Restless Legs Syndrome(RLS)

Alternative Name : Wittmaack–Ekbom syndrome

Definitipon:
Restless legs syndrome (RLS)  is a neurological disorder characterized by an irresistible urge to move one’s body to stop uncomfortable or odd sensations.  It most commonly affects the legs, but can affect the arms, torso, and even phantom limbs.  Moving the affected body part modulates the sensations, providing temporary relief.
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RLS sensations can most closely be compared to an itching or tickling in the muscles, like “an itch you can’t scratch” or an unpleasant “tickle that won’t stop.” The sensations typically begin or intensify during quiet wakefulness, such as when relaxing, reading, studying, or trying to sleep.  In addition, most individuals with RLS have limb jerking during sleep, which is an objective physiologic marker of the disorder and is associated with sleep disruption. Some controversy surrounds the marketing of drug treatments for RLS. It is a “spectrum” disease with some people experiencing only a minor annoyance and others experiencing major disruption of sleep and significant impairments in quality of life

Restless legs syndrome can begin at any age and generally worsens as you get older. Women are more likely than men to develop this condition.

A number of simple self-care steps and lifestyle changes may help you. Medications also help many people with restless legs syndrome.

Symptoms:
Commonly described sensations
People typically describe restless legs syndrome (RLS) symptoms as unpleasant sensations in their calves, thighs, feet or arms, often expressed as:

*Crawling

*Tingling

*Cramping

*Creeping

*Pulling

*Painful

*Electric

*Tense

*Uncomfortable

*Itchy

*Tugging

*Gnawing

*Aching

*Burning

Sometimes the sensations seem to defy description. Affected people usually don’t describe the condition as a muscle cramp or numbness. They do, however, consistently describe the desire to move or handle their legs.

It’s common for symptoms to fluctuate in severity, and occasionally symptoms disappear for periods of time.

NIH criteria
In 2003, a National Institutes of Health (NIH) panel modified their criteria to include the following:

1.An urge to move the limbs with or without sensations.

2.Improvement with activity. Many patients find relief when moving and the relief continues while they are moving. In more severe RLS this relief of symptoms may not be complete or the symptoms may reappear when the movement ceases.

3.Worsening at rest. Patients may describe being the most affected when sitting for a long period of time, such as when traveling in a car or airplane, attending a meeting, or watching a performance. An increased level of mental awareness may help reduce these symptoms.

4.Worsening in the evening or night. Patients with mild or moderate RLS show a clear circadian rhythm to their symptoms, with an increase in sensory symptoms and restlessness in the evening and into the night.
RLS is either primary or secondary.

*Primary RLS is considered idiopathic or with no known cause. Primary RLS usually begins slowly, before approximately 40–45 years of age and may disappear for months or even years. It is often progressive and gets worse with age. RLS in children is often misdiagnosed as growing pains.

*Secondary RLS often has a sudden onset after age 40, and may be daily from the beginning. It is most associated with specific medical conditions or the use of certain drugs

Causes:
Disease mechanism
Most research on the disease mechanism of restless legs syndrome has focused on the dopamine and iron system.   These hypotheses are based on the observation that iron and levodopa, a pro-drug of dopamine that can cross the blood-brain barrier and is metabolized in the brain into dopamine (as well as other mono-amine neurotransmitters of the catecholamine class) can be used to treat RLS, levodopa being a medicine for treating hypodopaminergic (low dopamine) conditions such as Parkinson’s disease, and also on findings from functional brain imaging (such as positron emission tomography and functional magnetic resonance imaging), autopsy series and animal experiments.  Differences in dopamine- and iron-related markers have also been demonstrated in the cerebrospinal fluid of individuals with RLS.  A connection between these two systems is demonstrated by the finding of low iron levels in the substantia nigra of RLS patients, although other areas may also be involved.

 

Heredity
RLS runs in families in up to half the people with RLS, especially if the condition started at an early age. Researchers have identified sites on the chromosomes where genes for RLS may be present.

Pregnancy
Pregnancy or hormonal changes may temporarily worsen RLS signs and symptoms. Some women experience RLS for the first time during pregnancy, especially during their last trimester. However, for most of these women, signs and symptoms usually disappear quickly after delivery.

Related conditions
For the most part, restless legs syndrome isn’t related to a serious underlying medical problem. However, RLS sometimes accompanies other conditions, such as:

*Peripheral neuropathy. This damage to the nerves in your hands and feet is sometimes due to chronic diseases such as diabetes and alcoholism.

*Iron deficiency. Even without anemia, iron deficiency can cause or worsen RLS. If you have a history of bleeding from your stomach or bowels, experience heavy menstrual periods or repeatedly donate blood, you may have iron deficiency.

* Kidney failure. If you have kidney failure, you may also have iron deficiency, often with anemia. When kidneys fail to function properly, iron stores in your blood can decrease. This, along with other changes in body chemistry, may cause or worsen RLS.

Risk Factors:
RLS can develop at any age, even during childhood. Many adults who have RLS can recall being told as a child that they had growing pains or can remember parents rubbing their legs to help them fall asleep. The disorder is more common with increasing age.

