Restless Legs Syndrome

Overview

Restless legs syndrome (RLS) is a condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation. It typically happens in the evening or nighttime hours when you're sitting or lying down. Moving eases the unpleasant feeling temporarily.

Restless legs syndrome, also known as Willis-Ekbom disease, can begin at any age and generally worsens as you age. It can disrupt sleep, which interferes with daily activities.

Simple self-care steps and lifestyle changes may help relieve symptoms. Medications also help many people with RLS.

Symptoms

The chief symptom is an urge to move the legs. Common accompanying characteristics of RLS include:

• Sensations that begin while resting. The sensation typically begins after you've been lying down or sitting for an extended time, such as in a car, airplane or movie theater.
• Relief with movement. The sensation of RLS lessens with movement, such as stretching, jiggling the legs, pacing or walking.
• Worsening of symptoms in the evening. Symptoms occur mainly at night.
• Nighttime leg twitching. RLS may be associated with another, more common condition called periodic limb movement of sleep, which causes the legs to twitch and kick, possibly throughout the night, while you sleep.

People typically describe RLS symptoms as compelling, unpleasant sensations in the legs or feet. They usually happen on both sides of the body. Less commonly, the sensations affect the arms.

The sensations, which generally occur within the limb rather than on the skin, are described as:

• Crawling
• Creeping
• Pulling
• Throbbing
• Aching
• Itching
• Electric

Sometimes the sensations are difficult to explain. People with RLS usually don't describe the condition as a muscle cramp or numbness. They do, however, consistently describe the desire to move the legs.

It's common for symptoms to fluctuate in severity. Sometimes, symptoms disappear for periods of time, then come back.

When to see a doctor

Some people with RLS never seek medical attention because they worry they won't be taken seriously. But RLS can interfere with your sleep and cause daytime drowsiness and affect your quality of life. Talk with your health care provider if you think you may have RLS.

Causes

Often, there's no known cause for RLS. Researchers suspect the condition may be caused by an imbalance of the brain chemical dopamine, which sends messages to control muscle movement.

Heredity

Sometimes RLS runs in families, especially if the condition starts before age 40. Researchers have identified sites on the chromosomes where genes for RLS may be present.

Pregnancy

Pregnancy or hormonal changes may temporarily worsen RLS signs and symptoms. Some women get RLS for the first time during pregnancy, especially during their last trimester. However, symptoms usually disappear after delivery.

Risk factors

RLS can develop at any age, even during childhood. The condition is more common with increasing age and more common in women than in men.

RLS usually isn't related to a serious underlying medical problem. However, it sometimes accompanies other conditions, such as:

• Peripheral neuropathy. This damage to the nerves in the hands and feet is sometimes due to chronic diseases such as diabetes and alcoholism.
• Iron deficiency. Even without anemia, iron deficiency can cause or worsen RLS. If you have a history of bleeding from the stomach or bowels, experience heavy menstrual periods, or repeatedly donate blood, you may have iron deficiency.
• Kidney failure. If you have kidney failure, you may also have iron deficiency, often with anemia. When kidneys don't function properly, iron stores in the blood can decrease. This and other changes in body chemistry may cause or worsen RLS.
• Spinal cord conditions. Lesions on the spinal cord as a result of damage or injury have been linked to RLS. Having had anesthesia to the spinal cord, such as a spinal block, also increases the risk of developing RLS.
• Parkinson's disease. People who have Parkinson's disease and take certain medications called dopaminergic agonists have an increased risk of developing RLS.

Complications

Although RLS doesn't lead to other serious conditions, symptoms can range from barely bothersome to incapacitating. Many people with RLS find it difficult to fall or stay asleep.

Severe RLS can cause marked impairment in life quality and can result in depression. Insomnia may lead to excessive daytime drowsiness, but RLS may interfere with napping.

Diagnosis

Your provider will take your medical history and ask for a description of your symptoms. A diagnosis of RLS is based on the following criteria, established by the International Restless Legs Syndrome Study Group:

• You have a strong, often irresistible urge to move the legs, usually accompanied by uncomfortable sensations.
• Your symptoms start or get worse when you're resting, such as sitting or lying down.
• Your symptoms are partially or temporarily relieved by activity, such as walking or stretching.
• Your symptoms are worse at night.
• Symptoms can't be explained solely by another medical or behavioral condition.

Your provider may conduct a physical and a neurological exam. Blood tests, particularly for iron deficiency, may be ordered to rule out other possible causes for your symptoms.

In addition, your provider may refer you to a sleep specialist. This may involve an overnight stay and a study at a sleep clinic if another sleep disorder such as sleep apnea is suspected. However, a diagnosis of RLS usually doesn't require a sleep study.

Treatment

Sometimes, treating an underlying condition, such as iron deficiency, greatly relieves symptoms of RLS. Correcting an iron deficiency may involve receiving iron supplementation orally or intravenously. However, take iron supplements only with medical supervision and after your provider has checked your blood-iron level.

If you have RLS without an associated condition, treatment focuses on lifestyle changes. If those aren't effective, your provider might prescribe medications.

Medications

Several prescription medications, most of which were developed to treat other diseases, are available to reduce the restlessness in the legs. These include:

• Medications that increase dopamine in the brain. These medications affect levels of the chemical messenger dopamine in the brain. Rotigotine (Neupro) and pramipexole (Mirapex) are approved by the Food and Drug Administration for the treatment of moderate to severe RLS.

