RLS is a common disease that affects about 10% of the general population [1].

1. What Is the Main Cause of Restless Leg Syndrome?

Although the cause is unknown, it is thought that the main cause of restless leg syndrome (RLS) is associated with an imbalance in the function of the neurotransmitter dopamine due to low levels of iron in the brain and body [1].

Dopamine is an organic chemical involved in the transmission of instructions between neurons to control muscle movements and reward-motivated behavior [2].

Other potential causes involve heredity, pregnancy, attention deficit hyperactivity disorder (ADHD), and medications.

1.1. What Is the Relation Between Restless Leg Syndrome and Heredity?

A role of heredity in RLS is associated with the high frequency of family history of RLS in patients diagnosed with this disease [3].

Monozygotic and dizygotic twin studies confirmed heredity involvement in RLS by showing the existence of a high concordance of RLS in monozygotic twins compared with that in dizygotic twins.

1.2. What Is the Relation Between Restless Leg Syndrome and Pregnancy?

Due to hormonal changes during the third semester of pregnancy, some women may experience RLS which disappears after delivery [4].

These changes involve an increase in the production of hormones, including estrogens, prolactin, progesterone, and thyroid hormone.

A reduction of iron and folate levels during pregnancy also appears to contribute to RLS due to their involvement in the synthesis of dopamine which further highlights the role of dopamine as the main cause of restless leg syndrome.

The prevalence of RLS during pregnancy was estimated to be in the range of 2.9-32% which is about 2-3 times higher than that in non-pregnant women.

1.3. What Is the Relation Between Restless Leg Syndrome and ADHD?

A relation Between Restless Leg Syndrome and ADHD was proposed by a study that showed that 44% of individuals with ADHD also had RLS.

Another important piece of information to add is that both ADHD and RLS have alterations related to dopamine levels in the brain [5].

1.4. What Is the Relation Between Restless Leg Syndrome and Medications?

Certain medications have been associated with restless leg syndrome, such as antidepressants (e.g., SSRIs, Tricyclics), withdrawal from sedative-hypnotic drugs (e.g., benzodiazepines), antiemetics (e.g., anticholinergics), antipsychotics, anticonvulsants, and antihistamines (e.g., diphenhydramine) [6].

Furthermore, alcohol and opioid withdrawal have also been associated with RLS.

2. Who Is Prone to Restless Leg Syndrome?

Restless leg syndrome (RLS) can develop at any age but is more common in women than men. There are also some factors that can increase the risk of RLS:

• Low Iron Levels
• Kidney Failure
• Neuropathy
• Rheumatoid Arthritis
• Diabetes Mellitus
• Celiac Disease
• Alcohol
• Iron Deficiency Anemia
• Parkinson’s Disease

2.1. Low Iron Levels

Iron is an essential cofactor in the production of dopamine and its deficiency can trigger RLS. Low iron levels can be due to blood loss through internal hemorrhage (e.g., gastrointestinal bleeding), excessive menstrual bleeding, frequent blood donations, or malabsorption.

2.2. Kidney Failure

Patients with chronic kidney disease on dialysis have decreased levels of iron due to the depletion of its storage in the blood.

2.3. Neuropathy

Increased levels of glucose in the blood such as during diabetes can lead to damage of nerves resulting in RLS.

2.4. Rheumatoid Arthritis

There is an elevated prevalence of RLS in patients with rheumatoid arthritis reaching between 27.7-31% [7].

2.5. Alcohol

Excessive consumption of alcohol (alcoholism) can lead to damage of nerves leading to RLS.

2.6. Celiac Disease

Celiac disease is an intestinal chronic disease characterized by a loss of appetite, malabsorption, and diarrhea due to gluten intolerance.

Celiac disease can also lead to iron deficiency which may lead to RLS. In fact, a study showed that 40% of studied patients with celiac disease had an iron deficiency [8].

