Restless Leg Syndrome: Conditions, Causes, Cautions and Control
A Twitch in Time
There you are, ready to go to sleep. You turn the lights down, slide under your sheets and close your eyes, hoping for some peace and rest. Just as your body begins to relax and you're about to slip into the arms of slumber, you notice some unpleasant sensations in your legs.
This could be an itch, a nagging ache, tingling, a sensation of something crawling, numbness or a feeling of water running down your legs. You close your eyes tight and wish it would go away. It doesn't. There is a overwhelming urge to move your legs. You try to shake it off by moving your legs about. You sigh, get out of bed, stretch and pace around. Soon the feeling has gone. You get back into bed, hoping to finally get some sleep.
But just as you begin to relax, it starts all over again.
This is not just one night. It happens with increasing frequency every week, much to your ( and your loved one's) despair.
If this sounds familiar, you have come to the right place. You may have a condition called Restless Leg Syndrome.
Restless Leg Syndrome is a name used freely to indicate all manner of things. There are a lot of innocent reasons for your legs feeling restless, equally there are all manner of other diseases that can make your legs uncomfortable and cause similar symptoms. Not every restless leg has RLS - but this doesn't mean we can't have a treatment plan for them all.
Chaos and Confusion
The internet is rife with information on RLS ( as it is affectionately known) People have spent small fortunes on dubious therapies trying to get rid of it. So, what, you ask me, is different about this article?
For one, I am not trying to sell you anything. I am also a medic with years of experience in diagnosing and treating this condition. I have seen many frustrated and fed up patients who have done the rounds and tried a hundred different treatments. I find that the biggest problem is not with treatment but in making an accurate diagnosis and isolating the underlying cause. Some Doctors and therapists are very good at throwing everything they've got at the symptoms and hope something would stick. I feel this can be a frustrating journey for the patient who may slowly lose faith in the system.
I tell my patients is that Restless Leg Syndrome is a name used freely to indicate a spectrum of problems. There are a lot of innocent reasons for your legs to feel restless. There are also other diseases that can make your legs uncomfortable and cause similar symptoms - but not all of them are RLS.
Not every restless leg has RLS - but this doesn't mean we can't treat them all.
The RLS that is also known as Willis-Ekbom disease (WED) is a distinct entity. It helps to separate the facts from fiction so you can identify RLS accurately, treat it and feel better.
So here we not only discuss the distinct neurological condition called RLS, we will also discuss all the other culprits that can cause similar symptoms. a thorough and accurate history and evaluation will go a long way to help you.
G25. Other extrapyramidal and movement disorders
G 25.8 Other specified extrapyramidal and movement disorders
Restless legs syndrome
What is RLS?
Back in 1945 Swedish Neurologist Karl Axel-Ekbom described Restless Leg Syndrome as a neurological movement disorder.
Understandably during Dr Ekbom's time although medicine was going through rapid paces of change, a lot of the technology that is available to us was not available then. This somewhat limited Dr Ekbom's ability to delineate some of the allied diseases that could cause the same or similar symptoms.
From a diagnostic point of view RLS can be primary or secondary.
Primary RLS ( also known as Idiopathic) is the one when all other underlying diseases have been eliminated, and what is left is a pure sleep/movement disorder. The exact cause for idiopathic RLS has not been fully described, however there is a lot of evidence pointing to a disorder of the nerve pathway and an imbalance in the chemicals that transmit nerve signals (neurotransmitters).
Secondary RLS is where the patients experience all the symptoms of RLS to varying degrees, but have underlying treatable conditions that can mimic or contribute to the symptoms. In many cases it is not a single contributing factor. As it is often the case in medicine, a combination of reasons can cause the problem.
We have to remember that individually these symptoms can happen to all us at some time, it is the collective nature of these symptoms and simultaneous presence that helps us to narrow down to RLS.
Symptoms and Signs
As with many diseases the symptoms and signs may vary with individuals in terms of frequency and severity.
However variable the symptoms can be, to make a diagnosis of RLS there needs to be some common features:
Discomfort of the Legs:
A nagging discomfort that could be tingling, numbness, ache, altered skin sensations such as creeping or crawling, pulling, perception of warmth or cold, itching or sense of pressure. In rare occasions symptoms have been known to affect the arms and even the head/neck area.
Symptoms triggered by rest:
Unlike other causes of discomfort where activity makes the symptoms worse, in RLS it is rest that triggers the symptoms. Rest as in sitting or lying down can bring on the above mentioned symptoms
Typically in RLS symptoms get worse at night. The problem mainly comes on when trying to sleep.
Movement helps to relieve:
Twitching, restless movements help to relieve this discomfort. Also pacing, walking can help. Symptoms tend to return when the movement stops. Massage helps too.
Urge to move:
Sometimes the urge to move the limb may occur even without the discomfort or unpleasant sensation.
More likely to affect both legs:
RLS is more likely to affect both legs at the same time.
