Restless Legs Syndrome Disease

DESCRIPTION

Restless leg syndrome (RLS) and periodic limb movement disorder (PLMS) are separate and distinct but related entities classified as intrinsic disorders of sleep.
Restless leg syndrome is characterized by vague dysesthesia to pain in the legs, causing an irresistible urge to move the legs while awake. Symptoms are most intense at rest, especially after 4pm.
Periodic limb movements are brief rhythmic and repetitive brief dystonic limb movements of 0.5-5 seconds duration occurring in clusters during the sleep period. They are most likely to occur in the first half of the night and with a predominant frequency of 5-90 seconds. Dorsiflexion at the ankle, or flexion at the knee or hip may be seen in severe cases. Can occur in the upper extremities. PLMS occur in more than 80% of cases of RLS, but can occur independently from RLS.
If symptoms onset is before age 45, they may have many more affected relatives; the disease usually progresses slowly. If symptoms onset is after age 45 it occurs less commonly in families; the disease usually progresses rapidly and may be associated with a low serum ferritin level."
System(s) affected: Nervous, Musculoskeletal
Genetics: N/A
Incidence/Prevalence in USA:
- 20-30% of patients seen in sleep centers will have PLMS
- Population prevalence is poorly documented
Predominant age:
- Mostly seen past age 30, and increases with age
- Rarely occur in childhood and adolescence
Predominant sex: N/A

SIGNS AND SYMPTOMS

PLMS patients are unaware of their movements during sleep. Their most frequent symptoms are daytime tiredness and fatigue.
RLS patients have an inability to sit still or remain immobile due to dysesthesia or pain. These symptoms are usually worse in the evening or night.

CAUSES

Unknown; hereditary factors are involved in some patients

RISK FACTORS

Chemical agents
- Caffeine and antidepressants will cause or aggravate PLMS and RLS (trazodone and nefazodone are exceptions)
- Dopamine antagonists (antipsychotics), metoclopramide, calcium channel blockers, theophylline, and adrenergics are among those agents reported to aggravate symptoms
- Withdrawal from sedatives/narcotics can augment symptoms
Diseases
- Primary neurological disorders should be considered. Among most common are peripheral neuropathies, radiculopathies, neurodegenerative disease, or another movement disorder such as Parkinson's disease
- Metabolic disorders
  - Diabetics have a much higher incidence of PLMS/RLS
  - Electrolyte deficiencies which may involve K, Ca, or Mg (low normal values may indicate a low tissue level)
  - Anemia (low tissue iron or low serum ferritin)
  - Uremic/renal failure patients will have a high percentage of PLMS/RLS symptoms

LABORATORY

Fasting glucose
Electrolytes: Na, K, Ca, Mg
Ferritin
B12, folate levels
BUN, creatinine

Drugs that may alter lab results: N/A Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

Nocturnal polysomnography (NPSG)

IMAGING

N/A

DIAGNOSTIC PROCEDURES

RLS is diagnosed by history alone, though excessive leg movements will be seen with nocturnal polysomnography
PLMS: affected individuals are often unaware and diagnosis by NPSG is appropriate

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Eliminate aggravating factors
- Diet and drugs
  - Removal of caffeine-containing foods, beverages, and OTC drugs can often result in improvement
  - Avoidance of most antidepressants (serzone and trazodone excepted)
  - Avoidance of dopamine blocker antipsychotics, metoclopramide (Reglan), and calcium channel blockers
Treatment of primary neurological and medical disorders
- Supplement essential minerals: K, Ca, Mg, if indicated - being careful not to overtreat (especially in presence of K-sparing diuretics)
- Ferrous sulfate in individuals with a ferritin level of 50 mcg/ml or less
Good sleep hygiene
- Regular sleep habit with adequate 7 ½ - 8 hrs sleep time
- Mild to moderate regular exercise is particularly helpful to RLS/PLMS patients

SURGICAL MEASURES

N/A

ACTIVITY

Regular mild to moderate exercise

DIET

N/A

PATIENT EDUCATION

The Restless Legs Syndrome Foundation Inc. publishes the "Nightwalkers Newsletter" and provides useful information and identifies support groups. Address: 4410 19th St. NW, Suite 201, Rochester MN 55901-662; http://www.rls.org
Sleep Thief by Virginia Wilson is recommended reading. Contact Galaxy Books Inc., P.O. Box 1421, Orange Park FL 32067

PREVENTION/AVOIDANCE

N/A

POSSIBLE COMPLICATIONS

Tolerance may develop to medications after months to years and necessitate change to another agent
Augmentation of RLS into daytime symptoms may develop, particularly with use of carbidopa/levodopa, in which case it should be reduced while adding another agent in increments
Side effects may occur with any medication and are usually dose related
Electrolyte and iron supplementation in excess can have serious consequences

EXPECTED COURSE AND PROGNOSIS

Periods of spontaneous remission may occur
RLS and PLMS tend to worsen with age

ASSOCIATED CONDITIONS

Sleep deprivation

AGE-RELATED FACTORS

Pediatric: RLS may be misdiagnosed as growing pains or ADHD in younger patients
Geriatric: Increased incidence in geriatric patients
Others: RLS/PLMS may occur at any age but usually after age 30.

PREGNANCY

PLMS often occur during pregnancy and resolve afterward.

OTHER NOTES

Extremely rare, RLS symptoms in the torso have been reported

ABBREVIATIONS

RLS = restless leg syndrome
PLMS = periodic limb movement disorder
NPSG = nocturnal polysomnography

Clinical Investigations

ROLE OF HOMOEOPATHY

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