Syndrome of "uneasy legs"

Description:

The Syndrome of Uneasy Legs (SUL) is the neurologic disease which is shown paresthesias in the lower extremities and their excess physical activity preferential at rest or during sleep.

Syndrome reasons of "uneasy legs":

SBN can be primary (idiopathic) and secondary (connected with various morbid conditions). Medical states at which secondary SBN can be noted are included below:

Often:
Pregnancy
Peripheral neuropathy
Deficit of iron
Radiculopathy
Renal failure
Parkinson's disease
Injuries of a spinal cord

Less often:
Porphyria
Postgastrectomy syndrome
Pseudorheumatism

It should be noted that not all patients with these states have SBN. Besides, these states can make heavier a current of idiopathic SBN at patients who had this disease earlier.
Primary SBN is often noted at close relatives and is regarded as a hereditary disease, however the exact nature of inheritance is not defined yet.
The pathogeny of this disease is not clear. So far it was not succeeded to reveal the specific disturbances of a nervous system leading to development of SBN.

Syndrome symptoms of "uneasy legs":

Unpleasant feelings in legs.
Usually they are described as crawlings of goosebumps, a shiver, a pricking, burning, twitching, action of the category of electric current, stir under skin, etc. About 30% of patients characterize these feelings as painful. Sometimes patients cannot precisely describe character of feelings, but they always are extremely unpleasant. These feelings in hips, shins, feet are localized and wavy there are each 5-30 seconds. There are considerable fluctuations of weight of the specified symptomatology. At some patients symptoms can arise only at the beginning of night, at others - continuously to disturb during the whole days.

Symptoms amplify at rest.
The most characteristic and unusual manifestation of SBN is strengthening of touch or motor symptoms at rest. Patients usually note deterioration in a sitting position or lying and especially when backfilling. Usually before emergence of symptomatology takes place from several minutes to an hour at stay in a quiet state.

Symptoms weaken at the movement.
Symptoms considerably weaken or disappear at the movement. The best effect is rendered most often by simple walking. In some cases the pandiculation, inclinations, exercises on the exercise bike or just standing helps. All this activity is under any control of the patient and can be suppressed in case of need. However it leads to considerable strengthening of symptoms. In hard cases the patient can suppress randomly the movements only for a short time.

Symptoms have circadian character.
The symptomatology considerably amplifies in the evening and in the first half of night (between 18 o'clock in the evening and 4 o'clock in the morning). Before dawn symptoms weaken and can disappear in general in the first half of day.

The periodic movements of extremities in a dream are noted.
During sleep (except REM of a dream) are noted involuntary periodic stereotypic short (on 0.5-3 c) the movements of the lower extremities every 5-40 seconds. They come to light at 70-90% of the patients suffering from SBN. In easy forms these movements happen within 1-2 hours after backfilling, in severe forms can continue all night long.

The disease often is followed by sleeplessness.
Patients complain of problems with backfilling and an uneasy night dream with frequent awakenings. Chronic sleeplessness can result in the expressed day drowsiness.

Diagnosis:

Recently created International group on a research of a syndrome of uneasy legs elaborated criteria of this disease. In total 4 criteria are necessary and sufficient for the diagnosis:
Need to move legs, usually connected with unpleasant feelings (paresthesias).
The motive concern including one or both types:
a) conscious autokinesias for reduction of symptoms,
b) short (0.5-10 c) the periods of the unconscious (involuntary) movements which are usually periodically repeating and arising preferential during rest or a dream.
Symptoms arise or amplify during rest and are considerably facilitated during physical activity, especially walking.
There is an expressed tsirkadnost of symptoms (dependence on time of day). Symptoms amplify in evening and night time (at most between 22 and 02 hours) and considerably weaken in the morning.

Unfortunately, there are no laboratory tests or researches which could confirm existence of SBN. So far the specific disturbances of a nervous system characteristic of SBN are not revealed. Out of the periods of aggravations any disturbances usually are not found in the patient. Moreover, in the afternoon the symptomatology often is absent i.e. when there is a contact with the doctor. Thus, the most valuable from the point of view of diagnosis is correctly collected anamnesis and understanding of essence of a disease.

