Everything you wanted to know about Restless Legs Syndrome

Restless Legs Syndrome is a common but often undiagnosed neurological disorder. Here's what you need to know about it.

Restless legs syndrome (RLS),also called Willis-Ekbom disease, is a neurological disorder characterized by unpleasant and, often, painful sensations in the legs, and an uncontrollable urge to move the legs while resting or trying to fall asleep. It is a common disorder, but one that is mostly undiagnosed and barely treated, especially in the Indian context.

Highlights of this disorder are

• Symptoms occur during inactive periods, mainly at night when the person is resting or trying to sleep, and increase in severity during the night, so much so, the person cannot sleep.
• Lack of sleep causes daytime fatigue and exhaustion, affecting the quality of life and daily activities. Driving /traveling becomes difficult. Discomfort and lack of sleep can lead to depression.
• RLS can occur in anyone, be it children, adults or older adults. However, incidence of RLS is almost twice as high in women.
• RLS is more common in women during the third trimester of their pregnancy, and in people with chronic diseases such as diabetes, kidney disease, and Parkinson s disease.
• RLS is often associated with sleep disorders such as insomnia and sleep apnoea.
• People with RLS may also experience periodic limb movement of sleep (PLMS) characterized by involuntary leg twitching or jerking that may occur typically every 15 to 40 seconds.

Symptoms

The characteristic symptom of RLS is the unpleasant sensation in the legs that causes an overwhelming urge to move the legs. The unpleasant sensations include:

• Tugging
• Burning
• Tightening
• Feels like insects crawling inside the legs
• Jolts of electricity
• Stabbing
• Painful

The symptoms are not always painful for many, however, in all cases the symptoms are distressing.

RLS symptoms may also involve the arms and other parts. [1]

Severity of the condition increases with age.

Factors that initiate or worsen the condition:

• Rest or inactivity. More restful the position or longer the duration, more likely the symptoms will occur /worsen.
• Leg symptoms are worse at night, but are distinctly symptom-free in the early morning. That is the time when a person with RLS can get some sleep.
• Long distance travel
• Immobilisation in a cast
• Relaxation exercises

Causes

The exact cause of RLS is still unknown. However, scientists have found that in most cases, family history of the disorder plays a major role. Genes along with the interaction between brain iron deficiency and impaired dopaminergic neurotransmission in the brain, seem to be the cause of RLS. [2] Read more about Get rid of muscle cramps in less than 10 minutes

RLS (secondary RLS) is known to be associated with peripheral neuropathy, Parkinson s disease, diabetes, kidney failure, rheumatoid arthritis, sleep disorders, and iron, magnesium, or B12 deficiency.

RLS can also be caused by medications that treat nausea, allergies, and drugs for seizures or depression.

Diagnosis

The criteria for diagnosis includes

• Overwhelming urge to move the leg/s because of abnormal sensation or spontaneous jerks.
• Worsening symptoms at rest or at night.
• Temporary relief through movement

Diagnosis is supported by positive family history and positive effect of dopaminergic treatment. [1]

That said, diagnosis of RLS is mostly missed out not only by general physicians, but also by specialists like neurologists and psychiatrists, according to a study. Common misdiagnoses for restless legs symptoms are arthritis, calcium deficiency, worms in the stomach, depression, anxiety, stress, and vitamin deficiency, found the researchers of this study. [3] Read more about 10 common causes of leg pain

Treatment

There is no cure for RLS. The most you can do is treat the symptoms. Mild symptoms, generally don t need treatment. However, it is important to get screened for iron deficiency.

Treatments for RLS can be

1. Non-pharmacologic treatment
2. Pharmacologic treatment

Non-pharmacological therapies recommended by experts include

• Good sleep hygiene
• Going to bed and rising at the same time every day
• Moderate exercise
• Avoiding triggers such as caffeine and red wine
• Using compression stockings
• Infra-red light treatment [4]

Pharmacological treatment

1. Iron supplementation: This treatment is effective only when the ferritin concentrations go below 50 microgram/litre. Supplementation is not effective if you do not have iron deficiency.

2. Levodopa: Levodopa along with beserazide or carbidopa is indicated in mild and intermittent RLS.

• Dosage: Initial 50 to 62.5 mg and final 100 to 250 mg to be taken 1-2 hours before going to bed.
• Side effects: Nausea, headache, dry mouth, altered taste sensation.Levodopa is frequently associated with augmentation, which means, symptoms occur earlier and are frequently associated with worsening severity and sometimes spread to other body areas.

3. Dopamine agonists: [5] There are three dopamine agonists that are approved by the FDA: ropinirole, pramipexole, and transdermal rotigotine. The dosage and side effects of these agonists are tabulated below.

