Restless legs syndrome (RLS), also known as restless legs syndrome, is characterized by extreme discomfort in both lower extremities during nighttime sleep, forcing the patient to keep moving the lower extremities or walking on the floor, resulting in severe sleep disturbances. This disease was first proposed by Wills (1685) in England, and then Ekbom (1945) made a systematic summary and described it comprehensively for the first time, so it is also called Ekbom syndrome. Although the disease is not life-threatening, it has a serious impact on the quality of life of patients. Epidemiological data from abroad indicate that its prevalence is 1-10% of the total population, and the prevalence in China is estimated to be around 1.2-5%, and it is common in middle-aged and elderly people. The disease is a more common disease, and its incidence is much higher than other neurological diseases, such as multiple sclerosis, Parkinson’s disease or Alzheimer’s disease.
I. Classification: The syndrome is divided into two categories: primary and symptomatic.
1. Primary restless legs syndrome: The cause of this type is unknown, and a few patients have a family history.
2, symptomatic restless legs syndrome: secondary to other diseases, commonly due to the following causes: uremia, iron deficiency anemia, folic acid deficiency, pregnancy, rheumatoid arthritis, Parkinson’s disease, multifocal neuropathy, metabolic diseases and drugs.
II. Clinical manifestations.
The clinical features are a spontaneous, unbearably painful abnormal sensation occurring in the lower extremities. It is most common in the gastrocnemius muscle, and can occasionally occur in the thighs or upper extremities, usually symmetrically. Patients often complain of a tearing, creeping, tingling, burning, painful or itchy sensation deep in the lower extremities. Patients have an urgent and intense feeling of needing to move and this leads to hyperactivity. Symptoms occur at rest and can be partially or completely relieved by activity. Normally, symptoms become intense at night while lying in bed and peak after midnight, forcing patients to kick their legs, move their joints or massage their legs, often describing “not having a comfortable place to put their legs.” In severe cases, the patient has to get up and walk constantly to get relief. As a corollary, most patients experience periodic movements of sleep (PMS), a stereotypical, repetitive flexion of the legs that occurs during REM sleep and wakes the patient. As a result of nocturnal sleep disorder, the patient suffers from severe daytime sleepiness and reduced work capacity.
III. Diagnostic criteria Minimum diagnostic criteria: The International Restless Legs Syndrome Study Group (IRLSSG) has developed a minimum diagnostic criteria consisting of four symptoms.
1. Abnormal sensations: indescribable discomfort in the limbs, resulting in a strong desire to move the limbs, mainly the lower limbs. These abnormal sensations often occur deep in the limbs rather than on the surface, such as the skin.
2. Motor symptoms: The patient cannot sleep and keeps moving the limbs to relieve the abnormal sensations. The main manifestations are walking back and forth, constantly shaking or flexing and stretching the lower limbs, or grinding and turning in bed.
3. Symptoms are aggravated at rest and can be temporarily relieved by activity.
4. Symptoms worsen at night and reach a peak late at night.
The American Health Organization revised the diagnostic criteria for RLS in 2003. a. Discomfort in both legs forces the patient to walk, and the discomfort is relieved by walking, sometimes involving the upper extremities and the rest of the limbs. Patients often have deep ankylosis, tingling, pain, crepitus, shaking, tension, and stroke like sensations in both legs, but both legs must be involved, and usually the first one is involved, with symptoms more pronounced in the lower leg than in the other parts.
b. Symptoms begin or worsen with rest or inactivity (e.g., lying or sitting).
c. The discomfort may be partially or completely relieved as long as the movement (e.g., walking or stretching) continues.
d. Discomfort occurs only at night, or is worse at night than during the day.
a. Family history: The incidence of RLS is 3 to 5 times higher in first-generation relatives with a family history than in those without a family history.
b. Response to dopaminergic therapy: Almost all patients are sensitive to lower than conventional doses of levodopa or dopaminergic agonists, but long-term therapy is less effective.
c. PLM S: PLM S occurs during sleep in more than 85% of patients.
(iii) Characteristics associated with RLS a. Natural clinical course: RL S occurs in patients younger than 50 years of age, where symptoms are not obvious at first and become more pronounced with increasing age, and in patients older than 50 years of age, where symptoms are sudden and severe. Many patients may experience intermittent or spontaneous remission for many years.
b. Sleep disturbance: This is the main symptom of RLS patients and is often the primary reason for their visit.
c. Physical examination: No positive signs, but often associated with iron metabolism, peripheral neuropathy, etc.