Rather sensitive test is the polisomnografiya. At the patient lengthening of the period of backfilling in connection with constant autokinesias of legs is noted ("does not find the place"). But even after backfilling remain involuntary periodic stereotypic short (on 0.5-3 c) the movements of the lower extremities every 5-40 seconds. They come to light at 70-90% of the patients suffering from SBN. These movements cause microawakenings of a brain (activation on EEG) that breaks structure of a dream. At full awakening the patient has again an insuperable desire to move legs or to go. In the SBN easy forms and the periodic movements of extremities in a dream are noted when backfilling and within the first one-two hours of a dream. After disturbance disappear and the dream is normalized. In hard cases the patient of disturbance remain all night long. Simplification is noted only under the morning. In very hard cases the patient can sleep only 3-4 hours, and the rest of the time goes or continuously moves legs that gives some relief. However repeated attempts to fall asleep lead to sharp emergence of symptoms again.

Integral indicator of disease severity is the frequency of movements of extremities in an hour registered at a polisomnografichesky research (an index of periodic movements):
easy form 5-20 in an hour
moderate form 20-60 in an hour
severe form> 60 in an hour

Identification of "secondary SBN" requires an exception of the accompanying pathology which can cause SBN (see. The medical states connected with SBN). For detection of anemia, deficit of iron and diabetes blood tests (the general blood test, ferritin, iron, folic acid, B12 vitamin, glucose) are required. At suspicion of neuropathy it is necessary to execute an electromyography and a research of conductivity of nerves.

Treatment of a syndrome of "uneasy legs":

Medical tactics depends on causes of illness (primary or secondary syndrome) and weights of clinical manifestations.

Non-drug treatment.
The best non-drug treatment is different types of activity which can facilitate disease symptoms as much as possible. It can be the following types of activity:
1. Moderate physical exercises, especially with load of legs. Sometimes loading just before a dream helps. It is necessary to avoid, however, an "explosive" considerable exercise stress which can aggravate symptoms after its termination. Often patients note that if they give an exercise stress at the very beginning of SBN symptoms, then it can prevent their development and the subsequent emergence even in a quiet state. If patients try to delay physical activity as long as possible, then symptoms constantly accrue and quickly arise even after loading again.
2. Intensive grinding of legs.
3. Very hot or very cold foot baths.
4. Intellectual activity which requires considerable attention (the video game, drawing, discussions, computer programming, etc.)
5. Use of various physiotherapeutic procedures is possible (magnetotherapy, лимфопресс, massage, dirt, etc.), however their efficiency is individual.

Substances and medicines which should be avoided.
It was shown that caffeine, alcohol, neuroleptics, tricyclic antidepressants and antidepressants with blocking of the return serotonin reuptake can strengthen SBN symptoms. However at certain patients use of tricyclic antidepressants can render positive effect. Metoclopramidum (a raglan, cerucal) and some blockers of calcium channels are dopamine agonists. It is necessary to avoid their reception at patients with SBN. Antiemetics, such as prochlorperazine (Compazinum), considerably make heavier SBN. In case of need suppression of nausea and vomiting should be applied домперидон.

Treatment of secondary SBN.
Treatment of scarce states often leads to simplification or elimination of symptoms of SBN. It was shown that the lack of iron (decrease in level of ferritin lower than 40 mkg/l) can be the cause of secondary SBN. Doctors should mean especially that the lack of iron can not be followed by clinically expressed anemia. Peroral purpose of tablets of ferrous sulfate on 325 mg 3 times a day (about 100 mg of elementary iron) within several months can recover iron reserves (it is necessary to support ferritin level more than 50 mkg/l) and to reduce or eliminate SBN.
Deficit of folic acid can also provoke SBN. At the same time the corresponding replacement therapy is required.
At emergence of SBN against the background of a renal failure treatment can include elimination of anemia, purpose of erythropoetin, a clonidine, dopaminergic drugs and opiates.

Medicinal treatment.
At medicinal treatment of SBN it is necessary to observe a number of the principles:
- to apply minimum effective doses of drugs
- to increase dosages gradually before achievement of desirable effect
- often consecutive testing of several drugs for the purpose of the choice of the most effective medicine in a specific case is required.
- the combination of drugs with various mechanism of action can give the best effect, than monotherapy.

Hypnotic drugs and tranquilizers.
In mild cases of SBN it is possible to apply tranquilizers and somnolent drugs. Klonopin's (clonazepam) efficiency in a dose from 0.5 to 4.0 mg, Restorila (temazepam) in a dose from 15 to 30 mg, Haltsiona (triazolama) in a dose from 0.125 to 0.5 mg, Ambiyena (zolpidema) was shown. Klonapin is most studied in this group. It should be noted, however, its very long time of action and a possibility of day sedation. Prolonged treatment by these drugs bears risk of development of accustoming.