Complications:
Although RLS doesn’t lead to other serious conditions, symptoms can range from barely bothersome to incapacitating. Many people with RLS find it difficult to get to sleep or stay asleep. Insomnia may lead to excessive daytime drowsiness, but RLS may prevent you from enjoying a daytime nap.

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Diagnosis:
The diagnosis of RLS relies essentially on a good medical history and physical examination. Sleep registration in a laboratory (polysomnography) is not necessary for the diagnosis. Peripheral neuropathy, radiculopathy and leg cramps should be considered in the differential diagnosis; in these conditions, pain is often more pronounced than the urge to move. Akathisia, a side effect of several antipsychotics or antidepressants, is a more constant form of leg restlessness without discomfort. Doppler ultrasound evaluation of the vascular system is essential in all cases to rule out venous disorders which is a common etiology of RLS. A rare syndrome of painful legs and moving toes has been described, with no known cause.

 

Treatment:
Treatment of restless legs syndrome involves identifying the cause of symptoms when possible. The treatment process is designed to reduce symptoms, including decreasing the number of nights with RLS symptoms, the severity of RLS symptoms and nighttime awakenings. Improving the quality of life is another goal in treatment. This means improving overall quality of life, decreasing daytime somnolence, and improving the quality of sleep. All of these goals are taken care of through nonpharmacologic and pharmacologic therapies. Pharmacotherapy involves dopamine agonists as first line drugs for daily restless legs syndrome; gabapentin (Horizant™) and opioids for treatment of resistant cases.

An algorithm created by Mayo Clinic researchers and endorsed by the RLS Foundation, provides guidance to the treating physician and patient, including non pharmacological and pharmacological treatments. Treatment of primary RLS should not be considered until possible precipitating medical conditions are ruled out, especially venous disorders. RLS Drug therapy is not curative and has side effects such as nausea, dizziness, hallucinations, orthostatic hypotension and daytime sleep attacks. In addition, it can be expensive (about $100–150 per month for life), and needs to be considered with caution.

Secondary RLS may be cured if precipitating medical conditions (anemia, venous disorder) are managed effectively. Secondary conditions causing RLS include iron deficiency, varicose veins, and thyroid problems. Karl-Axel Ekbom in his 1945 doctoral thesis on RLS suspected venous disease in about 12.5% of cases. But due to the unavailability of Doppler ultrasound imaging technology (the diagnostic tool detecting abnormal blood flow in the veins, “Venous Reflux”, the pathological basis for varicose veins) at that time, Ekbom may have underestimated the role of venous disease. In uncontrolled prospective series, improvement of RLS was achieved in a high percentage of patients presenting with a combination of RLS and venous disease and had sclerotherapy or other treatment for the correction of venous insufficiency.   In Nonpharmacologic treatments there are ways patients may be able to reduce the symptoms or decrease the severity of the symptoms. One thing that may worsen the symptoms is fatigue. Therefore using relaxation techniques, soaking in a warm bath or massaging the legs can all help aid in relaxation and relief of symptoms. Another technique is avoiding caffeine, alcohol, and tobacco. Also exercising every day and maintaining a schedule of relaxation and avoiding heavy meals before bed will all help with relief of symptoms. These techniques can be used with medication or just by themselves for those who do not want medication. For symptoms that occur in the evening patients may find that activities that alert the mind like crossword puzzles, and video games may reduce symptoms. Many patients may also benefit from RLS support groups.

Stretching and shaking legs
Stretching the leg muscles can bring relief lasting from seconds to days.   Walking around brings relief also. Tiredness can be a factor and some sufferers may find going to bed usually stops the discomfort. Bouncing or shaking the legs/feet in an up and down motion, with the ball of the foot on the floor when sitting down may bring temporary relief.

Iron supplements
According to some guidelines, all people with RLS should have their serum ferritin level tested. The ferritin level, a measure of the body’s iron stores, should be at least 50 µg for those with RLS. Oral iron supplements, taken under a doctor’s care, can increase ferritin levels. For some people, increasing ferritin will eliminate or reduce RLS symptoms. A ferritin level of 50 µg is not sufficient for some sufferers and increasing the level to 80 µg may further reduce symptoms. However, at least 40% of people will not notice any improvement. Treatment with IV iron is being tested at the US Mayo Clinic and Johns Hopkins Hospital. It is dangerous to take iron supplements without first having ferritin levels tested, as many people with RLS do not have low ferritin and taking iron when it is not called for can cause iron overload disorder, potentially a very dangerous condition

Medication therapy:
Several prescription medications, most of which were developed to treat other diseases, are available to reduce the restlessness in your legs. These include:

*Medications for Parkinson’s disease. These medications reduce the amount of motion in your legs by affecting the level of the chemical messenger dopamine in your brain. Two drugs, ropinirole (Requip) and pramipexole (Mirapex), are approved by the Food and Drug Administration for the treatment of moderate to severe RLS.

Doctors commonly also use other Parkinson’s drugs to treat restless legs syndrome, such as a combination of carbidopa and levodopa (Sinemet). People with RLS are at no greater risk of developing Parkinson’s disease than are those without RLS. Side effects of Parkinson’s medications are usually mild and include nausea, lightheadedness and fatigue.

