are often left undiagnosed, which may be due to the lack of knowledge surrounding the disorder. [3]

References

  1. Klingelhoefer, L., Bhattacharya, K. and Reichmann, H., 2016. Restless legs syndromeClinical Medicine16(4), pp.379-382.
  2. Bassetti, C., Dogas, Z. and Peigneux, P., 2014. Sleep medicine textbook. European sleep research society.
  3. Bogan, R.K. and Cheray, J.A., 2013. Restless legs syndrome: a review of diagnosis and management in primary carePostgraduate medicine125(3), pp.99-111.
  4. Allen, R.P. and Earley, C.J., 2007. The role of iron in restless legs syndromeMovement disorders: official journal of the Movement Disorder Society22(S18), pp.S440-S448.
  5. Weinstock, L.B., Walters, A.S., Mullin, G.E. and Duntley, S.P., 2010. Celiac disease is associated with restless legs syndromeDigestive diseases and sciences55(6), pp.1667-1673.
  6. Wali, S., Shukr, A., Boudal, A., Alsaiari, A. and Krayem, A., 2015. The effect of vitamin D supplements on the severity of restless legs syndromeSleep and Breathing19(2), pp.579-583.
  7. Guo, S., Huang, J., Jiang, H., Han, C., Li, J., Xu, X., Zhang, G., Lin, Z., Xiong, N. and Wang, T., 2017. Restless Legs Syndrome: from pathophysiology to clinical diagnosis and managementFrontiers in aging neuroscience9, p.171.

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