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What is Restless Legs Syndrome?
The
Restless Legs Syndrome (RLS, or Ekbom syndrome) refers to symptoms of painless, spontaneous, continuous leg movements associated with unpleasant paresthesias. These sensations
described as tingling, pins and needles,
crawling, itchy, or just pain
occur at rest and are relieved by movement. Sleep disturbance is common. Mild symptoms of restless legs occur in up to 5 to 10 percent of the population.
More than one-third of patients experience their first symptoms before the age of 10; misdiagnosis such as "growing pains" and attention deficit disorder are common. Medical attention is often not sought until after age 40 when the symptoms begin to progress.
What
causes RLS?
RLS is idiopathic in most cases, but it may be a feature of a variety of disorders:
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Abnormal iron metabolism
- serum ferritin levels should be measured in patients with RLS, and a trial of oral iron therapy considered in those with low levels.
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Uremia – RLS is a common manifestation of the neuropathy seen in
kidney failure. It is often seen in the dialysis population, occurring in 33 percent of patients in one study.
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Diabetes mellitus
– RLS can be a prominent feature of diabetic neuropathy. It and other sensory symptoms of neuropathy often improve following successful pancreatic-kidney transplantation.
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Rheumatic disease – In patients with rheumatoid arthritis, RLS was found in 25 percent (compared to 4 percent of controls with osteoarthritis or seronegative arthropathy) and was associated with greater disease activity and severity. It may be even more prevalent in patients with Sjögren's syndrome.
-
Venous insufficiency – Varicose veins may cause RLS due to pressure on a nerve from a varicosity. Treatment of varicose veins and chronic venous insufficiency may be helpful in some patients.
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Genetic
predisposition
– There may also be a genetic predisposition to RLS
-
Other miscellaneous conditions – Other potential
causes of RLS include pregnancy, spinal stenosis, excess caffeine intake, hypoglycemia, and hypothyroidism. The symptoms may be of hysterical origin if accompanied by expressions of exquisite
pain.
Is
there any treatment for RLS?
Spontaneous remissions lasting one month or more occur in about 15 percent of patients with idiopathic RLS. For those with persistent symptoms, stretching exercises for the posterior leg muscles should be performed before retiring.
Discomfort may be temporarily
relieved by massaging, stretching, walking, or doing knee bends.
Some find taking a hot bath or applying a heating pad or cold compress is
helpful.
A variety of pharmacologic regimens have been tried with some success in idiopathic RLS; this approach generally involves the use of benzodiazepines, dopaminergic drugs, and opioids.
- Benzodiazepines are useful in mild cases, particularly in younger patients. As an example, clonazepam (0.5 to 4.0 mg one hour before bedtime) may be be effective with a low risk of adverse effects or abuse. We have found high doses of diazepam (20 to 50 mg) helpful when used for brief intervals in severely distressed patients.
- Levodopa in a titrated dose of 50 to 150 mg at bedtime is recommended for elderly patients; it has a long-term response rate of approximately 70 percent
- Some patients develop tolerance to standard doses of levodopa. Another dopamine receptor agonist, pramipexole (Mirapex), has been found to be helpful. Most patients reported clinically significant improvement with a mean dose of 0.3 mg of pramipexole. By two to three months after the start of therapy, nocturnal leg restlessness, involuntary leg movements, and insomnia had decreased in 12, 10, and 11 patients, respectively. The drug was well tolerated; fatigue and stiffness were the most common complaints.
- Other similar medication such as pergolide or requip have also been found to be effective in the treatment of RLS.
- Other drugs that may be useful include carbamazepine (100 mg or more at bedtime with gradually increasing doses), clonidine (0.05 mg/day), and propranolol (40 to 120 mg/day).
The use of opioids should be restricted to patients with severe symptoms who fail to respond to benzodiazepines and/or levodopa. Oxycodone (15 mg) and propoxyphene both have been used.
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