The syndrome restless legs (RLS), acromelalgia or Willis-Ekbom disease, is a disorder of sensorimotor neurological, characterized by an uncontrollable urge to move the legs because of the presence of disturbing and unpleasant sensations (Baos Vicente et al., 2008).
People often describe these annoying sensations as burning, irritating, stabbing or painful (National Institute of Neurological Disorders and Stroke, 2015). These symptoms occur mainly when the individual is relaxed (AESPI, 2015). Thus, they usually worsen in a state of rest or during the night, and improve with movement (Fraguas Herráez el al., 2006).
This type of syndrome is usually associated with sleep disorders, especially insomnia of conciliation (Fraguas Herráez el al., 2006), since most people have difficulty in reconciling and maintaining sleep (Martínez García, 2008). It can also be associated with depressive or anxious disorders (Fraguas Herráez el al., 2006).
Restless Legs Syndrome Symptoms
The symptoms of Restless Legs Syndrome will greatly affect the quality of life of people who suffer from it, as they influence both professional and family life and even their mood (AESPI, 2015).
Many individuals who suffer from RLS offer subjective complaints about the affectation of their work, their personal relationships and daily activities as a result of fatigue. They also tend to show concentration difficulties, memory deficits or inefficiency in the relationship of daily tasks (National Institute of Neurological Disorders and Stroke, 2015).
Statistics of restless legs syndrome
The different prevalence studies of RLS show that it is a very frequent pathology. In Europe and the USA, it is estimated that the prevalence of this disorder ranges from 5% to 15% of the population (Martínez García, 2008).
On the other hand, it is more frequent in women than in men, with a ratio of 2: 1 and also its frequency increases with age (Martínez García, 2008).
The syndrome can appear at any age from the earliest stages of life, the majority of patients who suffer from it present a middle or advanced age (National Institute of Neurological Disorders and Stroke, 2015).
Several studies have shown that between 5 and 10% of the population between 18 and 65 years old suffer from RLS, while this percentage increases from 15% to 20% in older people (AESPI, 2015 Elderly patients they suffer symptoms more frequently and for longer periods of time (National Institute of Neurological Disorders and Stroke, 2015).
Although the SPI is related to the affectation of the quality of life, it is a disorder little diagnosed in the clinical practice (Fraguas Herráez el al., 2006). Normally, people suffering from this type of symptoms do not seek medical attention because they think that they are not too important or that this type of pathology can not be treated.
In addition, many clinical professionals attribute the symptoms to insomnia, nervousness, stress, aging, among others (National Institute of Neurological Disorders and Stroke, 2015).
Definition and symptoms of restless legs syndrome
The syndrome of restless legs (SPI) or retless legs syndrome (RLS) in English, is a pathology that has been known since the 17th century. However, it was not until 1945 when the neurologist Karl-Axel Ekbom coined the term.
Frequently the terms syndrome or disease of Ekbom or Willis-Ekbom are also used to refer to this pathology (Martínez García, 2008).
SPI is a neurological disorder of the movement that is characterized by the need or the irresistible desire to move the legs due to the presence of unpleasant and annoying sensations in the lower extremities, generally very annoying, and that some patients describe as painful ( AESPI, 2015).
Individuals usually present a burning, painful, stinging sensation or as if something were sliding down their legs. Patients often describe the symptoms as very annoying sensations of tingling, burning, itching, pain, bubbling, water running or worms on the legs (Martínez García, 2008).
The sensations that individuals perceive are usually called paresthesias (abnormal sensations) or dysesthesias (abnormal sensations of an unpleasant type ) and vary both in the severity of presentation and in the degree of irritability and / or pain (National Institute of Neurological Disorders and Stroke , 2015).
Most of the time these annoying sensations tend to diminish or disappear with the voluntary movement of the area, at least while the movement is being executed. The relief may be partial or complete and is more likely to occur at the beginning of the movement (AESPI, 2015).
Annoying sensations and pain usually get worse when the patient is resting and in a resting situation (Baos Vicente et al., 2008). Symptoms have a burden when lying down or trying to relax, Appear only at rest and have no relationship with previous activities (Martínez García, 2008).
The sensations usually predominate in an evening or nocturnal stage, reason why the periodic movements of the extremities will cause so much difficulty to conciliate the sleep as frequent “micro-awakenings” that are going to damage the capacity of maintenance of the dream (Baos Vicente et al., 2008).
