Restless legs syndrome
Restless leg syndrome is a sleep disorder characterized by leg
discomfort during sleep, which is only relieved by frequent movements of the legs.
Information about Restless legs syndrome
Restless leg syndrome (RLS) occurs most often in middle-aged and older adults. It is
worsened by stress. The cause is not known.
The disorder consists of sensations in the lower legs that make the person uncomfortable
unless the legs are moved. The sensations usually occur shortly after going to bed but may
also occur during the daytime.
The abnormal sensations occasionally occur in the upper leg, the feet or the arms in
addition to the lower leg. There are often no obvious vascular or neurologic abnormalities
associated with the disorder. Sometimes restless leg syndrome can be associated with
peripheral nerve diseases, however.
There is an irresistible urge to walk or move the legs to relieve the discomfort,
resulting in periodic episodes of leg movements during early sleep stages. The symptoms
may last for 1 hour or longer.
Restless leg syndrome can result in a decreased quality of sleep (insomnia) with
subsequent daytime sleepiness, anxiety or depression, and confusion or slowed thought
processes from lack of sleep.
Symptoms of Restless legs syndrome
- Sleeping difficulty
- Persistent leg movements during sleep hours
- Irresistible urge to move the legs
- Abnormal sensation in the legs (occasionally, feet, thighs, arms)
- Creeping sensations or discomfort (not pain, not cramps) relieved by movement of the
- May occur during the day
- Worse when lying down
Causes of Restless legs syndrome
Most people experience mild symptoms. They may lie down to rest at the end of the day
and, just before sleep, will experience discomfort in their legs that prompts them to
stand up, massage the leg, or walk briefly. Eighty-five percent of RLS patients either
have difficulty falling asleep or wake several times during the night, and almost half
experience daytime fatigue or sleepiness. It is common for the symptoms to be
intermittent. They may disappear for several months and then return for no apparent
reason. Two-thirds of patients report that their symptoms become worse with time. Some
older patients claim to have had symptoms since they were in their early 20s, but were not
diagnosed until their 50s. Suspected under-diagnosis of RLS may be attributed to the
difficulty experienced by patients in describing their symptoms.
More than 80% of patients with RLS experience periodic limb movements in sleep (PLMS).
These random movements of arms or legs may result in further sleep disturbance and daytime
fatigue. Most patients have restless feelings in both legs, but only one leg may be
affected. Arms may be affected in nearly half of patients.
There is no known cause for the disorder, but recent research has focused on several
key areas. These include:
- Central nervous system (CNS) abnormalities. Several types of drugs have been found to
reduce the symptoms of RLS. Based on an understanding of how these drugs work, theories
have been developed to explain the cause of the disorder. Levodopa and other drugs that
correct problems with signal transmission within the central nervous system (CNS) can
reduce the symptoms of RLS. It is therefore suspected that the source of RLS is a problem
related to signal transmission systems in the CNS.
- Iron deficiency. The body stores iron in the form of ferritin. There is a relationship
between low levels of iron (as ferritin) stored in the body and the occurrence of RLS.
Studies have shown that older people with RLS often have low levels of ferritin.
Supplements of iron sulfate have been shown to significantly reduce RLS symptoms for these
Diagnosis of Restless legs syndrome
A careful history enables the physician to distinguish RLS from similar types of
disorders that cause night time discomfort in the limbs, such as muscle cramps, burning
feet syndrome, and damage to nerves that detect sensations or cause movement
The most important tool the doctor has in diagnosis is the history obtained from the
patient. There are several common medical conditions that are known to either cause or to
be closely associated with RLS. The doctor may link the patient's symptoms to one of these
conditions, which include anemia, diabetes, disease of the spinal nerve roots (lumbosacral
radiculopathy), Parkinson's disease, late-stage pregnancy, kidney failure (uremia), and
complications of stomach surgery. In order to identify or eliminate such a primary cause,
blood tests may be performed to determine the presence of serum iron, ferritin, folate,
vitamin B12, creatinine, and thyroid-stimulating hormones. The physician may
also ask if symptoms are present in any close family members, since it is common for RLS
to run in families and this type is sometimes more difficult to treat.
In some cases, sleep studies such as polysomnography are undertaken to identify the
presence of PLMS that are reported to affect 70-80% of people who suffer from RLS. The
patient is often unaware of these movements, since they may not cause him to wake.
However, the presence of PLMS with RLS can leave the person more tired, because it
interferes with deep sleep. A patient who also displays evidence of some neurologic
disease may undergo electromyography
(EMG). During EMG, a very small, thin needle is inserted into the muscle and electrical
activity of the muscle is recorded. A doctor or technician usually performs this test at a
hospital outpatient department.
Treatment of Restless legs syndrome
The first step in treatment is to treat existing conditions that are known to be
associated with RLS and that will be identified by blood tests. If the patient is anemic,
iron (iron sulfate) or vitamin supplements (folate or vitamin B12) will be
prescribed. If kidney disease is identified as a cause, treatment of the kidney problem
will take priority.
In some people whose symptoms cannot be linked to a treatable associated condition,
drug therapy may be necessary to provide relief and restore a normal sleep pattern.