Dopaminergic drugs.
In more severe forms the drugs possessing dopaminergic action are used. It is most effective in this Sinemetum group, the immediate effect allowing to gain concerning SBN symptoms. This drug represents a combination of Karbidopy and the Levodopa who are predecessors of a dopamine. Even very small doses (1/2 or 1 tablet of Sinemetum 25/100) can eliminate symptomatology almost completely. The single dose can sometimes increase up to 2 tablets of Sinemetum 25/100. The effect usually develops in 30 minutes after reception and about 3 hours proceed. Sinemetum is appointed in 30 minutes before going to bed. At patients who do not test SBN symptoms every night drug is used as necessary. Unfortunately, duration of action of Sinemetum is insufficient to eliminate symptoms during the whole night. Sometimes there is a need of repeated administration of drug in the middle of the night. In these cases use of drug with gradual release of active agent (SR Sinemetum) is possible. Drug can be used in the afternoon for relief of symptoms of SBN in a slow-moving state, for example, at long flights or trips on the car.

The main problem connected with prolonged use of Sinemetum consists in gradual strengthening of symptoms of SBN. It is called "enhancement effect". The symptoms which were earlier arising only in the evening can appear after a lunch or even in the morning. For the purpose of prevention of this complication it is recommended to take no more than 2-3 pill of Sinemetum 25/100 in day. Attempts overcome "enhancement effect" by means of increase in dosages can aggravate a situation only even more. In this case it is the best of all to switch to other dopaminergic drug. For the termination of "enhancement effect" several days or after cancellation of Sinemetum can be required weeks. Other complications can include gastrointestinal discomfort, nausea, vomiting and a headache. Sometimes Parkinson's diseases arising at prolonged treatment by Sinemetum the pathological movements (dyskineses) extremely seldom are noted at long-term treatment of SBN in the small doses stated above.

Recently high performance Pergolida (Permaksa) concerning SBN was shown. This drug is an agonist of dopamine receptors. It is more effective, than Sinemetum, and causes "strengthening symptom" less often. However against the background of its use there are more side effects, in particular nausea and puffinesses mucous a nose. This drug should be considered as the second line of treatment at inefficiency of Sinemetum or development of "enhancement effect". The usual dosage of Pergolid makes from 0.1 to 0.6 mg in the separate doses accepted before going to bed and after a lunch if it is necessary. The dose should be increased carefully from 0:05 mg a day for the purpose of prevention of system hypotension. Frequent side effects include a nose congestion, nausea, hallucinations, a lock and hypotension.

Patients have data on efficiency of Parlodelum (bromkriptin) with SBN, however experience of its use is limited. Usual dosages make from 5 to 15 mg a day. Side effects are similar to those which are noted against the background of Pergolid's reception.

Recently the new agonist of dopamine receptors Pramipeksol was allowed for use for patients with Parkinson's disease (Мирапекс). Its efficiency at patients with SBN is studied now.

Antikonvulsanta.
The most perspective drug of this group is Gabapentin (Neyrontin). Drug is used in doses to 2700 mg a day and is especially effective at treatment of lungs or the SBN moderate forms at which patients describe unpleasant feelings in legs as painful. Also Carbamazepine (Tegretolum) is applied.

Opiates.
In hard cases of SBN use of opiates is possible. Usual the following dosages are applied: codeine from 15 to 240 mg/day, propoxyhair dryer from 130 to 520 mg/day, oxycodone from 2.5 to 20 mg/day, pentazocine from 50 to 200 mg/day, methadone from 5 to 50 mg/day. The side effects connected with reception of opiates include dizziness, sedation, nausea and vomiting. Are noted development of moderate tolerance, however many patients remain on constant doses for many years with permanent positive effect. At the same time dependence is minimum or does not develop in general. One more problem consists in invoicing by the doctor of these drugs which are strictly controlled.

Other drugs.
In separate observations efficiency of beta adrenoblockers, predecessors of serotonin, non-narcotic analgesics, vazodilatator, antidepressants was shown. However the same drugs can strengthen SBN symptomatology. Their use can be considered in that case when all other methods of treatment did not give effect or were badly transferable.

At patients with SBN the psychophysiological (conditioned-reflex) sleeplessness caused by problems with backfilling often develops. In case of effective treatment of SBN the remaining sleeplessness can demand independent behavioural or drug treatment.