The periodic movements of the legs that will cause the “micro-awakenings” are called nocturnal mycelia. The individuals will perform movements of flexion of the legs at the height of the knee and ankle, with an extension of the thumbs. The movements are presented in an organized and repetitive way in intervals of 20 to 40 seconds and usually last between 0, 5 and 5 seconds (Martínez García, 2008).
In summary, the main characteristics of the SPI are:
- Need or the irresistible desire to move the legs due to the presence of unpleasant and annoying sensations.
- Most of the time these annoying sensations tend to diminish or disappear with the voluntary movement of the area.
- Annoying sensations and pain usually get worse when the patient is resting and in a resting situation
- The sensations usually predominate in an evening or night stage.
Causes of restless legs syndrome
Current research on the determination of the causes of RLS is limited, so there is little conclusive experimental evidence. It is said that the SPI is idiopathic , that is, it does not present a known cause (AESPI, 2015). Thus, most cases are considered idiopathic, especially those of early onset (Fraguas Herráez et al., 2006).
However, in approximately 50% of cases, there is a family history related to the disorder (National Institute of Neurological Disorders and Stroke, 2015). Thus, the SPI can present a genetic or hereditary component, in this case the SPI is primary or family (AESPI, 2015).
Generally, people who have an RLS of hereditary type tend to be younger at the time of onset of symptoms and have a more slow progression of the disease (National Institute of Neurological Disorders and Stroke, 2015).
On the other hand, SPI can also be related to other types of diseases, which lead to its presentation or worsening, it is known as secondary SPI (AESPI, 2015).
Despite this, the National Institute of Neurological Disorders and Stroke (2015), relates the following factors or conditions with the SPI:
- Low levels of iron or anemia.
- Chronic diseases such as kidney failure, diabetes, Parkinson’s disease or peripheral neuropathy.
- Pregnancy. Particularly during the last months, up to 20% of women may have symptoms of RLS, which have to disappear after childbirth (AESPI, 2015).
- Some medications for the prevention of nausea, seizures, antipsychotics or drugs for the cold or allergy can aggravate the symptoms.
- Consumption of caffeine, alcohol or tobacco can aggravate or cause symptoms in patients with predisposition to RLS.
Among these, the most important and most frequent cause is iron deficiency Fraguas Herráez el al., 2006). Iron is an essential component of dopamine receptors (D2), which are widely located in the ganglia of the base. Its lack can interfere in the function of these receptors and cause this type of movement disorder (Martínez García, 2008).
The alteration of cerebral iron metabolism will lead to a dopaminergic dysfunction in a group of neurons that projects from the midbrain to the spinal cord, the limbic system and the cerebral cortex (Fraguas Herráez et al., 2006).
Iron concentrations below 45μg / l can increase the symptoms of RLS. In addition, the administration of dopaminergic drugs generally improves symptoms. All this suggests that both iron and dopamine are involved in the appearance of this clinical picture and that it is related to a dopaminergic hypo-function (Martínez García, 2008).
Consequences of restless legs syndrome
The main consequence of the condition of RLS is the alteration of normal and regular sleep patterns.
The insomnia is the main consequence of SIP. Approximately 80% experience periodic movements of the lower extremities during sleep (AESPI, 2015).
A significant number of patients report disturbances or disturbances of sleep such as insomnia of conciliation and / or maintenance and daytime sleepiness. Often, there is an increase in sleep latency and a notable decrease in effectiveness due to the presence of successive micro-awakenings (Martínez García, 2008).
In addition, the presence of an unsatisfactory or repairing dream will negatively affect the functionality of the patient and daily activities. Daytime sleepiness will cause deficiency in the execution of work or daily tasks.
On the other hand, lack of sleep can have a significant impact on the cognitive component of the person. Alterations of memory, attention, difficulty of concentration, executive functions, etc. may occur .
This as a whole will have important consequences in the personal life of the person who suffers it. In a study conducted by Baos Vicente and colleagues (2008), it shows that approximately 25% of patients with RLS report that their symptoms have a negative and detrimental effect on the person with whom they share the bed, affecting the need for special arrangements to sleep in 73% of cases or affecting the couple’s relationship by 20% (Baos Vicente et al., 2008).
