Restless Legs
What is restless legs?
Restless legs syndrome (RLS) is a neurological disorder characterized by unpleasant sensations in the legs and an uncontrollable urge to move when at rest in an effort to relieve these feelings. RLS sensations are often described by people as burning, creeping, tugging, or like insects crawling inside the legs. Often called paresthesias (abnormal sensations) or dysesthesias (unpleasant abnormal sensations), the sensations range in severity from uncomfortable to irritating to painful. The most distinctive or unusual aspect of the condition is that lying down and trying to relax activates the symptoms. As a result, most people with RLS have difficulty falling asleep and staying asleep. Left untreated, the condition causes exhaustion and daytime fatigue.
Many people with RLS report that their job, personal relations, and activities of daily living are strongly affected as a result of their exhaustion. They are often unable to concentrate, have impaired memory, or fail to accomplish daily tasks. Some researchers estimate that RLS affects as many as 12 million Americans. However, others estimate a much higher occurrence because RLS is thought to be underdiagnosed and, in some cases, misdiagnosed. Some people with RLS will not seek medical attention, believing that they will not be taken seriously, that their symptoms are too mild, or that their condition is not treatable. Some physicians wrongly attribute the symptoms to nervousness, insomnia, stress, arthritis, muscle cramps, or aging. RLS occurs in both genders, although the incidence may be slightly higher in women.
Although the syndrome may begin at any age, even as early as infancy, most patients who are severely affected are middle-aged or older. In addition, the severity of the disorder appears to increase with age. Older patients experience symptoms more frequently and for longer periods of time. More than 80 percent of people with RLS also experience a more common condition known as periodic limb movement disorder (PLMD). PLMD is characterized by involuntary leg twitching or jerking movements during sleep that typically occur every 10 to 60 seconds, sometimes throughout the night. The symptoms cause repeated awakening and severely disrupted sleep. Unlike RLS, the movements caused by PLMD are involuntary-people have no control over them. Although many patients with RLS also develop PLMD, most people with PLMD do not experience RLS. Like RLS, the cause of PLMD is unknown.
What are common signs and symptoms of restless legs?
As described above, people with RLS feel uncomfortable sensations in their legs, especially when sitting or lying down, accompanied by an irresistible urge to move about. These sensations usually occur deep inside the leg, between the knee and ankle; more rarely, they occur in the feet, thighs, arms, and hands. Although the sensations can occur on just one side of the body, they most often affect both sides. Because moving the legs (or other affected parts of the body) relieves the discomfort, people with RLS often keep their legs in motion to minimize or prevent the sensations. They may pace the floor, constantly move their legs while sitting, and toss and turn in bed. Most people find the symptoms to be less noticeable during the day and more pronounced in the evening or at night, especially during the onset of sleep.
For many people, the symptoms disappear by early morning, allowing for more refreshing sleep at that time. Other triggering situations are periods of inactivity such as long car trips, sitting in a movie theater, long-distance flights, immobilization in a cast, or relaxation exercises. The symptoms of RLS vary in severity and duration from person to person. Mild RLS occurs episodically, with only mild disruption of sleep onset, and causes little distress. In moderately severe cases, symptoms occur only once or twice a week but result in significant delay of sleep onset, with some disruption of daytime function. In severe cases of RLS, the symptoms occur more than twice a week and result in burdensome interruption of sleep and impairment of daytime function. Symptoms may begin at any stage of life, although the disorder is more common with increasing age. Sometimes people will experience spontaneous improvement over a period of weeks or months.
Although rare, spontaneous improvement over a period of years also can occur. If these improvements occur, it is usually during the early stages of the disorder. In general, however, symptoms become more severe over time. People who have both RLS and an associated condition tend to develop more severe symptoms rapidly. In contrast, those whose RLS is not related to any other medical condition and whose onset is at an early age show a very slow progression of the disorder and many years may pass before symptoms occur regularly.
What causes Restless legs syndrome?
In most cases, the cause of RLS is unknown (referred to as idiopathic). A family history of the condition is seen in approximately 50 percent of such cases, suggesting a genetic form of the disorder. People with familial RLS tend to be younger when symptoms start and have a slower progression of the condition. In other cases, RLS appears to be related to the following factors or conditions, although researchers do not yet know if these factors actually cause RLS.
