Restless legs syndrome

Restless Legs Syndrome (RLS), also known as Willis–Ekbom disease, is a neurological sensory-motor disorder characterized by an irresistible urge to move the legs, typically accompanied by uncomfortable sensations. These symptoms are usually worse during periods of rest or inactivity, particularly in the evening and night, and are temporarily relieved by movement. RLS can significantly impact sleep quality and daily functioning.

Etiology and Pathophysiology
The exact cause of RLS is not fully understood, but it is believed to involve dysfunction in dopamine pathways within the central nervous system, leading to impaired regulation of sensory and motor signals. Iron deficiency in the brain is also implicated, as iron is essential for dopamine synthesis. RLS can be classified as:

• Primary (Idiopathic): Often with a genetic predisposition, presenting in early adulthood and progressing slowly.

• Secondary: Associated with conditions such as iron deficiency anemia, pregnancy, chronic kidney disease, neuropathy, or certain medications.

Clinical Presentation

• Unpleasant sensations in the legs, often described as creeping, crawling, tingling, burning, or aching.

• Strong urge to move the legs, with temporary relief upon movement.

• Symptoms worsening at night or during rest.

• Sleep disturbances due to nocturnal symptoms, leading to fatigue, irritability, and reduced daytime concentration.

Diagnosis
RLS is diagnosed clinically using established criteria, which include the presence of characteristic symptoms, worsening during rest, relief with movement, and evening or nighttime predominance. Laboratory tests may be ordered to rule out secondary causes, particularly iron deficiency.

Treatment

Lifestyle and Non-Pharmacological Interventions

• Establishing regular sleep patterns.

• Engaging in moderate exercise, avoiding excessive physical activity late in the day.

• Avoidance of caffeine, nicotine, and alcohol.

• Mental alerting activities before bedtime (e.g., reading, puzzles) to reduce symptom perception.

• Warm baths, leg massages, or use of heating pads or cold packs.

Pharmacological Management
Treatment depends on symptom severity and underlying causes.

• Iron supplementation: For patients with low ferritin levels, to improve central dopamine function.

• Dopaminergic agents: Such as pramipexole, ropinirole, and rotigotine patches, effective in reducing symptoms.

• Alpha-2-delta ligands: Gabapentin enacarbil and pregabalin, particularly beneficial in patients with painful symptoms or comorbid insomnia.

• Opioids: Reserved for severe, refractory cases under close medical supervision.

• Benzodiazepines: Such as clonazepam, may improve sleep quality but do not directly relieve sensory symptoms.

Management of Secondary Causes

• Correction of iron deficiency.

• Management of renal failure, diabetes-related neuropathy, or pregnancy-related symptoms with safe approaches for each condition.

Prognosis
RLS is a chronic condition that may worsen over time without treatment, but with proper management, most patients can achieve significant symptom relief and improved quality of life.