Restless legs syndrome – uncomfortable sensations in the legs that occur mainly at night, provoking the patient to wake up and often leading to chronic insomnia. In most patients, it is accompanied by episodes of involuntary motor activity. Restless legs syndrome is diagnosed based on the clinical picture, neurological examination, polysomnography, ENMG data and examinations aimed at establishing causal pathology. Treatment consists of non-drug methods (physiotherapy, falling asleep ritual, etc. P.) and pharmacotherapy (benzodiazepines, dopaminergic and sedatives).
General information
Restless legs syndrome (RLS) was first described in 1672 by the English physician Thomas Willis. It was studied in more detail in the 40s of the last century by neurologist Karl Ekbom. In honor of these researchers, restless legs syndrome is called “Ekbom syndrome” and “Willis disease”. The prevalence of this sensorimotor pathology in adults varies from 5% to 10%. It is rare in children, only in the idiopathic variant. Elderly people are most susceptible to morbidity, among this age group the prevalence is 15-20%. According to statistical studies, women suffer from Ecboma syndrome 1.5 times more often than men. However, when evaluating these data, it is necessary to take into account the greater appeal of women to doctors. Clinical observations indicate that about 15% of chronic insomnia is caused by RLS. In this regard, restless legs syndrome and its treatment are an urgent task of clinical somnology and neurology.
Causes
There are idiopathic (primary) and symptomatic (secondary) restless legs syndrome. The former accounts for more than half of the cases of the disease. It is characterized by an earlier onset of clinical symptoms (in the 2-3 decade of life). There are family cases of the disease, the frequency of which, according to various data, is 30-90%. Recent genetic studies of RLS have revealed its connection with defects in some loci of chromosomes 9, 12 and 14. To date, it is generally accepted to understand idiopathic RLS as a multifactorial pathology formed under the influence of external factors against the background of the presence of a genetic predisposition.
Symptomatic restless legs syndrome manifests on average after 45 years and is observed in connection with various pathological changes occurring in the body, primarily with metabolic disorders, damage to nerves or vessels of the lower extremities. The most common causes of secondary RLS are pregnancy, iron deficiency and severe renal insufficiency, leading to uremia. In pregnant women, Ecboma syndrome occurs in 20% of cases, mainly in the 2nd and 3rd trimesters. As a rule, it passes a month after childbirth, but in some cases it may have a persistent course. The frequency of RLS in patients with uremia reaches 50%, it is noted in about 33% of hemodialysis patients.
Restless legs syndrome occurs with a deficiency of magnesium, folic acid, cyanocobalamin, thiamine; with amyloidosis, diabetes, cryoglobulinemia, porphyria, alcoholism. In addition, RLS can be observed against the background of chronic polyneuropathy, spinal cord diseases (discogenic myelopathy, myelitis, tumors, spinal injuries), vascular disorders (chronic venous insufficiency, obliterating atherosclerosis of the lower extremities).
The pathogenesis has not been studied definitively. Many authors adhere to the dopaminergic hypothesis, according to which the dysfunction of the dopaminergic system is the basis of RLS. It is supported by the effectiveness of therapy with dopaminergic drugs, the results of some studies using PET, increased symptoms during the daily decrease in the concentration of dopamine in cerebral tissues. However, it is not yet clear what kind of dopamine disorders we are talking about.
Restless legs syndrome symptoms
The basic clinical symptoms are sensory (sensitive) disorders in the form of dysesthesia and paresthesia and motor disorders in the form of involuntary motor activity. The indicated symptoms mainly affect the lower extremities and are bilateral, although they may be asymmetric. Sensory disorders appear at rest in a sitting position, and more often — lying down. As a rule, their greatest severity is observed in the period from 0 h to 4 h at night, and the least — in the interval from 6 h to 10 h in the morning. Patients are concerned about various sensations in the legs: tingling, numbness, pressure, itching, the illusion of “running goosebumps on the legs” or the feeling that “someone is scratching”. These symptoms do not have an acute painful character, however, they are very uncomfortable and painful.
Most often, the initial place of occurrence of sensory disorders are the lower legs, less often the feet. With the development of the disease, paresthesia covers the hips, can occur in the hands, perineum, in some cases — on the trunk. At the onset of the disease , unpleasant sensations in the legs appear after 15-30 minutes . from the moment when the patient went to bed. As the syndrome progresses, their earlier occurrence is observed, up to the appearance in the daytime. A distinctive feature of sensory disorders in RLS is their disappearance during the period of motor activity. To relieve unpleasant sensations, patients are forced to move their legs (bend-unbend, turn, shake), massage them, walk on the spot, move around the room. But often, as soon as they lie down again or stop moving their legs, unpleasant symptoms return again. Over time, each patient develops an individual motor ritual that allows them to get rid of discomfort most effectively.