Prescription drugs that are normally used for RLS include:
- Benzodiazepines and low-potency opioids. These drugs are prescribed for use only on an
"as needed" basis, for patients with mild RLS. Benzodiazepines appear to reduce
nighttime awakenings due to PLMS. The benzodiazepine most commonly used to treat RLS is
clonazepam (Klonopin, Rivotril). The main disadvantage of this drug type is that it causes
daytime drowsiness. It also causes unsteadiness that may lead to accidents, especially for
an elderly patient. Opioids are narcotic pain relievers. Those commonly used for mild RLS
are low potency opioids, such as codeine (Tylenol #3) and propoxyphene (Darvocet). Studies
have shown that these can be successfully used in the treatment of RLS on a long-term
basis without risk of addiction. However, narcotics can cause constipation and difficulty
- Levodopa (L-dopa) and carbidopa (Sinemet). Levodopa is the drug most commonly used to
treat moderate or severe RLS. It acts by supplying a chemical called dopamine to the
brain. It is often taken in conjunction with carbidopa to prevent or decrease side
effects. Although it is effective against RLS, levodopa may also causes a worsening of
symptoms during the afternoon or early evening in 50-80% of patients. This phenomenon is
known as "restless legs augmentation," and if it occurs, the physician will
probably discontinue Levodopa for a brief period while an alternate drug is used. Levodopa
can often be reintroduced after a short break.
- Pergolide (Permax). Pergolide acts on the same part of the brain as Levodopa. It is less
likely than Levodopa to cause daytime worsening of symptoms (occurs in about 25% of
patients). However, it is not recommended as the first choice in drug therapy since it
causes a high rate of minor side effects. Pergolide is often used only if Levodopa has
- High potency opioids. If the symptoms of RLS are difficult to treat with the above
medication, higher dose opioids will be used. These include methadone (Dolophine),
oxycodone, and clonidine (Catapres, Combipres, Dixarit). A significant disadvantage of
these drugs is risk of addiction.
- Anticonvulsants. Some cases of RLS may be improved by anticonvulsant drugs, such as
- Combination therapy. Some patients respond well to combinations of drugs such as a
benzodiazepine and Levodopa.
Many drugs have been investigated for treatment of RLS, but it seems as though the
perfect therapy has not yet been found. However, careful monitoring of side effects and
good communication between patient and doctor can result in a flexible program of therapy
that minimizes side effects and maximizes effectiveness.
Alternative treatment of Restless legs syndrome
It is likely that the best alternative therapy will combine both conventional and
alternative approaches. Levodopa may be combined with a therapy that relieves pain,
relaxes muscles, or focuses in general on the nervous system and the brain. Any such
combined therapy that allows a reduction in dosage of levodopa is advantageous, since this
will reduce the likelihood of unacceptable levels of drug side effects. Of course, the
physician who prescribes the medication should monitor any combined therapy. Alternative
methods may include:
- Acupuncture. Patients who also suffer from rheumatoid arthritis may especially benefit
from acupuncture to relieve RLS symptoms. Acupuncture is believed to be effective in
arthritis treatment and may also stimulate those parts of the brain that are involved in
- Homeopathy. Homeopaths believe that disorders of the nervous system are especially
important because the brain controls so many other bodily functions. The remedy is
tailored to the individual patient and is based on individual symptoms as well as the
general symptoms of RLS.
- Reflexology. Reflexologists claim that the brain, head, and spine all respond to
indirect massage of specific parts of the feet.
- Nutritional supplements. Supplementation of the diet with vitamin E, calcium, magnesium,
and folic acid may be helpful for people with RLS.
Some alternative methods may treat the associated condition that is suspected to cause
restless legs. These include:
- Anemia or low ferritin levels. Chinese medicine will emphasize stimulation of the spleen
as a means of improving blood circulation and vitamin absorption. Other treatments may
include acupuncture and herbal therapies, such as ginseng (Panax ginseng) for
- Late-stage pregnancy. There are few conventional therapies available to pregnant women,
since most of the drugs prescribed are not recommended for use during pregnancy. Pregnant
women may benefit from alternative techniques that focus on body work, including yoga,
reflexology, and acupuncture.
Prognosis of Restless legs syndrome
RLS usually does not indicate the onset of other neurological disease. It may remain
static, although two-thirds of patients get worse with time. The symptoms usually progress
gradually. Treatment with Levodopa is effective in moderate to severe cases that may
include significant PLMS. However, this drug produces significant side effects, and
continued successful treatment may depend on carefully monitored use of combination drug
therapy. The prognosis is usually best if RLS symptoms are recent and can be traced to
another treatable condition that is associated with RLS. Some associated conditions are
not treatable. In these cases, such as for rheumatoid arthritis, alternative therapies
such as acupuncture may be helpful.
Prevention of Restless legs syndrome
Diet is key in preventing RLS. A preventive diet will include an adequate intake of
iron and the B vitamins, especially B12 and folic acid. Strict vegetarians
should take vitamin supplements to obtain sufficient vitamin B12. Ferrous
gluconate may be easier on the digestive system than ferrous sulfate, if iron supplements
are prescribed. Some medications may cause symptoms of RLS. Patients should check with
their doctor about these possible side effects, especially if symptoms first occur after
starting a new medication. Caffeine, alcohol, and nicotine use should be minimized or
eliminated. Even a hot bath before bed has been shown to prevent symptoms for some