2.7. Parkinson’s Disease

The characteristic dysfunction of dopamine in Parkinson’s Disease may explain why RLS is observed in some PD patients [9].

2.8. Iron Deficiency Anemia

Iron deficiency anemia is caused by a lack of iron in the body resulting in a reduction of the number of red blood cells leading to anemia. This lack of iron can also affect dopamine production.

3. What Symptoms Come with Restless Leg Syndrome?

Restless leg syndrome manifests with the following symptoms:

• An urge to move the legs due unpleasant sensations in the legs.
• An urge to move the legs during periods of rest or inactivity.
• The urge to move the legs may partially or totally be relieved by movement, such as walking or stretching.
• The urge to move the legs is increased in the evening or night than during the day.

4. Is Restless Leg Syndrome Psychological?

Although restless leg syndrome (RLS) is considered a neurological disease, a study that included 38 patients with RLS and 42 non-RLS controls, showed that patients with RLS have a lower internal locus of control (ability to impact its own health) and negative sleep-related personality traits compared to the non-RLS controls [10].

A negative sleep-related personality trait is associated with lower self-confidence, depression, higher mental arousal, and poorer quality of life.

5. How do you get rid of restless legs syndrome?

The treatment of RLS is aimed at relieving the associated symptoms that are caused by underlying physical conditions such as diabetes, celiac disease, or iron deficiency.

Medications to relieve the symptoms of RLS involve the use of dopaminergic drugs to improve dopamine effects, opioids to relieve the symptoms of severe RLS, and benzodiazepines for restful sleep.

Changes in lifestyle such as stopping alcohol, exercising (e.g., aerobics, stretching), taking iron supplements, respecting a regular sleep pattern, can help relieve some of the moderate symptoms.

Conclusion

Restless leg syndrome (RLS) can cause uncomfortable sensations that can affect sleep and the quality of life of the affected individual. The cause is unknown, but many studies highlighted the potential involvement of dopamine as the main cause.

RLS is also associated with several diseases which share with RLS the deficiency in iron which is an essential cofactor in the production of dopamine. However, other diseases and conditions such as diabetes or alcoholism can lead to nerve damage due to high blood levels of glucose or alcohol, respectively.

Although there is no specific treatment for RLS, dealing with this disease involves symptomatic treatments that aim at alleviating or reducing the undesirable and overwhelming manifestations of RLS.

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However, pain is not only physical because a sensory experience can also be due to mental health conditions such as depression, anxiety, or anger.

Therefore, a difference exists between pain and the cause of the pain. The link between the two is mediated by our nervous system through a process known as nociception.

It was estimated that 20.4% of adult individuals had chronic pain and that 7.4% of adult individuals had chronic pain which limited their activities, such as working, in the past 3 months [2].

1- What is emotional pain?

Emotional pain can be defined by the heartache we feel when losing someone or something that was important to us.

2- Is pain an emotion or feeling?

A Feeling is the outcome or expression of our interpretation of an emotion that was caused by pain (physical or psychological).

3- What is the worst mental pain?

They are several mental conditions that are characterized by unbearable psychological and emotional pain that is characterized by suicidal thoughts (suicidal ideation).

These include Emotionally unstable personality disorder (borderline personality disorder) and seasonal affective disorder.

4- What are Nociceptors?

Nociceptors are sensory neurons that respond to damage or potential damage through alerting communications to the brain and spine [3].

Nociceptors can be mechanical, thermal, mechano-thermal, polymodal, or silent.

Mechanical nociceptors respond to mechanical damage or pressure, while thermal nociceptors respond to cold or hot temperatures.

Mechano-thermal nociceptors respond to both mechanical and thermal stimuli, while silent nociceptors respond to inflammatory mediators.

5- What Are the Types of Pain?

• Acute Pain

Acute pain is caused by spasms of skeletal muscles and the activation of the sympathetic nervous system that is due to an injury or a trauma. The duration of the pain is short and disappears with the healing of the injury.