About 80% of patients with Ecboma syndrome suffer from excessive motor activity, episodes of which disturb them at night. Such movements have a stereotypical repetitive character, occur in the feet. They represent the back flexion of the thumb or all the toes of the foot, their dilution to the sides, flexion and extension of the entire foot. In severe cases, flexion-extensor movements in the knee and hip joints may be noted. An episode of involuntary motor activity consists of a series of movements, each of which takes no more than 5 seconds, the time interval between the series is on average 30 seconds. The duration of the episode varies from a few minutes to 2-3 hours. In mild cases, these motor disorders remain unnoticed by the patient and are detected during polysomnography. In severe cases, motor episodes lead to nocturnal awakenings and can be observed several times a night.
Insomnia is a consequence of sensorimotor disorders occurring at night. Due to frequent night awakenings and difficult falling asleep, patients do not get enough sleep and feel exhausted after sleep. During the day, they have reduced performance, the ability to concentrate suffers, and fatigue occurs quickly. As a result of sleep disorders, irritability, emotional lability, depression, neurasthenia may occur.
Diagnostics
The diagnosis of RLS does not pose significant difficulties for a neurologist, however, it requires a thorough examination of the patient for the presence of the disease that caused it. If the latter exists in the neurological status, corresponding changes may be detected. With the idiopathic nature of the RLS, the neurological status is without features. For diagnostic purposes, polysomnography, electroneuromyography, a study of the level of iron (ferritin), magnesium, folic acid, vitamins g is carried out. In, rheumatoid factor, assessment of kidney function (blood biochemistry, Rehberg test), ultrasound of the vessels of the lower extremities, etc.
Polysomnography makes it possible to register involuntary motor acts. Considering that their severity corresponds to the intensity of sensitive manifestations of RLS, according to polysomnography data in dynamics, it is possible to objectively assess the effectiveness of the therapy. It is necessary to differentiate restless legs syndrome from night cramps, anxiety disorders, akathisia, fibromyalgia, polyneuropathy, vascular disorders, arthritis, etc.
Restless legs syndrome treatment
The therapy of secondary RLS is based on the treatment of a causal disease. A drop in serum ferritin concentration of less than 45 mcg / ml is an indication for the appointment of iron pharmaceuticals. If other deficient conditions are detected, their correction is carried out. Idiopathic restless legs syndrome has no etiopathogenetic treatment, drug and non-drug symptomatic therapy is carried out against it. It is necessary to review the medications taken before the diagnosis of RLS. Often they are neuroleptics, antidepressants, calcium antagonists, etc. medications that enhance symptoms.
As non-drug measures, normalization of the regime, moderate daily physical activity, walking before going to bed, a special ritual of falling asleep, eating without consuming caffeinated products, abstaining from alcohol and smoking, a warm foot bath preceding sleep are important. In a number of patients, some types of physiotherapy (magnetotherapy, darsonvalization of the shins, massage) give a good effect.
Restless legs syndrome needs medical treatment for severe symptoms and chronic sleep disorders. In mild cases, it is sufficient to prescribe sedatives of plant origin (valerian, motherwort). In more severe cases, therapy is carried out with one or more pharmaceuticals of the following groups: anticonvulsants, benzodiazepines (clonazepam, alprazolam), dopaminergic agents (levodopa, levodopa + benserazide, bromocriptine, pramipexole). Effectively eliminating the symptoms of RLS, dopaminergic pharmaceuticals do not always solve sleep problems. In such situations, they are prescribed in combination with benzodiazepines or sedatives.
Special care is required for the treatment of RLS during pregnancy. They try to use only non—drug therapies, light sedatives, according to indications – iron or folic acid preparations. If necessary, it is possible to prescribe small dosages of levodopa or clonazepam. Antidepressants and neuroleptics are contraindicated in patients with depressive syndrome, MAO inhibitors are used in therapy. Opioid pharmaceuticals (tramadol, codeine, etc.) can significantly reduce restless legs syndrome, however, due to the likelihood of addiction, they are used only in exceptional cases.
Prognosis and prevention
Idiopathic restless legs syndrome is usually characterized by a slow increase in symptoms. However, its course is uneven: there may be periods of remission and periods of worsening of symptoms. The latter are provoked by intense loads, stress, caffeinated products, pregnancy. Approximately 15% of patients have long-term (up to several years) remissions. The course of symptomatic RLS is associated with the underlying disease. In most patients, adequately selected therapy can achieve a significant reduction in the severity of symptoms and a significant improvement in the quality of life.
The prevention of secondary RLS includes timely and successful treatment of kidney diseases, vascular disorders, spinal cord lesions, rheumatic diseases; correction of various deficient conditions, metabolic disorders, etc. The prevention of idiopathic RLS is facilitated by observing a normal daily routine, avoiding stressful situations and excessive loads, refusing to drink alcohol and caffeinated beverages.