Restless legs syndrome

Clinic

• RLS also known as Willis-Ekbom disease (WED)
• It is a long-term disorder that causes a strong urge to move legs or limb twitching during sleep.
• An unpleasant feeling in the legs that amel by moving, therefore can make it hard to sleep.
• This is often described as aching, tingling, or crawling in nature.
• Occasionally arms may also be affected.
• RLS is not the same as habitual foot tapping or leg rocking.

Related disease

• Low iron levels
• Kidney failure
• Parkinson's disease
• Diabetes mellitus
• Rheumatoid arthritis
• Celiac disease

Signs and symptoms

• Different sensations: Pain / Muscle ache / An itch that you can't scratch / Buzzing sensation/ An unpleasant tickle that won't stop / Crawling feeling / Limbs jerking
• The sensations typically begin or intensify during quiet wakefulness, such as when relaxing, reading, studying, or trying to sleep.
• It is a "spectrum" disease with some people experiencing only a minor annoyance and others having major disruption of sleep and impairments in quality of life.

• The sensations are unusual and unlike other common sensations therefore it is hard to describe them
  • Uncomfortable/ Painful / Antsy / Electrical / Creeping / Itching / Pins and needles / Pulling / Crawling / Buzzing / Numbness.

• Motor restlessness, expressed as activity, which relieves the urge to move.
• Movement usually brings immediate relief, although temporary and partial.
• Walking is most common; however, stretching, yoga, biking, or other physical activity may relieve the symptoms.
• Continuous, fast up-and-down movements of the leg, and/or rapidly moving the legs toward then away from each other, may keep sensations at bay without having to walk. Specific movements may be unique to each person.

• Worsening of symptoms by relaxation.

• Variability over the course of the day-night cycle, with symptoms worse in the evening and early in the night.
• Some experience RLS only at bedtime, while others experience it throughout the day and night. Most people experience the worst symptoms in the evening and the least in the morning.

• Restless legs feel similar to the urge to yawn, situated in the legs or arms.

RLS Miasmatic analysis

Entities	HTLV-1	NVCJD	GSS
Dysesthesia Hyperstasia	++	++	+
Fasciculation Myoclonous	++	++	+
Hyper Reflexia	++	++	++

As you see, Here we have a big question. Twitching, Myoclonous, Fasciculation, Tremor and Jerking are very similar entities, therefore which of them are the exact entity of RLS?

My answer is, RLS is related to Upper motor neuron because of its Jerking / Twitching / Hyperreflexia. Therfore I prefer tremor to Fasciculation

• Fasciculation or muscle twitch, is a spontaneous, involuntary muscle contraction and relaxation, involving fine muscle fibers.
• Tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving oscillations or twitching movements of one or more body parts.
• Myoclonus is a brief, involuntary, irregular (lacking rhythm) twitching of a muscle or a group of muscles
• I think Myoclonus is the best for RLS because of its briefness and irregularity. Tremor is rhythmic and Fasciculation involve fine muscle fibers. Therefore I consider Myoclonous at first and Fasciculation for the second position
• This means that NVCJD/ HTLV-1 /GSS and PLV are the first and second candidate for RLS.
• Due to strong relation of RLS to RBD, I consider Hyper reflexia as a good entity of RLS.

4 Causes

• While the cause is generally unknown, it is believed to be caused by changes in the nerve transmitter dopamine resulting in an abnormal use of iron by the brain. RLS is often due to iron deficiency (low total body iron status). Other associated conditions may include end-stage kidney disease and hemodialysis, folate deficiency, magnesium deficiency, sleep apnea, diabetes, peripheral neuropathy, Parkinson's disease, and certain autoimmune diseases, such as multiple sclerosis. RLS can worsen in pregnancy, possibly due to elevated estrogen levels. Use of alcohol, nicotine products, and caffeine may be associated with RLS. A 2014 study from the American Academy of Neurology also found that reduced leg oxygen levels were strongly associated with restless legs Syndrome symptom severity in untreated patients.
• Many medical conditions are linked to low levels of dopamine, including
  • Parkinson's disease
  • Depression
  • Schizophrenia
  • ADHD

Related disease

ADHD

• There is an association between ADHD and RLS
• Both have links to dysfunctions related to the neurotransmitter dopamine
• A 2005 study suggested that up to 44% of people with ADHD had comorbid RLS, and up to 26% of people with RLS had confirmed ADHD or symptoms of the condition.

Parasomnia

• Obstructive sleep apnea and other sleep-related respiratory events have been recognized as triggers of disorders of arousal in children.
• Previous studies suggest that parasomnias occur commonly in children with RLS and can be precipitated by periodic limb movements in sleep (PLMS).

Mood disorder

• RLS may contribute to higher rates of depression and anxiety disorders in RLS patients.

Mechanism

• Although it is only partly understood, pathophysiology of restless legs syndrome may involve dopamine and iron system anomalies. There is also a commonly acknowledged circadian rhythm explanatory mechanism associated with it, clinically shown simply by biomarkers of circadian rhythm, such as body temperature. The interactions between impaired neuronal iron uptake and the functions of the neuromelanin-containing and dopamine-producing cells have roles in RLS development, indicating that iron deficiency might affect the brain dopaminergic transmissions in different ways.
• Medial thalamic nuclei may also have a role in RLS as part as the limbic system modulated by the dopaminergic system which may affect pain perception. Improvement of RLS symptoms occurs in people receiving low-dose dopamine agonists.