Restless legs syndrome

The Willis-Ekbom syndrome or restless legs syndrome is a neurological disorder characterized by unpleasant sensations in the legs (less frequently in the arms) and a uncontrollable urge to move and walk when resting, in an effort by the patient to relieve these sensations (sometimes called 'night walkers'). Some authors postulate that this disorder could affect 10% of the world population, and its causes are unknown at the beginning of the XXI century. A small percentage of people is correctly diagnosed, because their syndrome is addressed to specialists such as neurologists, rheumatologists, psychologists, etc. It is not a serious disease, which is a cause per se of death, but rather terrible restlessness that diminishes the quality of life of the patient and those around him. If left untreated, they can lead to nervous breakdowns and depression. In order to alleviate, share and improve coexistence, specific associations have been created in each country. The name "Ekbom syndrome" It can be confused with the delusion of parasitosis or dermatozoic delusion.

A 2019 review concludes that it is the second most common gluten-related movement disorder. These develop regardless of the presence of symptoms or intestinal lesion, that is, both in celiac and non-celiac patients. More than half of people improve with the strict removal of gluten from the diet, without the need for any other additional treatment.

History

The first medical descriptions of the disorder are known as early as the second half of the XVII century, coming from the English doctor Thomas Willis (Charles II chamber doctor). Willis describes a case in 1672 of a London farmer. In 1861, the well-known German clinician Theodor Wittmaack included it for the first time in his list of diseases, describing it as restlessness of the lower limbs: Anxietas tibiarum . The current name of Restless Legs became official internationally in 1945 thanks to the description of the Stockholm neurologist Karl Ekbom.In his publication he shows the symptoms and describes eight cases. After his description, the word syndrome was added to describe the disease, not a process. During the fifties, attempts were made to link the causes of the disease to the gestation period, iron deficiency, and chronic renal failure. Later studies linked some of the causes to a failure in the limbic system of the human brain.

Epidemiology

Some researchers estimate that this syndrome affects up to 10% of the European and US population. There are few diagnosed cases in India, Japan, and Singapore. This appearance of the disease in certain places evidences the existence of racial or ethnic factors. However, others consider that the occurrence is greater because, in some cases, it is not correctly diagnosed. Restless legs syndrome occurs in both sexes, but the incidence may be slightly higher in females. Although the syndrome can begin at any age, even as early as infancy, most severely affected patients are elderly. medium or higher. Furthermore, the severity of the disorder appears to increase with age. Older patients experience symptoms more frequently and for longer periods of time. Some patients show symptoms as early as childhood. Some people with the syndrome do not seek medical attention thinking that they will not be taken seriously, that their symptoms are very mild, or that their problem cannot be treated. Some doctors mistakenly attribute the symptoms to nervousness, insomnia, stress, arthritis, muscle cramps, or aging.

Etiology

Restless leg syndrome is frequently associated with iron deficiency (approximately 20% of cases). Elevated estrogen levels are another related cause of symptom onset, as occurs during pregnancy Risk factors include advanced age and the use of certain medications, such as dopamine antagonists, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Tobacco and excessive caffeine or alcohol intake can worsen symptoms.

It is also very common in people with inflammatory diseases of the gastrointestinal tract, such as undiagnosed or untreated celiac disease (which can present without digestive symptoms), Crohn's disease, and intestinal bacterial overgrowth. they lead to iron deficiency and increased levels of systemic inflammation. This inflammation could be a direct cause of the development of restless legs syndrome, by affecting dopamine neurotransmission in the brain and spinal cord.

Restless legs syndrome is the second most common gluten-related movement disorder (gluten ataxia is first). These disorders develop regardless of the existence of intestinal symptoms or lesions, that is, both in celiacs and non-celiacs. More than half of people experience clear improvement with strict removal of gluten from the diet, without the need for any additional treatment. (see Gluten-Related Neurological Disorders)

Clinical picture

The rest period during the afternoon, or night, triggers the effect of 'uneasy legs' and their desire to walk.

Those affected often describe the sensations of restless legs syndrome as "burning," as if something were slipping, or as if insects were crawling up the inside of their legs (tingling sensation). Often called paresthesias (abnormal sensations) or dysesthesias (unpleasant abnormal sensations), these sensations range in severity from unpleasant to irritating to painful. these sensations when the patient is at rest. The sensation of relief seems to arise if the patient walks or moves, and it is for this reason that it becomes a sleep disorder, due to his inability to develop a resting activity. This situation generates a decrease in the quality of life of the patient. The symptoms of restless leg syndrome in the extremities are usually unleashed in the afternoon or at night.

The most distinctive or unusual aspect of the disorder is that the symptoms are triggered by lying down and trying to relax. As a result, most people with restless legs syndrome have trouble falling asleep and staying asleep. In the literature of the late 20th century, patients with restless leg syndrome were referred to as: "night walkers" (nightwalkers). Secondly, it can cause social disorders due to the impossibility of going to the theater or the cinema. Sometimes impediment to travel. Loss of concentration at work. If left untreated, the disorder causes exhaustion and fatigue during the day. Many people with restless legs syndrome report that their work, personal relationships, and daily activities are greatly affected as a result of being tired. They often cannot concentrate, have impaired memory, or fail to complete their daily tasks.

This syndrome presents different levels of intensity among those who suffer from it. The mild forms are very frequent in the population, but sometimes the discomfort can be intolerable for those who suffer from it. Thus, there is a categorization of severity of the disease that goes from some intermittent symptoms of discomfort, through moderate (symptoms that appear daily), to the extremes that its habitual appearance can cause serious psychological problems. In severe cases, it also affects the upper limbs, reaching full-body shaking similar to epilepsy (of course, if it happens in this case, both can be confused).

Diagnosis

Doctors who suspect restless legs syndrome often treat patients in sleep clinics to further refine the diagnosis. To diagnose RSL, any one of four symptoms must be detected:

1. An urgent need to move the legs, usually accompanied by an uncomfortable and unpleasant feeling in the limbs.
2. The need to move, or the unpleasant feeling in the limbs, which begins when rest periods begin.
3. The need to move, or the unpleasant sensations in the limbs, are partially diminished by the patient's movement. Generally walking, stretching, etc.
4. The need for movement, or the unpleasant sensations in the extremities, is greater in the late/night periods, being less likely in the morning.

Due to a possible cause of hereditary transmission, patients who have a case of restless legs syndrome among their relatives are potential patients. In the same way a blood test looking for low levels of ferritins that indicate low levels of iron in the blood.

Differential diagnosis

More than 80% of people with restless legs syndrome also have a more common condition known as periodic leg movement syndrome (PLMD for its names). acronym in English). The association of iron deficiency anemia with restless legs syndrome has been described along with akathisia. PLMD is characterized by sudden involuntary movements of the legs, such as pulling or jerks, that occur during sleep, generally with a frequency of 10 to 60 seconds, sometimes all night. These symptoms cause the patient to wake up repeatedly and severely disrupt sleep. Unlike restless legs syndrome, movements caused by PLMD are involuntary. Although many patients with this syndrome also develop periodic leg movement syndrome, most people with this disorder do not have restless legs syndrome.

As with restless legs syndrome, the cause of PLMD is unknown, although recent studies conducted at Harvard Medical School tentatively conclude that behind the relationship between erectile dysfunction and involuntary movement of the legs could be low levels of dopamine, a neurotransmitter hormone of the nervous system associated with both disorders.

Treatment

It is treated with various medications ranging from levodopa, dopaminergics, opioids, benzodiazepines, antiepileptics, and dietary iron supplements.