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Introduction to RLS

History

The term Restless Leg Syndrome was coined by Professor Karl-Axel Ekbom in 1944 and is therefore also known as "Ekbom's disease". Ekbom studied medicine at the Karolinska Institute and later became the first Professor and head of the department of neurology at Uppsala university hospital. In his 1945 publication entitled "Restless Legs", Ekbom described the disease and presented eight cases.

Ekbom was not the first to describe the disease. The earliest documentation was appears to be by Thomas Willis, a 17th century English physician of Charles II. Willis studied at the private school of Edward Sylvester in Oxford and is probably most famous for his publication Cerebri anatome, published in 1664, a foundational text on the anatomy of the cerebral system. This book was the first to describe the term reflex action and the Circle of Willis was outlined and understood.

In 1672 described what may have been RLS. Willis wrote in a chapter entitled "Instructions for curing the Watching evil":

.......Wherefore to some, when being in bed they betake themselves to sleep, presently in the arms and legs. Leaping and contractions of the tendons and so great a restlessness and tossing of the members ensure, that the diseased are no more able to sleep, than if they were in the place of the greatest torture!....

Willis went on to think that the diseases originated in the spinal cord and was a product of spinal irritation and used opiates as his therapy of choice.

Sometimes since I was advised with for a lady of quality, who in the night was hindered from sleep by reason of these spasmodic effects which came upon her only twice a week; she took afterward daily for almost three months, receiving no injury thereby, either on the brain or about any other function, and when while by the use of other remedies; the dyscrasia of the blood and nervous juice being corrected, the animal spirits became more benign and mild. She afterward leaving wholly the opium was able to sleep indifferently well!!

What is restless legs?

Restless legs syndrome (RLS) is a neurological disorder with unpleasant sensations in the legs and an uncontrollable urge to move when at rest to try to relieve these feelings. RLS sensations are often described by people as burning, creeping, tugging, or like insects crawling inside the legs, and a wide variety of descriptions is included in diagnostic criteria. Often called paresthesias (abnormal sensations) or dysesthesias (unpleasant abnormal sensations), the sensations range in severity from uncomfortable to irritating to painful.

Lying down and trying to relax activates the symptoms or makes them worse. Most people with RLS have difficulty falling asleep and staying asleep. People are exhausted with daytime fatigue and sleepiness. Many people with RLS report that job, personal relations, and activities of daily living are strongly affected as a result of this exhaustion, because they are unable to concentrate, or have impaired memory.

RLS probably affects 5-10% of people, but may be underdiagnosed and, in some cases, misdiagnosed. Some people with RLS will not seek medical attention, believing that they will not be taken seriously, that their symptoms are too mild, or that their condition is not treatable. Some physicians wrongly attribute the symptoms to nervousness, insomnia, stress, arthritis, muscle cramps, or aging.

RLS occurs in women and men, probably slightly more often in women. Although the syndrome may begin at any age, even as early as infancy, most patients who are severely affected are middle-aged or older. In addition, severity appears to increase with age. Older patients experience symptoms more frequently and for longer.

Most people with RLS also experience a more common condition known as periodic limb movement disorder (PLMD). PLMD is involuntary leg twitching or jerking movements during sleep that typically occur every 10 to 60 seconds, in periods or throughout the night. The symptoms cause repeated awakening and disrupted sleep. Unlike RLS, the movements caused by PLMD are involuntary-people have no control over them. Although many patients with RLS also develop PLMD, most people with PLMD do not experience RLS. Like RLS, the cause of PLMD is unknown.

What are the symptoms of restless legs?

People with RLS feel uncomfortable sensations in their legs, especially when sitting or lying down, often more in the evening than the day, with an irresistible urge to move about. Although the sensations can occur on just one side of the body, most often they affect both sides.

Because moving the legs (or other affected parts of the body) relieves the discomfort, people with RLS often keep their legs moving to reduce the unpleasant sensations. They may pace the floor, constantly move their legs while sitting, and toss and turn in bed.

Most people find the symptoms to be less noticeable during the day and more pronounced in the evening or at night, especially going to sleep. For many people, the symptoms disappear by early morning, allowing for more refreshing sleep at that time. Other triggering situations are periods of inactivity such as long journeys, or other behaviours that reduce movement.

The symptoms of RLS vary in severity and duration from person to person. Mild RLS occurs episodically, with only mild disruption of sleep onset, and causes little distress. In moderately severe cases, symptoms occur only once or twice a week but result in significant delay of sleep onset, with some disruption of daytime function. In severe cases of RLS, the symptoms occur more than twice a week and result in burdensome interruption of sleep and impairment of daytime function. There is a standard symptom scoring system.

What causes RLS?

In most cases, the cause of RLS is unknown (and then doctors call it idiopathic RLS). Family history of the condition is common, perhaps in half the sufferers. People with familial RLS tend to be younger when symptoms start and have a slower progression of the condition.

In other cases, RLS appears to be related to the following factors or conditions, although researchers do not yet know if these factors actually cause RLS.

How is RLS diagnosed?

Currently, there is no single diagnostic test for RLS. The disorder is diagnosed clinically by evaluating the patient's history and symptoms. In 1995, the International Restless Legs Syndrome Study Group identified four basic criteria for diagnosing RLS:

  1. a desire to move the limbs, often associated with paresthesias or dysesthesias,
  2. symptoms that are worse or present only during rest and are partially or temporarily relieved by activity,
  3. motor restlessness, and
  4. nocturnal worsening of symptoms.

A 10-question scoring system is available for RLS diagnosis and severity scoring.

A more detailed description of diagnostic criteria in adults, children, and cognitively impaired adults is available.

How is RLS treated?

Relief on movement is generally only temporary. However, RLS can be controlled by finding any possible underlying disorder. Often, treating the associated medical condition, like anaemia, peripheral neuropathy or diabetes, will alleviate many symptoms. For patients with idiopathic RLS, treatment is directed toward relieving symptoms.

For those with mild to moderate symptoms, prevention is key, and many physicians suggest certain lifestyle changes and activities to reduce or eliminate symptoms. Decreased use of caffeine, alcohol, and tobacco may provide some relief. Doctors may suggest the use of supplements to correct deficiencies in iron, folate, and magnesium. Studies also have shown that maintaining a regular sleep pattern can reduce symptoms. Some individuals, finding that RLS symptoms are lower in the early morning, change their sleep patterns. Others have found that a program of regular moderate exercise helps them sleep better. Taking a hot bath, massaging the legs, or using a heating pad or ice pack can help relieve symptoms in some patients. Although many patients find some relief with such measures, rarely do these efforts completely eliminate symptoms, and for many of these measures there is only anecdotal evidence that they work.

A variety of drugs have been tried, often not in large or long trials. Some seem to work well in reducing periodic leg movements, or daytime tiredness, or improving sleep, or reducing RLS symptom severity, but there is no magic bullet as yet.