Restless Legs Syndrome - Mayo Clinic

[David Baxter PhD]

Restless Legs Syndrome
Mayo Clinic
Dec. 23, 2009

Restless legs syndrome (RLS) is a condition in which your legs feel extremely uncomfortable while you're sitting or lying down. It makes you feel like getting up and moving around. When you do so, the unpleasant feeling of restless legs syndrome temporarily goes away.
Restless legs syndrome can begin at any age and generally worsens as you get older. Women are more likely than men to develop this condition. Restless legs syndrome can disrupt sleep ? leading to daytime drowsiness ? and make traveling difficult.

A number of simple self-care steps and lifestyle changes may help you. Medications also help many people with restless legs syndrome.

Symptoms
Commonly described sensations. People typically describe restless legs syndrome (RLS) symptoms as unpleasant sensations in their calves, thighs, feet or arms, often expressed as:

• Crawling
• Tingling
• Cramping
• Creeping
• Pulling
• Painful
• Electric
• Tense
• Uncomfortable
• Itchy
• Tugging
• Gnawing
• Aching
• Burning

Sometimes the sensations seem to defy description. Affected people usually don't describe the condition as a muscle cramp or numbness. They do, however, consistently describe the desire to move or handle their legs.

It's common for symptoms to fluctuate in severity, and occasionally symptoms disappear for periods of time.

Commonly reported patterns. Common characteristics of RLS signs and symptoms include:

• Starts during inactivity. The sensation typically begins after you've been lying down or sitting for an extended period of time, such as in a car, airplane or movie theater.
• Relief by movement. The sensation of RLS lessens if you get up and move. People combat the sensation of restless legs in a number of ways ? by stretching, jiggling their legs, pacing the floor, exercising or walking. This compelling desire to move is what gives restless legs syndrome its name.
• Worsening of symptoms in the evening. Symptoms typically are less bothersome during the day and are felt primarily at night.
• Nighttime leg twitching. RLS may be associated with another condition called periodic limb movements of sleep (PLMS). Once called myoclonus, PLMS causes you to involuntarily flex and extend your legs while sleeping ? without being aware you're doing it. Hundreds of these twitching or kicking movements may occur throughout the night. If you have severe RLS, these involuntary kicking movements may also occur while you're awake. PLMS is common in older adults, even without RLS, and doesn't always disrupt sleep. More than 4 out of 5 people with RLS also experience PLMD.

When to see a doctor. Some people with restless legs syndrome never seek medical attention because they worry that their symptoms are too difficult to describe or won't be taken seriously. Some doctors wrongly attribute symptoms to nervousness, stress, insomnia or muscle cramps. But RLS has received more media attention and focus from the medical community in recent years, making more people aware of the condition.
If you think you may have RLS, call your doctor.

Causes
In many cases, no known cause for restless legs syndrome exists. Researchers suspect the condition may be due to an imbalance of the brain chemical dopamine. This chemical sends messages to control muscle movement.

Heredity
RLS runs in families in up to half the people with RLS, especially if the condition started at an early age. 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 experience RLS for the first time during pregnancy, especially during their last trimester. However, for most of these women, signs and symptoms usually disappear quickly after delivery.

Related conditions
For the most part, restless legs syndrome isn't related to a serious underlying medical problem. However, RLS sometimes accompanies other conditions, such as:

• Peripheral neuropathy. This damage to the nerves in your 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 your 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 fail to function properly, iron stores in your blood can decrease. This, along with other changes in body chemistry, may cause or worsen RLS.

Risk factors
RLS can develop at any age, even during childhood. Many adults who have RLS can recall being told as a child that they had growing pains or can remember parents rubbing their legs to help them fall asleep. The disorder is more common with increasing age.

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 get to sleep or stay asleep. Insomnia may lead to excessive daytime drowsiness, but RLS may prevent you from enjoying a daytime nap.

[What you can do in the meantime
Consider changing your sleep patterns to try resting when your symptoms are most manageable. If your symptoms are worse at night, don't fight it. Keep active and busy with distracting activities until early morning, when you may feel comfortable enough to try sleeping.
Cutting back on or eliminating caffeine, alcohol and tobacco may help improve your symptoms. Other self-care steps that may provide relief include taking an over-the-counter pain reliever such as ibuprofen (Advil, Motrin, others) and massaging your legs while soaking in a warm bath.

Tests and diagnosis
Doctors diagnose RLS by listening to your description of your symptoms and by interviewing you about your medical history. In order to be diagnosed with RLS, you must meet four criteria established by the International Restless Legs Syndrome Study Group:

• You have a strong, often irresistible urge to move your legs, usually accompanied by uncomfortable sensations. These sensations are typically described as crawling, creeping, cramping, tingling, pulling, tugging or itching.
• 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, for as long as you keep moving.
• Your symptoms are worse at night.

Blood tests or muscle or nerve studies may be ordered to exclude other possible causes for your symptoms.

In addition, your doctor may refer you to a sleep specialist for additional evaluation. This may require that you stay overnight at a sleep clinic, where doctors can study your sleep habits closely and check for leg twitching (periodic limb movements) during sleep ? a possible sign of RLS. However, a diagnosis of RLS usually doesn't require a sleep study.

