yoga book / pathology / restless leg syndrom
Contents
Definition
RLS is a sensorimotor disorder of unclear aetiology, mainly affecting the lower extremities, which manifests itself with distinct to agonising sensory disturbances at rest, which improve with movement, resulting in a sometimes imperative urge to move. The symptoms intensify – with a normal rhythm of life – in the evening and at night, so that sometimes severe sleep disorders with secondary mental and emotional symptoms develop, including mnestic disorders, concentration disorders, chronic states of exhaustion, daytime sleepiness, listlessness, irritability, dizziness, migraines and depression. Physical disorders of the heart and vascular system, diabetes mellitus, dementia and obesity can also occur secondarily.
The typical symptoms can be bilateral or unilateral, in which case they can also alternate. In addition to the sharpness of the urge to move, immediate and reliable relief through movement is also characteristic. The (very limited) duration of remission depends on the severity of the disease. Some of those affected are not aware of the disorder, as it only occurs during sleep and at best leads to unconscious waking states (arousals) without the affected person consciously waking up and noticing the symptoms.
More rarely, the arms are affected instead of the legs, which is known as restless arm syndrome. Involuntary movements such as tics or teremor are not part of the symptoms, but muscle twitching (so-called Periodic Limb Movements PLM), which can occur during sleep or when awake. The characteristic sensations are described in a variety of ways, for example as pulling, tension, tingling, formication, pressure, coldness, warmth, indefinable pain, cramps or pulsation, all of which are usually quite profound and only rarely superficial. The symptoms can radiate from the affected extremity to the trunk, for example to the buttocks or, in the case of restless arm syndrome, to the shoulder. Other radiations have been described. In some cases, the symptoms only occur after falling asleep, so that they are not noticed until the affected person wakes up.
In addition to the absence of symptoms in the sense of the characteristic circadian rhythm with onset or worsening in the evening, longer remission phases of days to months can occur. In mild cases, the disorder only appears from time to time. In particularly severe cases, sleep is so difficult that the circadian rhythm is completely lost.
In addition to an unclear origin, some cases (secondary) are due to iron deficiency, which is why iron is substituted even if the ferritin level is normal. Several pathomechanisms are being discussed as to how an iron deficiency could cause this disorder. Other deficiencies and medications (see below) can also cause the disorder. Various medications are contraindicated in RLS, and noxious substances such as coffee, alcohol and nicotine also appear to be aggravating. Those affected report the positive effect of moderate exercise during the day or in the evening, but the detrimental effect of intensive or excessive exercise.
The disorder was first described by Willis in 1685 as „restlessness with an urge to move“ and can be found as early as 1861 in the textbook on nervous disorders (Wittmaack). The distinction between primary and (more frequently unilaterally occurring) secondary RLS, i.e. occurring as a result of medication or deficiency states, which was common for a long time, is now also questioned. The primary form begins earlier than the secondary form and is usually insidious; its progression is also slower.
Epidemiology
The disorder affects 5-10% of the population in America and Europe, of which 10-15% require medication. M:W 1:2. The disorder is much less common in Asia. The disorder can occur in childhood and must then be differentiated from AHDS. During and after pregnancy, RLS occurs in 25%, in 97% the disorder subsides after birth.
Comorbidities
Various comorbidities can occur in RLS, especially cardiovascular, neurological and rheumatological ones such as rheumatoid arthritis, diabetes mellitus, fibromyalgia, but also psychomental disorders such as depression or anxiety disorders, further polyneuropathy, somatoform disorders, disorders of the respiratory tract such as COPD or obstructive sleep apnoea, see also predispositions.
Cause
- Primary form: unknown
- Secondary form: Iron deficiency and other deficiency anaemias, adverse drug reactions
Predisposing
for the secondary form:
- Iron deficiency anaemia, folic acid deficiency, vitamin B12 deficiency, magnesium deficiency, pernicious anaemia, uraemia, renal insufficiency requiring dialysis, chronic liver disease, RA, diabetes mellitus, hypothyroidism, fibromyalgia, polyneuropathy, multiple sclerosis, Parkinson’s disease, varicose veins, pregnancy
- Drug-induced: various antidepressants, antiemetics, neuroleptics, antihistamines, lithium
Diagnose
- Neurological tests and imaging are usually O.B.
- clinically, the German Society of Neurology (DGN) defined essential (mandatory) and supporting (optional) criteria in 2012:
Essential criteria
- Urge to move the legs (possibly the arms), usually caused by paraesthesia or pain
- Occurrence or intensification of the urge to move during rest and relaxation, not during movement
- Relief or cessation of symptoms with movement
- Increase in complaints in the evening and at night
Supporting criteria
- Periodic leg movements during sleep (PLMS) or resting wakefulness (PLMW) beyond an expected level
- Improvement of symptoms under test administration of levodopa (L-dopa test)
- Positive family history of RLS (1st degree relatives)
The Restless Legs Diagnosis Index, which is primarily intended to facilitate differential diagnosis, was developed in 2009. The diagnosis is not always easy to make, as sufferers are not necessarily able to clearly describe the symptoms, and misdiagnoses also occur (especially: somatoform disorders, depression, hypochondriasis). RLS, which only occurs during sleep, is quite regularly only discovered in the sleep laboratory.
Symptome
- Various paraesthesias and pain phenomena that urge movement, which then improves. Increase in the evening, worsening at rest, see above
- Various secondary symptoms, for example due to lack of sleep
Therapie
- secondary form: causative
- Primary form: Dopa agonists or L-dopa (not as long-term medication due to augmentation), possibly combination therapy or off-label use of opioids, anticonvulsants, benzodiazepines
DD
- pAVK
- Polyneuropathie
- Radiculopathies
- Vitamin B12 deficiency and funicular myelosis
- Venenleiden
- nocturnal calf cramps
- Pruritus
- Myoclonia (twitching) when falling asleep