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Restless Leg Syndrome

Do you have restless legs syndrome?

When sitting or lying down, do you have unpleasant or creepy-crawly sensations in your legs (and sometimes in other parts of your body), tied to a strong feeling or urge to move?
Do the sensations and urge to move come on during periods of rest or inactivity and are they relieved by movement?
Do the sensations and urge to move bother you more in the evening and at night rather than during the day?
Do you often have trouble falling asleep or staying asleep?
Does your bed partner tell you that you jerk your legs (or your arms) when you are asleep; do you sometimes, have involuntary leg jerks when you are awake?
Are you frequently tired or fatigued during the day?
Do you have family members who experience these same sensations and urge to move?
Have medical tests not revealed a cause for your sensations and urge to move?

If you do have restless legs syndrome (RLS), you are not alone. Up to 8% of the U.S. population may have the neurologic condition. Many have a mild form of the disorder, but RLS severely affects the lives of millions of individuals.

Primary Feature of RLS

Adults with RLS will typically have all four of these primary features.

The bothersome, but usually not painful, sensations deep in the legs produce an irresistible urge to move. Some words used to describe these sensations include creeping, itching, pulling, creepy-crawly or tugging. (These sensations may involve a strong urge to move the legs. These may also occasionally occur in the arms.)
Symptoms are worse or exclusively present when the afflicted individual is at rest, and the sensations are typically lessened by voluntary movement of the affected extremity.
Symptoms are worse in the evenings and at night, especially when the individual lies down.
Movement of the toes, feet, or legs (known as restlessness) are typically seen when the affected individual is sitting or lying down in the evening. The restlessness may be seen as fidgetiness or nervousness.

Associated features

RLS symptoms can cause difficulty in falling and staying asleep. Approximately 80% of people with RLS will also have periodic limb movements of sleep, which are jerks that typically occur every 20 to 30 seconds on and off during the night, often causing partial arousals that disrupt sleep.

Because you may experience difficulties with falling asleep and staying asleep at night, you may be abnormally tired or even sleepy during wake hours. Chronic sleep deprivation and its resultant daytime sleepiness can affect your ability to work, participate in social activities, and partake in recreational pastimes, such as going to a theater.

Cause

Research into the cause of RLS is ongoing and answers are limited, but we do think that RLS may have different but perhaps overlapping causes.

RLS often runs in families. Researchers are currently looking for the gene or genes that may be responsible for this form of RLS, known as primarily or familial RLS.

RLS may be the result of another condition, which, when present, worsens the underlying RLS. This is called secondary RSL. During pregnancy, particularly during the last few months, up to 25% of women develop RLS. After delivery, their symptoms often vanish. Anemia and low levels of iron in the blood are associated with symptoms of RLS, as are chronic conditions such as peripheral neuropathy (damage to the nerves in the hands and feet) and kidney failure.

If you have no family history of RLS and no underlying or associated conditions causing the disorder, your RLS is said to be idiopathic, meaning without a known cause.

Age of onset

Though RLS is diagnosed most often in people in their middle years, many individuals with RLS, particularly those with primary RLS, can trace their symptoms back to childhood. These symptoms may have been called growing pains or the children may have been thought to be hyperactive because they had difficulty sitting quietly.

Diagnosis

With its classic symptoms, RLS is diagnosed by reviewing your medical history. After ruling out other medical conditions as the cause of your symptoms, your healthcare provider can make the diagnosis of RLS by listening to your description of these sensations. No laboratory test exists that can confirm your diagnosis of RLS. However, a thorough physical examination, including the results of necessary laboratory tests, can reveal temporary disorders, such as iron deficiency, that may be associated with RLS. Some people (including those with periodic limb movements of sleep and without the abnormal sensations of RLS) will require an overnight testing of sleep to determine other causes of their sleep disturbance.

Treatment

The goal of any medical treatment, including the treatment of RLS, is to achieve the greatest benefit while incurring the fewest risks. Sound treatment strategy, therefore involves weighing these risks and benefits and beginning with the least-risky treatments. Low-risk therapies involve treating symptoms that are caused by underlying disorders and making lifestyle changes.