Treatments and drugs
Sometimes, treating an underlying condition, such as iron deficiency or peripheral neuropathy, greatly relieves symptoms of restless legs syndrome. Correcting the iron deficiency may involve taking iron supplements. However, take iron supplements only with medical supervision and after your doctor has checked your blood-iron level.

If you have RLS without any associated condition, treatment focuses on lifestyle changes, and, if those aren't effective, medications.

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

• Medications for Parkinson's disease. These medications reduce the amount of motion in your legs by affecting the level of the chemical messenger dopamine in your brain. Two drugs, ropinirole (Requip) and pramipexole (Mirapex), are approved by the Food and Drug Administration for the treatment of moderate to severe RLS.
  
  Doctors commonly also use other Parkinson's drugs to treat restless legs syndrome, such as a combination of carbidopa and levodopa (Sinemet). People with RLS are at no greater risk of developing Parkinson's disease than are those without RLS. Side effects of Parkinson's medications are usually mild and include nausea, lightheadedness and fatigue.
  
  
• Opioids. Narcotic medications can relieve mild to severe symptoms, but they may be addicting if used in too high doses. Some examples include codeine, oxycodone (Roxicodone), the combination medicine oxycodone and acetaminophen (Percocet, Roxicet), and the combination medicine hydrocodone and acetaminophen (Lortab, Vicodin).
  
  
• Muscle relaxants and sleep medications. This class of medications, known as benzodiazepines, helps you sleep better at night. But these medications don't eliminate the leg sensations, and they may cause daytime drowsiness. Commonly used sedatives for RLS include clonazepam (Klonopin), triazolam (Halcion), eszopiclone (Lunesta), ramelteon (Rozerem), temazepam (Restoril), zaleplon (Sonata) and zolpidem (Ambien).
  
  
• Medications for epilepsy. Certain epilepsy medications, such as gabapentin (Neurontin), may work for some people with RLS.

It may take several trials for you and your doctor to find the right medication and dosage for you. A combination of medications may work best.

Caution about medications
One thing to remember with drugs to treat RLS is that sometimes a medication that has worked for you for a while becomes ineffective. Or you notice your symptoms returning earlier in the day. For example, if you have been taking your medication at 8 p.m., your symptoms of RLS may start at 6 p.m. This is called augmentation. Your doctor may substitute another medication to combat the problem.

Most of the drugs prescribed to treat RLS aren't recommended for pregnant women. Instead, your doctor may recommend self-care techniques to relieve symptoms. However, if the sensations are particularly bothersome during your last trimester, your doctor may approve the use of pain relievers.

Some medications may worsen symptoms of RLS. These include most antidepressants and some anti-nausea drugs. Your doctor may recommend that you avoid these medications if possible. However, should you need to take these medications, restless legs can still be controlled by adding drugs that manage the condition.

Lifestyle and home remedies
Making simple lifestyle changes can play an important role in alleviating symptoms of RLS. These steps may help reduce the extra activity in your legs:

• Take pain relievers. For very mild symptoms, taking an over-the-counter pain reliever such as ibuprofen (Advil, Motrin, others) when symptoms begin may relieve the twitching and the sensations.
• Try baths and massages. Soaking in a warm bath and massaging your legs can relax your muscles.
• Apply warm or cool packs. You may find that the use of heat or cold, or alternating use of the two, lessens the sensations in your limbs.
• Try relaxation techniques, such as meditation or yoga. Stress can aggravate RLS. Learn to relax, especially before going to bed at night.
• Establish good sleep hygiene. Fatigue tends to worsen symptoms of RLS, so it's important that you practice good sleep hygiene. Ideally, sleep hygiene involves having a cool, quiet and comfortable sleeping environment, going to bed at the same time, rising at the same time, and getting enough sleep to feel well rested. Some people with RLS find that going to bed later and rising later in the day helps in getting enough sleep.
• Exercise. Getting moderate, regular exercise may relieve symptoms of RLS, but overdoing it at the gym or working out too late in the day may intensify symptoms.
• Avoid caffeine. Sometimes cutting back on caffeine may help restless legs. It's worth trying to avoid caffeine-containing products, including chocolate and caffeinated beverages such as coffee, tea and soft drinks, for a few weeks to see if this helps.
• Cut back on alcohol and tobacco. These substances also may aggravate or trigger symptoms of RLS. Test to see whether avoiding them helps.
• Stay mentally alert in the evening. Boredom and drowsiness before bedtime may worsen RLS. Mentally stimulating activities such as video games or crossword puzzles can help you stay alert and may reduce symptoms of RLS.

Alternative medicine
Because restless legs syndrome is sometimes due to an underlying nutritional deficiency, taking supplements to correct the deficiency may improve your symptoms. Your doctor can order blood tests to pinpoint nutritional deficiencies and give you a good sense of which supplements may help.

Your doctor can also tell you whether certain dietary supplements may interfere with the way your prescription medications work or may pose health risks for you.

If blood tests show that you are deficient in any of the following nutrients, your doctor may recommend taking dietary supplements as part of your treatment plan:

• Iron
• Folic acid
• Vitamin B
• Magnesium

More research is needed to reliably establish the safety and effectiveness of all of these supplements in the treatment of RLS.


References

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5. Restless legs syndrome: Causes, diagnosis and treatment. Restless Legs Syndrome Foundation. http://www.rls.org/Document.Doc?&id=428 Accessed Oct. 5, 2009.
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