In general, the continued or chronic sleep deprivation and its consequences in the ability to concentrate during the day can affect their ability to work, their ability to participate in social and leisure activities. It can also cause mood swings that can affect their personal relationships (AESPI, 2015).
Currently we can not find a specific diagnostic test for RLS. This pathology is clinically diagnosed, integrating both the patient’s history and the symptoms it refers to and presents (National Institute of Neurological Disorders and Stroke, 2015).
In general, the diagnostic criteria described by the International Study Group on Restless Legs Syndrome (IRLSSG) are usually used :
- Desire to move the legs accompanied by generally unpleasant or annoying sensations.
- Need to move the legs, which starts or worsens during periods of inactivity or rest (lying or sitting).
- Partial or total improvement of the symptomatology with the activity.
- Worsening of unpleasant sensations in the legs in the afternoon and at night.
- Unpleasant sensations in the legs are not attributable to any other disease (venous insufficiency, edema, myalgia, arthritis, leg cramps , poor posture, peripheral neuropathy, anxiety, myalgia and / or myopathy, local lesion in the legs, akathisia due to drugs , myelopathy, vascular or neurological claudication, orthostatic tremor or pain in the legs).
In addition to these criteria, some labotary tests may also be used to rule out other diseases and support the diagnosis of RLS as
described by the National Institute of Neurological Disorders and Stroke (2015), as follows:
Blood tests should be done to exclude anemia, reduced iron storage, diabetes, and kidney dysfunction.
Electromyography and nerve conduction studies can also be recommended to measure electrical activity in the muscles and nerves, and Doppler ultrasonography can be used to evaluate leg muscle activity.
These tests can document any collateral damage or disease in nerves and nerve roots (such as peripheral neuropathy and radiculopathy) or other movement disorders related to the legs. The negative results of these tests may indicate that the diagnosis is RLS.
In some cases, sleep studies are performed as a polysomnography (a test that records brain waves, heart rhythm and patient’s breathing throughout the night) to identify the presence of PLMD.
The treatment of RLS is symptomatic generally, not etiologic. For mild conditions , with moderate symptoms that in most cases have to disappear with movement, many specialists recommend changes in lifestyle and activities (National Institute of Neurological Disorders and Stroke, 2015).
Thus, the Spanish Association of Restless Legs Syndrome (2015), recommends the following changes in lifestyle:
- Eliminate substances that favor the appearance of symptoms (caffeine, alcohol, tobacco), take necessary vitamin and mineral supplements (iron, folate or magnesium) and engage in self-directed activity (walking, stretching, taking baths with changes in temperature, etc.)
- Sleep hygiene programs (going to bed and getting up regularly at the same time during times with symptoms or having a quiet and comfortable sleep).
On the other hand, doctors can also prescribe a variety of medications for the treatment of the SPI National Institute of Neurological Disorders and Stroke, 2015).
– Dopamine agonists dopamine receptor agonists, such as pramipexole and ropyrinol. They are usually prescribed in low doses and increasing very slowly in order to reduce possible side effects, such as nausea, and hypotension (AESPI, 2015).
– Sedatives: are usually used to alleviate the symptoms that appear aggravated during the night. It is not usually used continuously as they can produce sedition diurnal and cognitive problems (AESPI, 2015).
– Analgesics : people with symptoms of serious restlessness are used. Its use is controversial because they present the possibility of addiction (AESPI, 2015).
– Anticonvulsants : they are particularly effective for the treatment of painful symptoms that do not respond to dopaminergic drugs (AESPI, 2015).
On the other hand, due to the consequences that lack of sleep and chronic pain can have on the cognitive functioning of many individuals suffering from RLS, it is likely that, in many cases, some type of neuropsychological intervention is required.
The intervention on memory, attention and executive functions through the development and enhancement of skills and compensation of deficits can have a significant positive impact on the quality of life of patients.
How to know if you have restless legs syndrome
First, look at these four basic criteria for diagnosis:
You feel an unstoppable desire to move your legs that appears when you have strange sensations such as drag, tingling or pulling.
Symptoms appear or get worse when you are at rest: lying down or sitting up.
Symptoms get worse at night.
You move your legs all the time so that the sensations go away.
If you feel identified with this description, then you should consult the doctor. There is no test that can make the diagnosis, the doctor must be guided by the symptoms you tell him.