If an underlying iron or vitamin deficiency is found to be the cause of your restless legs, supplementing your iron may be sufficient to relieve your symptoms. Current recommendations include checking a serum level (to evaluate iron-storage status) and supplementing with iron if your ferritin level is less than 50 mcg/L.

The use of some medications seems to worsen the symptoms of RLS. These drugs include calcium-channel blockers (used to treat high blood pressure and heart conditions), most antinausea medications, some cold and allergy medications, major tranquilizers, phenytoin, and most medications used to treat depression.

Lifestyle changes involve determining, on an individual basis, which habits and activities worsen or improve your symptoms of RLS. A healthy balanced diet is important in reducing the severity of your RLS. The best solution is to avoid all caffeine-containing products, including chocolate and caffeinated beverages such as coffee, tea, and soft drinks. The consumption of alcohol increases the span or intensity of symptoms for most individuals; again, refraining from the use of alcohol is your best solution.

Because fatigue and drowsiness tend to worsen the symptoms of RLS, implementing a program of good sleep hygiene should be a first step toward resolving your symptoms. You may find that you achieve your best sleep later in the 24-hour cycle – for example, sleeping from 2am until 10am may work best for you. Some people find that performing isometric exercises for a few minutes before bed is helpful.

Self-directed activities that counteract your symptoms of RLS appear to be effective, although temporary, solutions to managing the disorder. You may find that walking, stretching, taking a hot or cold bath, massaging your affected limb, applying hot or cold packs, using vibration, performing acupressure, and practicing relaxation techniques (such as biofeedback, meditation, or yoga) may help reduce or relieve your symptoms. You may also find that keeping your mind actively engaged through activities such as participating in a stimulating discussion or argument, performing intricate needlework, or playing video games helps during times that you must stay seated, such as when you are traveling.

Unfortunately, in most cases, the symptoms of RLS either initially do not resolve with treatment of underlying disorders and the implementation of lifestyle changes or, over time, progress so that relief is insufficient with these methods. In either case, the use of medications (pharmacologic therapy) may become necessary.

Pharmacologic therapy

These medications fall into four main classes- dopaminergic agents, sedatives, pain relievers, and anticonvulsants. Each drug or class of drugs has its own benefits, limitations, and side-effect profile. Dopaminergic agonists are the only FDA-approved medications for RLS. The choice of medication is dependent upon the timing and severity of your symptoms.

Dopaminergic agents

The primary and first-line treatment for RLS is with dopaminergic agents: primarily dopamine-receptor agonists like Mirapex (pramipexole), and Requip (ropinirole), but also drugs like Sinemet (Carbidopa/ Levodopa) that add dopamine to the system. Although dopaminergic agents are used to treat Parkinson’s disease, RLS is not a form of Parkinson’s disease, and RLS is not a precursor to Parkinson's Disease. All of these drugs should be started at low doses and increased very slowly to decrease potential side effects.

Sedatives

Sedative agents are most effective for relieving the nighttime symptoms of RLS. They are used either at bedtime in addition to a dopaminergic agent or for individuals who have primarily nighttime symptoms. The most commonly used sedative is clonazepam (Klonopin).

Pain relievers

Pain-relieving drugs are most often for people with severe relentless symptoms of RLS. Some examples of medications in this category include codeine, Darvon or Darvocet (propoxyphene), Dolophine (methadone), Percocet (Oxycodone), Ultram (Tramadol), and Vocodin (Hydrocodone).

Anticonvulsants

These drugs are particularly effective for some, but not all, patients with marked daytime symptoms, particularly people who have pain syndromes associated with their RLS. Gabapentin (Neurontin) is the anticonvulsant that has been shown the most promise in treating the symptoms of RLS.

Summary

Because no single treatment for RLS is entirely effective for everyone, continued research of it is of vital importance. Until we find the cause of RLS and a cure, working closely with your healthcare provider, interacting with a local support group, and exploring nondrug treatments as well as pharmacologic therapy will help you find the answer to a happy productive life in spite of having RLS.

*Adapted from the Restless Legs Syndrome Foundation