Restless legs syndrome, is a common, chronic, multifactorial, movement disorder of the limbs in which patients have an irresistible urge to move the legs. (1)
It is also called as Willis-Ekbom Disease.
What are the Symptoms of Restless Legs Syndrome?
- Crawling, creeping, pulling, an itch you can’t scratch, a buzzing sensation, an unpleasant tickle that won’t stop, pins and needles sensation, drawing or stretching, all localized to deep structures rather than the skin.
- Symptoms aggravate during the day and is maximum at night. They appear 15 to 20 minutes after reclining in bed.
- Limb Twitching during sleep – Involuntary forceful dorsiflexion of the foot lasting for 0.5 sec to 5 sec., occurring every 40 to 50 seconds.
- Occasionally, arms may also be involved.
- Fatigue and sleepless nights is common.
Causes of Restless Legs Syndrome:
1.Primary Cause: It is idiopathic (unknown). It usually begins slowly, before approximately 40–45 years of age. It is often progressive and gets worse with age.
2.Secondary Cause: It has a sudden onset after age 40, and may be daily from the beginning. It is most associated with specific medical conditions like Iron deficiency, End-Stage Renal Disease, Diabetes Mellitus, Rheumatic disease, Venous insufficiency, Peripheral neuropathy, Folate or magnesium deficiency, Amyloidosis, Lumbosacral radiculopathy, Fibromyalgia, Celiac disease. It can also be due to the use of certain drugs like antidopaminergic medications or antidepressants.
Pathophysiology of Restless Legs Syndrome:
Idiopathic Restless Legs Syndrome –
In this type, there is a dysfunction of the dopaminergic system. Iron stores in specific regions like Substantia niagra and Thalamus in the brain diminish. There may be an autosomal dominant inheritance. This suggests a genetic basis for the disease. Polymorphisms in genes including BTBD9 and MEIS1 are associated with Restless Legs Syndrome.
Uremic Restless Legs Syndrome –
Calcium/phosphate imbalance, anemia, functional iron deficiency, and subclinical peripheral nerve abnormalities is involved in this type.
Restless Legs Syndrome in Pregnancy –
It is extremely common during pregnancy, especially during the third trimester. Vitamin D deficiency and calcium metabolism, pre-eclampsia, a strong family history, low serum iron and ferritin level, high estrogen levels play a role in Restless Legs Syndrome in pregnancy.
Diagnostic Criteria of Restless Legs Syndrome: (2)
(All criteria must meet for diagnosis)
- There is an uncontrollable urge to move the lower extremities and it may be accompanied by unpleasant and uncomfortable sensations.
- The urge to move the extremities is less during the day but gets progressively worse in the evenings and at night. The symptoms also appear at rest or during periods of sleep and inactivity.
- The urge to move the lower extremities may partially or completely be relieved by ambulation or stretching the legs. As long as the activity is continued, the symptoms are mild or absent.
- The urge to move the lower extremities are worse during the evenings and make it impossible to sleep. Thus, the patient is often fatigued during the day.
- The presence of these symptoms must not be attributed to other behaviour conditions, such as tardive dyskinesia, leg cramps, muscle spasms or discomfort from the position.
Facts on Restless Legs Syndrome…
- Between 5% to 15% of the population may have Restless Legs Syndrome.
- Women are affected more than men.
- 11% to 29% of pregnant women are affected. It is threefold more common in pregnant women than in nonpregnant women and has a higher prevalence in the third trimester.
- As many as 25% to 50% of patients with end-stage renal disease have Restless Legs Syndrome with symptoms, particularly during hemodialysis.
Investigations for Restless Legs Syndrome:
No specific investigation tests are available to diagnose Restless Legs Syndrome. However investigations are done to rule out other underlying pathologies, which include:
- Total Blood Count
- Electromyography (EMG) and Nerve Conduction Velocity (NCV) to rule out radiculopathy and neuropathy.
- Polysomnography to quantify the frequency of leg movements and characterize the pattern of sleep.
Medical Treatment of Restless Legs Syndrome:
- Medicines to improve sleep quality and establish sleep cycle. (Dopamine agonists, sedatives, painkillers, alpha 2 delta calcium channel ligand).
- Iron supplementations
Physiotherapy Treatment for Restless Legs Syndrome:
1. Exercise Therapy – Gentle stretches like Thigh stretches, calf stretches and hip stretches improve the flexibility in the lower limb muscles. Low to moderate intensity exercises for 30 to 40 minutes daily, which may include Yoga, Pilates, walking, swimming improves strength in the muscles and hence reduces fatigue. Musculoskeletal and Cardiovascular endurance increases. However, one should avoid exercising just before going to bed.
2. Quantum Resonance Therapy – This is a combination therapy of Pulsed Electromagnetic Field Therapy (PEMF) and Magneto Mechanical Oscillator (MMO). The oscillatory frequencies (vibrations) produced by MMO restores the microvasculature with oxygenated blood and enhances the functioning of the lymphatics. This reduces fatigue in the muscles and improves strength. It works on the principle of “Counterstimulation”. The vibrations produced by MMO override the sensations coming from the leg. So the patient senses vibrations instead of the sensory symptoms. The therapy also induces sufficient relaxation in the muscles by activating the parasympathetic nervous system.
3. Pneumatic Compression Therapy – The therapy includes the application of a sleeve or socks to the limbs which alternately inflates and deflates. This gently squeezes and releases the muscles. Thus, circulation in the area improves by enhancing oxygenated blood in the muscles.
4. Hot and Cold Therapy – This causes vasodilatation in the microvasculature, replenishing the localised area.
5.Transcutaneous Electrical Nerve Stimulation – It is a device that produces small electrical currents which relieve pain. It also acts on the principle of “Counterstimulation” where the electrical current sensation overrides the sensory symptoms.
6. Lifestyle Modifications – Avoid alcohol, smoking, tobacco and caffeine. Develop healthy sleep habits and avoid stress.
Prognosis of Restless Legs Syndrome:
In about 70% of the patients, symptoms progress from moderate to severe. They are prone to hypertension, frequent headaches and sleep difficulties. Quality of life is affected.
“ A rest to your brain and exercise to your legs, is the mantra to tackle your Restless Leg!”