- People with low iron levels or anemia may be prone to developing RLS. Once iron levels or anemia is corrected, patients may see a reduction in symptoms.
- Chronic diseases such as kidney failure, diabetes, Parkinson's disease, and peripheral neuropathy are associated with RLS. Treating the underlying condition often provides relief from RLS symptoms.
- Some pregnant women experience RLS, especially in their last trimester. For most of these women, symptoms usually disappear within 4 weeks after delivery.
- Certain medications-such as antinausea drugs (prochlorperazine or metoclopramide), antiseizure drugs (phenytoin or droperidol), antipsychotic drugs (haloperidol or phenothiazine derivatives), and some cold and allergy medications-may aggravate symptoms. Patients can talk with their physicians about the possibility of changing medications.
How is restless legs syndrome treated?
Although movement brings relief to those with RLS, it is generally only temporary. However, RLS can be controlled by finding any possible underlying disorder. Often, treating the associated medical condition, such as peripheral neuropathy or diabetes, will alleviate many symptoms. For patients with idiopathic RLS, treatment is directed toward relieving symptoms. For those with mild to moderate symptoms, prevention is key, and many physicians suggest certain lifestyle changes and activities to reduce or eliminate symptoms. Decreased use of caffeine, alcohol, and tobacco may provide some relief. Physicians may suggest that certain individuals take supplements to correct deficiencies in iron, folate, and magnesium.
Studies also have shown that maintaining a regular sleep pattern can reduce symptoms. Some individuals, finding that RLS symptoms are minimized in the early morning, change their sleep patterns. Others have found that a program of regular moderate exercise helps them sleep better; on the other hand, excessive exercise has been reported by some patients to aggravate RLS symptoms. Taking a hot bath, massaging the legs, or using a heating pad or ice pack can help relieve symptoms in some patients. Although many patients find some relief with such measures, rarely do these efforts completely eliminate symptoms Physicians also may suggest a variety of medications to treat RLS. Generally, physicians choose from dopaminergics, benzodiazepines (central nervous system depressants), opioids, and anticonvulsants.
Dopaminergic agents, largely used to treat Parkinson's disease, have been shown to reduce RLS symptoms and PLMD and are considered the initial treatment of choice. Good short-term results of treatment with levodopa plus carbidopa have been reported, although most patients eventually will develop augmentation, meaning that symptoms are reduced at night but begin to develop earlier in the day than usual. Dopamine agonists such as pergolide mesylate, pramipexole, and ropinirole hydrochloride may be effective in some patients and are less likely to cause augmentation. In 2005, ropinirole became the only drug approved by the U.S. Food and Drug Administration specifically for the treatment of moderate to severe RLS. The drug was first approved in 1997 for patients with Parkinson’s disease. Benzodiazepines (such as clonazepam and diazepam) may be prescribed for patients who have mild or intermittent symptoms. These drugs help patients obtain a more restful sleep but they do not fully alleviate RLS symptoms and can cause daytime sleepiness. Because these depressants also may induce or aggravate sleep apnea in some cases, they should not be used in people with this condition.
For more severe symptoms, opioids such as codeine, propoxyphene, or oxycodone may be prescribed for their ability to induce relaxation and diminish pain. Side effects include dizziness, nausea, vomiting, and the risk of addiction. Anticonvulsants such as carbamazepine and gabapentin are also useful for some patients, as they decrease the sensory disturbances (creeping and crawling sensations). Dizziness, fatigue, and sleepiness are among the possible side effects. Unfortunately, no one drug is effective for everyone with RLS. What may be helpful to one individual may actually worsen symptoms for another. In addition, medications taken regularly may lose their effect, making it necessary to change medications periodically.
What is the prognosis of people with restless legs?
RLS is generally a lifelong condition for which there is no cure. Symptoms may gradually worsen with age, though more slowly for those with the idiopathic form of RLS than for patients who also suffer from an associated medical condition. Nevertheless, current therapies can control the disorder, minimizing symptoms and increasing periods of restful sleep. In addition, some patients have remissions, periods in which symptoms decrease or disappear for days, weeks, or months, although symptoms usually eventually reappear. A diagnosis of RLS does not indicate the onset of another neurological disease.
Credit: National Institute of Health.