  Short-term side effects of these medications are usually mild and include nausea, lightheadedness and fatigue. However, they can also cause impulse control disorders, such as compulsive gambling, and daytime sleepiness.

• Drugs affecting calcium channels. Certain medications, such as gabapentin (Neurontin, Gralise), gabapentin enacarbil (Horizant) and pregabalin (Lyrica), work for some people with RLS.
• Muscle relaxants and sleep medications. These drugs help you sleep better at night, but they don't eliminate the leg sensations, and they may cause daytime drowsiness. These medications are generally only used if no other treatment provides relief.
• Opioids. Narcotic medications are used mainly to relieve severe symptoms, but they may be addicting if used in high doses. Some examples include tramadol (Ultram, ConZip), codeine, oxycodone (Oxycontin, Roxicodone, others) and hydrocodone (Hysingla ER).

It may take several trials for you and your provider to find the right medication or combination of medications that work best for you.

Caution about medications

Sometimes dopamine medications that have worked for a while to relieve your RLS become ineffective, or you notice your symptoms returning earlier in the day or involving your arms. This is called augmentation. Your provider may substitute another medication to combat the problem.

Most drugs prescribed to treat RLS aren't recommended during pregnancy. Instead, your provider may recommend self-care techniques to relieve symptoms. However, if the sensations are particularly bothersome during your last trimester, your provider may approve the use of certain drugs.

Some medications may worsen symptoms of RLS. These include some antidepressants, some antipsychotic medications, some anti-nausea drugs, and some cold and allergy medications. Your provider may recommend that you avoid these drugs, if possible. However, if you need to take these medications, talk to your provider about adding drugs to help manage your RLS.

Lifestyle and home remedies

Making simple lifestyle changes can help alleviate symptoms of RLS:

• Try baths and massages. Soaking in a warm bath and massaging the legs can relax the muscles.
• Apply warm or cool packs. Use of heat or cold, or alternating use of the two, may lessen the limb sensations.
• Establish good sleep hygiene. Fatigue tends to worsen symptoms of RLS, so it's important that you practice good sleep hygiene. Ideally, have a cool, quiet, comfortable sleeping environment; go to bed and rise at the same time daily; and get at least seven hours of sleep nightly.
• Exercise. Getting moderate, regular exercise may relieve symptoms of RLS, but overdoing it or working out too late in the day may intensify symptoms.
• Avoid caffeine. Sometimes cutting back on caffeine may help restless legs. Try to avoid caffeine-containing products, including chocolate, coffee, tea and soft drinks, for a few weeks to see if this helps.
• Consider using a foot wrap or a vibrating pad. A foot wrap specially designed for people with RLS puts pressure under the foot and may help relieve your symptoms. You may also find relief using a pad that vibrates on the back of the legs.

Coping and support

RLS is generally a lifelong condition. It may help you to develop coping strategies that work for you, such as:

• Tell others about your condition. Sharing information about RLS will help your family members, friends and co-workers better understand when they see you pacing the halls, standing at the back of the theater or walking to the water cooler many times throughout the day.
• Don't resist your need for movement. If you attempt to suppress the urge to move, you may find that your symptoms worsen.
• Keep a sleep diary. Keep track of the medications and strategies that help or hinder your battle with RLS, and share this information with your provider.
• Stretch and massage. Begin and end your day with stretching exercises or gentle massage.
• Seek help. Support groups bring together family members and people with RLS. By participating in a group, your insights not only can help you but also may help someone else.

Preparing for your appointment

If you have symptoms of RLS, make an appointment with your provider. After an initial evaluation, he or she may refer you to a doctor who specializes in conditions affecting the nervous system (neurologist) or a sleep specialist.

Here's some information to help you get ready for your appointment.

What you can do

• Write down your symptoms, including when they started and when they tend to occur.
• Write down key medical information, including other conditions you have and any prescription or over-the-counter medications you're taking, including vitamins and supplements. Also note whether there's a history of RLS in your family.
• Take a family member or friend along. Someone who accompanies you may remember information you missed or forgot.
• Write down questions to ask your provider.

Some basic questions to ask your provider about RLS include:

• What is the most likely cause of my signs and symptoms?
• Are there other possible causes?
• What tests do I need?
• What treatment options are available for this condition?
• I have other health conditions. How can I best manage them together?
• What self-care steps might improve my symptoms?
• Do you have educational materials I can have? What websites do you recommend?
• Where can I find a support group for people with RLS?

What to expect from your doctor

Your provider is likely to ask you a number of questions, including:

• Do you get an irresistible urge to move your legs?
• What words describe your symptoms?
• Do your symptoms start while you're sitting or lying down?
• Are your symptoms worse at night?
• Does movement make you feel better?
• Have you been told that you kick, shake or otherwise move your legs while sleeping?
• Do you often have trouble falling or staying asleep?
• Are you tired during the day?
• Does anyone else in your family have restless legs?
• How much caffeine do you have daily?
• What is your typical exercise program?
• Are you at risk of low iron due to such things as limiting meat in your diet, donating blood frequently or blood loss from a recent surgery?

What you can do in the meantime

To ease your symptoms, try:

• Cutting back on or eliminating caffeine, alcohol and tobacco
• Massaging your legs while soaking in a warm bath