Restless legs syndrome and the role of pramipexole in its correction

Restless legs syndrome

The basic clinical symptoms are sensory (sensitive) disorders in the form of dys- and paresthesia and motor disorders in the form of involuntary motor activity. These symptoms affect mainly the lower extremities and are bilateral, although they can be asymmetrical. Sensory disorders appear at rest in a sitting position, and more often - lying down. As a rule, their greatest severity is observed in the period from 0 o'clock to 4 o'clock in the morning, and the least - in the interval from 6 o'clock to 10 o'clock in the morning. Patients are concerned about various sensations in the legs: tingling, numbness, pressure, itching, the illusion of “goosebumps running down the legs” or the feeling that “someone is scratching.” These symptoms are not acutely painful, but are very uncomfortable and painful.

Most often, the initial site of sensory impairment is the legs, less often the feet. As the disease develops, paresthesia covers the thighs and can occur in the arms, perineum, and in some cases on the torso. At the onset of the disease, discomfort in the legs appears after 15-30 minutes. from the moment the patient went to bed. As the syndrome progresses, their onset occurs earlier, even during the daytime. A distinctive feature of sensory disorders in RLS is their disappearance during the period of physical activity. To relieve discomfort, patients are forced to move their legs (bend-unbend, turn, shake), massage them, walk in place, and move around the room. But often, as soon as they lie down again or stop moving their legs, the unpleasant symptoms return again. Over time, each patient develops an individual movement ritual that allows them to most effectively get rid of discomfort.

About 80% of patients with Ekbom syndrome suffer from excessive motor activity, episodes of which bother them at night. Such movements are of a stereotypical, repetitive nature and occur in the feet. They represent the dorsiflexion of the big toe or all the toes, their extension to the sides, flexion and extension of the entire foot. In severe cases, flexion-extension movements in the knee and hip joints may be observed. An episode of involuntary motor activity consists of a series of movements, each of which takes no more than 5 s, the time interval between series is on average 30 s. The duration of the episode varies from several minutes to 2-3 hours. In mild cases, these movement disorders go unnoticed by the patient and are detected during polysomnography. In severe cases, motor episodes lead to night awakenings and may occur several times during the night.

The consequence of sensorimotor disorders that occur at night is insomnia. Due to frequent awakenings at night and difficulty falling asleep, patients have poor sleep and feel groggy after sleep. During the day, they experience decreased performance, the ability to concentrate suffers, and fatigue occurs. As a result of sleep disturbances, irritability, emotional lability, depression, and neurasthenia may occur.

Causes of pathology

The main cause of hyperkinesis is dysfunction of the cerebral motor system. This disorder can be caused by various factors:

• degenerative processes in the central nervous system that are hereditary in nature;
• conditions associated with perinatal trauma;
• suffered traumatic brain injuries;
• brain tumors;
• various toxic lesions - alcoholism, CO2 poisoning;
• previous neuroinfections – meningitis, encephalitis;
• cerebrovascular accidents;
• endocrine diseases;
• psychogenic factors – neuroses, psychoses, anxiety disorders.

Hyperkinesis in some cases occurs as a side effect when taking psychostimulants or antipsychotics.

Drug treatment

In cases of mild disease, only these measures may be sufficient, and the disease will recede. If they do not help, and the disease causes persistent disruption of sleep and vital functions, then they resort to medications.

Medicines used for illness:

1. Dopaminergic drugs (preparations containing L-DOPA - Nakom, Madopar, Sinemet; dopamine receptor agonists - Pramipexole Pronoran, Bromocriptine). These are the first-line drugs of choice; treatment begins with them. For medications containing L-DOPA, the initial dosage is 50 mg levodopa 1-2 hours before bedtime. If this is not enough, then after about a week the dose is increased by another 50 mg. The maximum dose is 200 mg. Dopamine receptor agonists have an effect comparable in effect to L-DOPA drugs. Pramipexole is prescribed starting from 0.125 mg, the dosage can be increased to 1 mg, Bromocriptine - from 1.25 mg (up to 7.5 mg), Pronoran - from 50 mg (up to 150 mg). If one dopamine receptor agonist is ineffective, it is advisable to replace it with another.
2. Benzodiazepines. Among this chemical group, Clonazepam (from 0.5 mg at night and up to 2 mg) and Alprazolam (from 0.25 mg to 0.5 mg at night) are most often used. Benzodiazepines have a greater effect on sleep than on discomfort and periodic movements in the legs, so they are considered “backup” drugs for the treatment of restless legs syndrome.
3. Anticonvulsants (Gabapentin, Neurontin, Carbamazepine) and opioid drugs (Tramadol, Codeine, Dihydrocodeine, Oxycodone). These drugs are used as a last resort only if dopaminergic and benzodiazepine drugs are ineffective or produce significant side effects. Gabapentin is prescribed in increasing dosages, starting with 300 mg and reaching a maximum dose of 2700 mg (stopping at the dose that has an effect). The entire dose is taken at night in one dose. Tramadol is taken 50-400 mg at night, Codeine - 15-60 mg, Dihydrocodeine - 60-120 mg, Oxycodone - 2.5-20 mg. These narcotic drugs are used only in particularly severe cases of restless leg syndrome because they can be addictive.