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The primary RLS is a purely neurological disorder thought to be due to an imbalance in the brain pathway involving Dopamine ( a neurotransmitter). The latter is linked to control muscle activity in movement and at rest. Some research has shown this is linked to the Basal Ganglia of the brain- the same area affected in Parkinson's disease. Restless legs is one of the common features in advanced Parkinson's disease.
It is important to rule out all the secondary causes including lifestyle issues that can produce restless leg symptoms before narrowing it down as primary idiopathic. The main causes of RLS are listed below.
a neurological disorder possibly caused by neurotransmitter imbalance as well as altered pathways of sensory perception
Usually through Perpiheral neuropathy
Alcohol, Vitamin B12 deficiency etc.
Associated restless limbs and movements
usually in the last trimester- thankfully transient
Carrying a lot of weight especially in the middle
venous insufficiency causing stasis of blood
Thick swelling in the skin compressing the nerves
see separate table
Drugs that can worsen RLS
certain cold/allergy medicines such as Benadryl,NyQuil, Dimetapp
Prozac, Efexor, Cipralex etc)
those used for psychosis, schizophrenia, bipolar illnesses
Dramamine, Compazine, antivert etc.)
Calcium channel blockers
Nifedipine, Amlodipine, Felodipine etc.
Over the counter sleep aids
those that contain chlorpheniramine, chlorpromazine
Direct marketing, seeding internet sites with information linking to their drug, convincing gullible patients and medical professionals that the 'syndrome' is being under-diagnosed and capitalising on the patient frustration is rife with this condition.
There have been some unscrupulous attempts to push drug therapy as first line for RLS. This type of syndrome-mania is common among Drug companies attempting to sell their specific products.
For mild to moderate RLS symptoms simple lifestyle modifications and therapy options alone will suffice. The drugs that are used to treat severe uncontrolled RLS can carry their own hefty side effects. So one has to weigh the benefits and risks.
In the absence of a clear diagnosis and sensible advice, it is likely that sufferers may get frustrated and feel drug therapy is the only option. It is always worth revisiting the diagnosis and ensuring other conditions and options have been explored with support and understanding.
Perhaps some Physicians who may not have the skill and patience in counselling, communicating the disease spectrum and exploring options or simply find it hard to reach to the patient may resort to drug options early.
Similarly assertive patients who are impatient for a quick-fix may force the Doctors to prescribe. It is important to take a considered opinion and evaluate the severity first through proper investigations.
If other easily treatable causes such as iron deficiency, varicose veins or vitamin deficiency are found, they can be resolved quickly.
An ideal therapeutic evaluation should include some or all in step by step approach ( simple tests first and more complex tests only if needed):
- Cut back on Cola, Caffeine, Fizzy drinks
- Reduce Weight
- Exercise in moderation
- Reduce or stop Alcohol/ Smoking
- Relaxation techniques
Before resorting to meds
- Be honest and evaluate whether you have made the necessary lifestyle changes
- Weigh up benefits and risks
- Check if the drugs interfere with other medications you may take
- Plan the dosage and regular review with your Doctor
- Have a plan for objective evaluation before and after therapy
- Don't let frustration cloud your mind
Treat any underlying disease
If any of the secondary causes ( Diabetes, Neuropathy, Vitamin or iron deficiency) are identified they need to be treated promptly and effectively.
It is silly to expect RLS to resolve quickly without making any necessary lifestyle modifications as much as we can. While this can be long drawn out and frustrating, it should hopefully also be a motivation. Even if medication is prescribed, lifestyle changes can help reduce dosage and duration of treatment.
Dietary changes and Supplements
There are certain supplements such as trace minerals ( Zinc, Magnesium) , Vitamin B12, iron that have been known to help relieve the symptoms. Discuss with your Doctor first.
Currently three drugs have been licensed by FDA for treating advanced RLS when all of the above have failed. All three also also anti-parkinson's drugs and do carry a long list of side effects. It is important to weight the benefits vs risks.
- Pramipexole (Mirapex)
- Ropinirole (Requip)
- Rotigotine transdermal system (Neupro)
Small doses of benzodiazepines such as Diazepam, Temazepam, Clonazepam in a planned treatment schedule ( to avoid addiction) have been shown to help.
Certain opioid pain relief agents such as Codeine, Vicodin, Percoset, Tramadol may help in severe cases. These are also highly addictive so caution needs to be exercised o avoid dependancy.
Some anti-epileptics such as Gabapentin and Pregabalin are now licensed to treat nerve pain. These can be tried to see if they help in severe cases of RLS.
Restless Leg Syndrome can be frustrating, demoralising and always impacting the quality of life. This along with lack of considered advice can make us vulnerable to seeking treatments anyone and everyone may suggest.
It is important to be systematic and considered in our approach right from diagnostic assessment to treatment. I know this can be hard when you haven't been sleeping for days and when it is affecting your mood and relationships.
Let's not fall prey to snake oil salesmen. Hopefully this article can help somewhat in understanding the problem and dealing with it to get the best and safe outcome.
© Mohan Kumar 2013
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© Mohan Kumar 2013
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