It will ask you how frequent they are, their duration and intensity and if they prevent you from sleeping properly at night.
It is likely that the doctor will indicate some studies to rule out other possible causes.
It is important that you make the medical consultation. Do not think that your symptoms are too mild or that they have no solution.
Some doctors mistakenly think that the symptoms are due to nervousness, stress, insomnia or muscle cramps, but do not give up.
If you have restless legs syndrome, your symptoms may find relief.
5 keys to control the syndrome and rest better
Change your lifestyle to promote sleep
First of all, what you should do is encourage a good night’s sleep.
If you decrease the consumption of caffeine, alcohol and tobacco, it is possible that the symptoms are relieved and you can rest better.
On the other hand, if you lie down and you always get up at the same time, this can also help you sleep better at night.
Relieves sensations with cold or hot packs
Some people with restless legs syndrome have been able to alleviate the strange sensations in their legs by applying cold or warm compresses before going to sleep.
You can do it by applying a bag of hot water or an ice pack on your legs, a while before going to bed.
Taking a hot shower and massaging your legs can also help.
Perform moderate exercise to improve circulation
It is possible that doing light or moderate exercises, especially those that strengthen the lower legs, can help reduce the annoying sensations.
But be careful, excessive exercise can be counterproductive and worsen the symptoms instead of relieving them.
Compression and therapy devices with infrared light can also be useful
If with these simple measures your symptoms are not alleviated, do not worry. There are still many other treatments you can follow to control the syndrome.
For example, elastic compression stockings may be useful to eliminate tingling or drag.
They are made of strong elastic material, which will gently compress your legs and stimulate blood circulation, while avoiding strange sensations.
Another good option may be pneumatic compression devices. They are covers for the legs that are inflated by a small pump to compress the legs.
This is a treatment that can be very effective to eliminate sensations and so you can leave your legs still. So you can rest well at night. There are also data that indicate that infrared light therapy can help.
An infrared light device applied to the legs helps improve circulation and may also be effective in avoiding the symptoms of restless legs, although more research is still needed to show how effective it is. Anyway, nothing you lose with trying.
Medications to control the symptoms
If you have not been able to avoid the sensations with the previous treatments, do not despair, the doctor can prescribe some medications to relieve the annoying sensations in your legs and help you sleep better.
However, not all medications are equally effective in all patients and you may have to try different medications before finding the most effective treatment for you.
Dopamine agonist medications
They are commonly used for Parkinson’s disease, but they can also be useful for relieving restless legs.
It has been shown that both pramipexole, ropinirole and rotigotine patches for the skin can be effective, as they relieve symptoms, improve the quality of life of the patient and improve sleep.
In general, these are the drugs that are recommended as initial treatment of preference, in patients who have not been able to relieve their legs by changing their lifestyle or applying other therapies without medication.
You do not have to suffer seizures for the doctor to prescribe this type of medication.
It has been seen that pregabalin, gabapentin and gabapentin enacarbilo are also able to improve symptoms and the patient’s night rest, which of course improves their quality of life.
They are medicines that will help you sleep better. It is not exactly relieving the symptoms of restless legs, but they will relax your muscles and you can rest properly.
Clonazepam, diazepam, oxazepam and temazepam are some examples of this class of medications. If you take them at night, you may feel a little lethargic the next day.
If you have sleep apnea, then this type of medication does not suit you, because the symptoms can be aggravated.
If the symptoms of restless legs are intense and are not easily relieved, the doctor may prescribe powerful painkillers so you can rest at night, such as opioids.
Oxycodone, codeine and morphine are some examples. The trouble is that they can cause adverse symptoms, such as dizziness, nausea and dependency or addiction.
It is indicated only for those who have low levels of iron in their body. As you may have read at the beginning, having little iron can trigger the symptoms of restless legs.
Therefore, a treatment with intravenous iron or iron pills can be effective in these cases.
The Restless Legs Syndrome can affect the quality of life, since sometimes problems of conciliation and maintenance of sleep, also produces painful and unpleasant symptoms when the person tries to relax (AESPI, 2015).
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Therefore, sleep deprivation can negatively affect the functional capacities of the individual producing deficits in their ability to concentrate, work problems, social deficits, etc. (AESPI, 2015)