Willis disease is insidious in that patients often require long-term medication, so the doctor tries to select the minimum dosage of medications to relieve symptoms and have a gentle toxic effect on the body.

It is especially difficult to treat pregnant women. In such cases, the specialist tries to identify and eliminate the cause of the disease. In most cases, the culprit is a lack of microelements, especially iron. This condition is normalized after a course of iron-containing medications. If more serious disorders are detected in the body, doctors advise eliminating the symptoms of restless leg syndrome in pregnant women using non-drug methods, and small doses of drugs (usually Clonazepam or Levodopa) are prescribed for a short time and only in extreme cases. [adsen]

Treatment at home

At home, you can completely follow all the measures that will reduce the symptoms of the disease to a minimum.

1. It is imperative to create your own sleep schedule - fall asleep and wake up at the same time. If a patient suffers from neuropsychiatric disorders, the doctor will definitely advise training the mind.
2. Physical exercise. Moderate physical activity has a positive effect on the condition of the legs. During the day and before bed, it is useful to do exercise therapy, walk, do Pilates, swimming, yoga or stretching. But too active sports can provoke an increase in symptoms, so running, jumping, football and volleyball are contraindicated for people suffering from Willis disease.
3. Contrasting douches. Take contrasting foot baths, alternating cold and hot water.
4. Hobbies. At home you can find something to do: drawing, knitting, reading. Concentration helps relieve stress.
5. Systematic foot massage. Rubbing the lower extremities before bed can reduce discomfort and make it easier to fall asleep.

You can take cream or resort to the folk remedies that we indicated earlier. Be sure to avoid caffeine-containing products. Eat iron-containing foods and sleep in cotton socks. Some sources talk about the benefits of wearing sheep wool socks. Don't overeat at night. Having received a boost of energy, it will be more difficult for the body to fall asleep.

Statistics and historical background

Despite the apparent rarity of the disease, it occurs in 5-10% of the world's population. Simply isolating all the signs into a separate diagnosis is quite rare (unfortunately, due to the lack of awareness of medical personnel).

Humanity has known about restless legs syndrome for quite some time. The first description was given in 1672 by Thomas Willis, but this problem was studied quite well only in the 40s of the 20th century by the Swede Ekbom, so sometimes this disease is used under the names of these scientists - Willis disease or Ekbom disease.

The disease is most common among middle-aged and elderly people. The female gender suffers 1.5 times more often. About 15% of cases of chronic insomnia are due to restless legs syndrome.

Diagnostics

During polysomnography, periodic movements in the limbs are recorded.
Precisely because the main signs of restless legs syndrome are associated with subjective sensations, which are expressed to the patient in the form of complaints, the diagnosis of this disease is based solely on clinical signs.

In this case, additional research methods are carried out to find the possible cause of the disease. After all, some pathological conditions can occur unnoticed by the patient, manifesting only as restless leg syndrome (for example, iron deficiency in the body or the initial stage of a spinal cord tumor). Therefore, such patients undergo a general blood test, a blood sugar test, a general urinalysis, determine the level of ferritin in the plasma (reflects the saturation of the body with iron), and do electroneuromyography (shows the condition of the nerve conductors). This is not the entire list of possible examinations, but only those that are carried out for almost every patient with similar complaints. The list of additional research methods is determined individually.

One of the research methods that indirectly confirms the presence of restless legs syndrome is polysomnography. This is a computer study of the human sleep phase. In this case, a number of parameters are recorded: electrocardiogram, electromyogram, leg movements, chest and abdominal walls, video recording of the sleep itself, and so on. During polysomnography, periodic movements in the limbs are recorded that accompany restless legs syndrome. Depending on their number, the severity of the syndrome is conditionally determined:

• mild course - up to 20 movements per hour;
• moderate severity - from 20 to 60 movements per hour;
• severe course - more than 60 movements per hour.

Prevention

There is no consensus among patients on how to get rid of unpleasant attacks in the legs at night. Each patient has his own methods and means. We can only note that to reduce night attacks it is useful to carry out preventive measures:

1. Cancel late dinner, do not go to bed on a full stomach;
2. Yoga or Pilates classes;
3. Swimming;
4. In the autumn and spring, taking vitamins;
5. Change your working position frequently, take breaks with small gymnastic exercises;
6. Walk outside before bed;
7. Wear only cotton clothes, no synthetic materials. Feet should always be warm.

In general, there is no specific prevention for the hereditary form of restless legs syndrome. The main preventive measures are aimed at treating primary diseases, which over time can lead to the development of polyneuropathy and disruption of the dopaminergic system.