*Opioids. Narcotic medications can relieve mild to severe symptoms, but they may be addicting if used in too high doses. Some examples include codeine, oxycodone (Roxicodone), the combination medicine oxycodone and acetaminophen (Percocet, Roxicet), and the combination medicine hydrocodone and acetaminophen (Lortab, Vicodin).

*Muscle relaxants and sleep medications. This class of medications, known as benzodiazepines, helps you sleep better at night. But these medications don’t eliminate the leg sensations, and they may cause daytime drowsiness. Commonly used sedatives for RLS include clonazepam (Klonopin), triazolam (Halcion), eszopiclone (Lunesta), ramelteon (Rozerem), temazepam (Restoril), zaleplon (Sonata) and zolpidem (Ambien).

*Medications for epilepsy. Certain epilepsy medications, such as gabapentin (Neurontin), may work for some people with RLS.It may take several trials for you and your doctor to find the right medication and dosage for you. A combination of medications may work best.

Caution about medications:
One thing to remember with drugs to treat RLS is that sometimes a medication that has worked for you for a while becomes ineffective. Or you notice your symptoms returning earlier in the day. For example, if you have been taking your medication at 8 p.m., your symptoms of RLS may start at 6 p.m. This is called augmentation. Your doctor may substitute another medication to combat the problem.

Most of the drugs prescribed to treat RLS aren’t recommended for pregnant women. Instead, your doctor may recommend self-care techniques to relieve symptoms. However, if the sensations are particularly bothersome during your last trimester, your doctor may approve the use of pain relievers.

Some medications may worsen symptoms of RLS. These include most antidepressants and some anti-nausea drugs. Your doctor may recommend that you avoid these medications if possible. However, should you need to take these medications, restless legs can still be controlled by adding drugs that manage the condition.

 

Lifestyle and home remedies

Making simple lifestyle changes can play an important role in alleviating symptoms of RLS. These steps may help reduce the extra activity in your legs:

*Take pain relievers. For very mild symptoms, taking an over-the-counter pain reliever such as ibuprofen (Advil, Motrin, others) when symptoms begin may relieve the twitching and the sensations.

*Try baths and massages. Soaking in a warm bath and massaging your legs can relax your muscles.

*Apply warm or cool packs. You may find that the use of heat or cold, or alternating use of the two, lessens the sensations in your limbs.

*Try relaxation techniques, such as meditation or yoga. Stress can aggravate RLS. Learn to relax, especially before going to bed at night.Establish good sleep hygiene. Fatigue tends to worsen symptoms of RLS, so it’s important that you practice good sleep hygiene. Ideally, sleep hygiene involves having a cool, quiet and comfortable sleeping environment, going to bed at the same time, rising at the same time, and getting enough sleep to feel well rested. Some people with RLS find that going to bed later and rising later in the day helps in getting enough sleep.

*Exercise. Getting moderate, regular exercise may relieve symptoms of RLS, but overdoing it at the gym or working out too late in the day may intensify symptoms.

*Avoid caffeine. Sometimes cutting back on caffeine may help restless legs. It’s worth trying to avoid caffeine-containing products, including chocolate and caffeinated beverages such as coffee, tea and soft drinks, for a few weeks to see if this helps.

*Cut back on alcohol and tobacco. These substances also may aggravate or trigger symptoms of RLS. Test to see whether avoiding them helps.

*Stay mentally alert in the evening. Boredom and drowsiness before bedtime may worsen RLS. Mentally stimulating activities such as video games or crossword puzzles can help you stay alert and may reduce symptoms of RLS.

Alternative Medication:
Because restless legs syndrome is sometimes due to an underlying nutritional deficiency, taking supplements to correct the deficiency may improve your symptoms. Your doctor can order blood tests to pinpoint nutritional deficiencies and give you a good sense of which supplements may help.

Doctor may also tell you whether certain dietary supplements can interfere with the way your prescription medications work or may pose health risks for you.

If blood tests show that you are deficient in any of the following nutrients, your doctor may recommend taking dietary supplements as part of your treatment plan:

*Iron
*Folic acid
*Vitamin B
*Magnesium

More research is needed to reliably establish the safety and effectiveness of all of these supplements in the treatment of RLS.

 

Prognosis:
RLS is generally a lifelong condition for which there is no cure. Symptoms may gradually worsen with age, though more slowly for those with the idiopathic form of RLS than for patients who also suffer from an associated medical condition. Nevertheless, current therapies can control the disorder, minimizing symptoms and increasing periods of restful sleep. In addition, some patients have remissions, periods in which symptoms decrease or disappear for days, weeks, or months, although symptoms usually eventually reappear. Being diagnosed with RLS does not indicate or foreshadow another neurological disease.

Prevention:
Other than preventing the  causes, no method of preventing RLS has yet been established or studied.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
http://www.mayoclinic.com/health/restless-legs-syndrome/DS00191
http://en.wikipedia.org/wiki/Restless_legs_syndrome
http://www.sleepdisordersguide.com/restless-leg-syndrome-causes.html

Restless Legs Syndrome

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