Differential diagnosis: The differential diagnosis of restless legs syndrome can be made clinically on the basis of the following symptoms.
(1) Sedentary inability (akathisia): Most of the adverse reactions occur in people who have been using anti-psychotic drugs and tranquilizers for a long time, sometimes even in small amounts, patients often complain that they are anxious and restless, and that they cannot land on their legs and feet. Treatment with anxiolytic therapy is effective.
(2) Periodic leg movement in sleep: Periodic involuntary movements of the foot muscles on both sides occur during nighttime sleep. It often coexists with restless leg syndrome, and both have a common pathophysiological basis. It is not accompanied by sensory abnormalities when it develops alone, but awakening during sleep due to lower limb movement, and patients often complain of insomnia.
(3) Painful legs and moving toes: Pain in the lower extremities and feet, accompanied by discomfort and characteristic involuntary movements of the toes, which can occur in one or both limbs. The involuntary movements of the lower limbs are mainly manifested by the extension and internal and external rotation of the toes and the flexion and extension of the foot joints, which are different from the nature and characteristics of the pain of restless leg syndrome. It is commonly seen in spinal cord and nerve endings diseases such as achalasia, lumbago, sciatica, etc.
(4) Abnormal extremity sensation (acroparesthesia): numbness and pins-and-needles pain in the fingers and toes during sleep at night, with frequent awakenings due to pain. It is common in adult women. Prevalent at the end of the lower limbs.
V. Treatment.
1. General treatment: Patients with RLS should pay attention to sleep hygiene and regular rest and relaxation. Use less coffee and coffee-containing beverages, quit smoking, drink less alcohol or take a hot bath before bedtime. Excessive daytime sleep should be avoided to reduce the resulting sleep disorders. In addition, excessive physical exercise during the day may also aggravate the symptoms of RLS.
2. Drug treatment.
When patients complain of severe motor symptoms and/or sleep disturbances or fatigue of RLS, they should be treated with appropriate medications. In general, treatments are symptomatic and only provide temporary relief. Since the symptoms of RLS may resolve spontaneously, the physician may consider medication reduction or leave therapy when appropriate.
3. For the pharmacological treatment of primary RLS, dopaminergic drugs are preferred. For mild to moderate symptoms, levodopa is preferred, starting with small doses, such as 50 mg to 100 mg. Depending on the patient’s needs, doses of 100 mg to 400 mg can be taken throughout the night, up to one hour before bedtime. Commonly used preparations are combinations of levodopa with dopa decarboxylase inhibitors, such as methyldopa or xylazine. If the patient’s symptoms progress into the daytime or the first half of the night, the amount of levodopa should not be increased and a switch to a dopamine agonist can be considered.
4. For severe RLS, dopamine receptor agonists such as pramipexole (mirapexin/sifrol) may be preferred, which is currently available in China, and there will be pramipexole extended-release agents available. Dopamine agonists can be used if patients have contraindications to dopaminergic drugs or experience adverse reactions to levodopa such as rebound or worsening of symptoms. Dopamine agonists have become the mainstay of treatment for this disease. Alternatively, clonidine 0.5 mg to 2 mg can be used alternatively or in combination with dopaminergic drugs. Anticonvulsants such as carbamazepine, sodium valproate or gabapentin are used as second-line drugs and can be used when the above drugs are ineffective or the side effects are not tolerated.
5. For secondary RLS, the first step is to treat the primary disease. With the elimination of the cause of the disease, the symptoms of RLS will also disappear. For example, kidney transplantation for uremic patients, iron therapy for patients with iron deficiency anemia, and folic acid supplementation for patients with folic acid deficiency. Therefore, RLS has become a treatable disease.
Sixth, rehabilitation exercise: proper exercise helps patients to recover and sleep, so adhere to exercise and develop good habits, especially pay attention to strengthening leg exercises, such as walking, jogging, squatting, kicking, etc. It helps to improve the symptoms of restless legs, but it must be moderate and not too fatiguing. At the same time, every day early in the morning or before bedtime after washing the feet with the hands rub the heart of the feet until hot and red, to help improve the blood circulation and nutritional status of the legs, to prevent numbness, cold and other symptoms of ischemia.