Drug name	Initial dose	Final dose	Side effects
Ropinirole	0.25 mg daily approximately 1 3 h before bedtime	0.50 4.00 mg daily approximately 1 3 h before bedtime	Nausea, drowsiness, fatigue, headache, augmentation, impulse control disorders, hypotension
Pramipexole	0.125 mg daily approximately 1 3 h before bedtime	0.125 1.000 mg daily approximately 1 3 h before bedtime	Nausea, drowsiness, fatigue, headache, augmentation, impulse control disorders, hypotension
Transdermal rotigotine (adhesive medicated patch placed on skin)	1 mgdaily	1 3 mg daily	Skin irritation, Nausea, drowsiness, fatigue, headache, augmentation, impulse control disorders, hypotension

Source: Neurotherapeutics. 2014 Jan; 11(1): 177 187.doi: 10.1007/s13311-013-0247-9

3. Anticonvulsants: Anticonvulsants such as gabapentin, carbamazepine, and valproic acid have been found to be quite effective for some people with RLS. However, these drugs are not FDA approved.

• Gabapentin is recommended as a first choice in painful RLS due to polyneuropathy.
• Dosage: Initial 300 mg and final 1,500 - 3,000 mg.
• Side effects: Ataxia (lack of muscle coordination), dizziness, drowsiness, fatigue, tremor, and dry mouth. In children, it can cause hyperactivity, anxiety, changing moods, and restlessness as well.
• Anticonvulsants, in general can also cause sedation, blood count abnormalities, rash, weight gain, edema, and some problems thinking. [6]

4. Other pharmacologic treatments include opioids and benzodiazepines. Opioids are not used as the first line of treatment now because of the possibility of addiction and, secondly, exacerbation of sleep apnoea. Benzodiazepines such as clonazepam, although improve sleep in some patients, are not that effective in reducing RLS.

Remedies

Medications may or may not help for some people with RLS. But self-care steps and lifestyle changes may help for most RLS patients. Following are some of these remedies that seemed to work with people with RLS.

• For some people, drinking lots of water during the day causes them to wake up frequently with RLS at night. They advise reducing water intake.
• On the other hand, for some, bad night with RLS can be relieved if they get up and drink about a litre of water.
• If you have chronic RLS, you can try soaking your legs (not just your feet) in ice-cold water for as long as you can. Repeat several times a day.
• If you find, however, that cold water treatment worsens your RLS,try covering your leg with a small weighted blanket instead. You may find relief within minutes.
• You can also try eating certain foods earlier in the day. For example, eat sugary foods during the first half of the day to avoid RLS at night.
• Some people may have a milk RLS connection. Check if eliminating dairy foods helps reduce your RLS.
• Many find rubbing Vicks VapoRub to be useful for RLS. Light rubbing with eucalyptus oil may also be effective.
• Tonic water with quinine, too, seems to help some. For example, an elderly patient found relief after half an hour of taking 8-ounce of Schweppes tonic water! Normally, if it is effective for you, you should continue using it regularly, and not when you get RLS.
• Again, for some people a deep massage works wonders.
• Massaging with a rolling pin may also help in some cases. Always roll up from ankle to the heart. Do not try this if you have varicose veins.
• If just nothing works, try sleep aids.

What works for them may or may not help you. Check out these remedies, but try to identify the measures or lifestyle changes that work for you to help alleviate your discomfort.

Reference:

1. Singh H, Verma S, Aggarwal S. Restless Legs Syndrome. Journal, Indian Academy of Clinical Medicine. 2008:9(3): 188-92.

2. Cotter PE, O Keeffe ST. Restless leg syndrome: is it a real problem? Therapeutics and Clinical Risk Management. 2006;2(4):465-475.

3. Gupta R, Lahan V, Goel D. Restless Legs Syndrome: A common disorder, but rarely diagnosed and barely treated - an Indian experience. Sleep Medicine. 2012;13(7):838-841. doi:10.1016/j.sleep.2012.03.018.

4. Wilt TJ, MacDonald R, Ouellette J, Tacklind J, Khawaja I, Rutks I, Butler M, Fink HA. Treatment for Restless Legs Syndrome. Comparative Effectiveness Review No. 86. AHRQ Publication No. 12(13)-EHC147-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2012.

5. Comella CL. Treatment of Restless Legs Syndrome. Neurotherapeutics. 2014;11(1):177-187. doi:10.1007/s13311-013-0247-9.
6. Medications for Willis-Ekbom disease/ Restless Legs Syndrome: A Guide To Help You Control and Manage Your WED/RLS. https://www.rls.org/document.doc?id=2333.

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