• Chronic Pain

Chronic pain is also caused by an injury or a disease, but the pain would continue even after the healing period.

• Nociceptive Pain

Nociceptive pain is caused by an injury, trauma, chemicals, or surgery that results in the activation and release of inflammatory mediators by nociceptor neurons (sensory neurons) which activate inflammation in the injured area [4].

• Neuropathic Pain

Neuropathic pain is due to direct damages or compression of the sensory nerves associated with sciatica, neuropathies such as phantom limb pain, Wallerian degeneration, segmental demyelination, or diabetic neuropathies.

5- Are There Other Classifications of Pain?

• Allodynia

Allodynia is a pain that is caused by a stimulus that is not the one that initiated the pain, such as feeling pain after a gentle shake of hands or light touch on the back.

• Analgesia

Analgesia is characterized by the inability to feel the pain caused by a stimulus (cause) that should normally have caused pain.

• Hyperpathia

Hyperpathia is a neuropathic pain characterized by an abnormal, repetitive, and elevated pain reaction to the stimulus (cause).

• Causalgia

Causalgia is neuropathic pain that combines a sensation of burning pain, hyperpathia, and allodynia.

• Dysesthesia

Dysesthesia is an unpleasant and abnormal sensation such as cold sensation, tingling, burning, numbness, tickling, or pain that is caused by nerve trauma or irritation.

• Hyperalgesia

Hyperalgesia is characterized by an abnormally increased sensitivity to pain due to the release of inflammatory hormone-like substances, known as prostaglandins, that increase the sensitivity of the nociceptors.

Hyperalgesia can be caused by fibromyalgia, diabetes, infection, trauma, postherpetic neuralgia, and complex regional pain syndrome.

• Hyperesthesia

Hyperesthesia is characterized by an increased sensitivity to stimuli associated with senses such as hearing, tasting, touch, smelling,

Hyperesthesia is caused by excessive stimulation of the nervous system such as overconsumption of caffeine.

• Hypoalgesia

Unlike analgesia characterized by the inability to feel pain, hypoalgesia is associated with a reduced response to a painful stimulus.

6- What Are the Symptoms of Pain?

The symptoms of pain are categorized corresponding to the pain intensity, duration, and pain-related disability [5]. These categories allow the classification of pain into mild, moderate, or severe using assessment methods:

• Visual Analogue Scale

This method consists in drawing a line between two points. The first point is the “no pain” and the second point is the “as bad as it could be”.

The individual in pain is requested to mark the level of pain within the two endpoints.

• Graphic Rating Scale (GRS)

This method represents a drawing of a line with levels from 1 to ten representing the intensity of pain. No pain is represented by the number 0 and “as bad as it could be” is represented by the number 10.

The individual in pain is requested to indicate the number from 0 to 10 which represents the level of pain experienced by the individual.

• Verbal Rating Scale

This method evaluates the pain experienced by the patient using adjectives to describe the level of pain.

• Pain Drawing

In this method, the patient is requested to indicate the location of the pain on a drawn human body.

• McGill Pain Questionnaire (MPQ)

This questionnaire assesses the pain-rating index, the number of words describing the pain, and the level of pain on a scale of 1-5.

8- What Is the Treatment of Pain?

Pain is mainly managed.

• Non-pharmacological Management

Non-pharmacological management involves:

– Exercise such as swimming, walking, yoga, Pilates, and exercise bike.

– Physical therapy through physiotherapists and occupational therapists who will help with stretching and pain-relieving exercises.

– Psychological management through social support, psychologists, and psychotherapists.

• Pharmacological Management

For mild and moderate pain, non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are used.

Although there is a high risk of dependency, opioid analgesics (e.g., morphine) are used for the treatment of severe pain.

Conclusion

Although the risk factors in the progression from acute to chronic pain are well known, identifying patients who are predisposed to this progression through assessing the status of the acute pain, the physiological and reactivity of the patients to pain, should help better manage this switch from acute to chronic pain.

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