The first description of restless legs associated with severe sleep disturbances was written by the English physician Sir Thomas Willis (1621-1675):
"Wherefore to some, when being a Bed they betake themselves to sleep, presently in the Arms and Leggs Leapings and Contractions to the Tendons, and so great Restlessness and Tossing of their Members ensue, that the diseased are no more able to sleep than if they were in a Place of the greatest Torture."
Although we now know more about the features and treatment of this condition, the cause of this neurological condition remains elusive.
Who gets it?
Restless legs syndrome (RLS) can occur in 2 forms: idiopathic (no cause is known), and secondary (associated with other medical conditions such as kidney failure or anemia). The idiopathic form affects between 1% and 5% of the general population. Men and women are equally affected, and it is more common in seniors. Also, during the last few months of pregnancy up to 15% of women develop RLS; in most cases, the symptoms disappear after delivery. Complete our questionnaire to see if you suffer from RLS.
Main features of restless legs syndrome
The main feature of RLS is the presence of troublesome, but usually not painful, sensations in the legs that produce an irresistible urge to move. It is often difficult to describe these sensations, but terms such as creeping, burning, itching, pulling, or tugging are frequently used. Sometimes sufferers experience sharp "pins and needles" or numb feelings as well.
The symptoms occur or worsen only when the patient is at rest, typically ease with voluntary movement of the affected extremity, yet frequently return again upon resting. Finally, symptoms of RLS are worse in the evening and at night, especially when the sufferer lies down. Restlessness, fidgeting, or nervousness manifests as movements of the toes, feet, or legs when the individual is sitting or lying down in the evening.
People with RLS have difficulty in both getting to sleep and staying asleep. Problems in getting to sleep are due to the discomfort and need to move the affected limb, which delays the onset of sleep. Problems with staying asleep are related to periodic limb movements (PLMs) that occur during sleep. PLMs are jerks that typically occur 20 to 30 seconds apart, on and off throughout the night, which cause sleep disruption and often disturb the bed partner. The affected individual is usually unaware of their own movements or of the accompanying partial arousals or brief awakenings which disrupt sleep. Although most people with restless legs syndrome have PLMs, most people with these nighttime limb movements, especially the elderly, do not have any other features of restless legs syndrome.
Because of difficulty sleeping, people with RLS may be abnormally tired or even sleepy during waking hours. Chronic sleep deprivation and its effects on alertness, mood, and mental efficiency can affect work, relationships, and recreational activities.
Assessment for restless legs syndrome
Before undertaking any treatment for RLS, you should have a complete medical assessment, including a detailed medical history, physical examination, selected laboratory tests, and usually an evaluation in a sleep laboratory. A careful medical evaluation is required to distinguish between idiopathic RLS and the secondary forms of RLS, since secondary forms of RLS are treated by treating the associated disorder, for example, anemia.
Devising a treatment strategy
The best treatment plan for RLS requires close interaction between you and your doctor. As outlined below, choosing a healthy lifestyle, eliminating symptom-producing substances and engaging in self-directed activities will all help reduce or eliminate the need for medications. However, if medications are required, careful trials are usually necessary to find the best medication and best dosage for each person.
Lifestyle changes to ease the symptoms
Simple lifestyle changes can lessen the symptoms of RLS. As caffeine can worsen symptoms, the intake of coffee, tea, and soft drinks containing caffeine should be reduced or eliminated. Also, since the consumption of alcohol and the use of tobacco products increase the duration or intensity of RLS symptoms for most individuals, their use should be reduced or eliminated.
Fatigue and drowsiness tend to worsen the symptoms of RLS. Therefore, implementing a program of sleep hygiene is often helpful to feel well rested and, over time, reduce the RLS sensations. Sleep hygiene includes ensuring that the sleeping environment is comfortably cool (or warm) and quiet, going to bed at the same time every night, and rising at the same time every morning.
A variety of self-directed activities also provide effective, although temporary, relief: walking, stretching, taking a hot or cold bath, massaging the affected limb, applying hot or cold packs, using vibration, performing acupressure, and practicing relaxation techniques (such as biofeedback, meditation, or yoga). When movement is impossible or restricted, as when traveling, distracting activities can be helpful, such as reading a gripping novel, performing intricate needlework, or playing video games.
Unfortunately, most people with RLS eventually need treatment with medications to provide relief. Four major classes of medications are used, each with its own benefits, limitations, and possible side effects.
Dopaminergic agents are the primary and first-line treatment for RLS. These medications work in the central nervous system by increasing the levels of dopamine, a chemical that the body naturally produces and that regulates the delivery of messages between cells in the nervous system. The most frequently used dopaminergic agent is carbidopa-levodopa (Sinemet®). It is inexpensive and causes few serious effects. However, it has one significant disadvantage. Up to 85% of people who take this medication for the treatment of RLS develop a phenomenon known as "augmentation," in which the symptoms of RLS occur with increased intensity during the morning or afternoon as opposed to at night. Most people with RLS who develop augmentation must switch to another medication.
A newer dopaminergic medication, pergolide mesylate (Permax®), is showing great promise in treating RLS. Recent studies have shown that this medication is as effective as Sinemet, but has much less potential for causing augmentation (10% for Permax® vs. 80% for Sinemet®). The disadvantages of Permax are that it is more expensive than Sinemet and it has not been used as long, so doctors are less familiar with prescribing this drug. The primary side effects are dizziness, nausea, and nasal congestion.
Pramipexole (Mirapex®) is a new medication that works through dopamine pathways in the brain. It shows promise in treating RLS although there is concern that some people with Parkinson's Disease who take pramipexole experience sudden sleep attacks during the day.
Benzodiazepines work by promoting sleep (due to their sedative-hypnotic effect) and by minimizing the sleep-disruptive effects of limb jerks and other RLS sensations. The most commonly used benzodiazepine is clonazepam (Klonopin®). Side effects of benzodiazepines include daytime drowsiness or confusion, especially in seniors.
The opioids, which are narcotic analgesic (pain-killing) medications, are used most often for people with severe and unrelenting symptoms of RLS. Some examples of medications in this category are codeine, propoxyphene (Darvon® or Darvocet®) and oxycodone (Percocet®). Side effects include dizziness, sedation, nausea, vomiting, constipation, hallucination, and headache.
Anticonvulsants appear to work by decreasing the unpleasant sensations of RLS and the urge to move. Gabapentin (Neurontin®) is the anticonvulsant that has shown the most promise in treating the symptoms of RLS. Possible side effects of gabapentin include dizziness, sleepiness, fatigue, increased appetite, and unsteadiness.
Web site for RLS information: www.rls.org
Support group: The Southern California Restless Leg Syndrome Support Group: surf.to/rls
Book: Wilson, Virginia N., Walters, Arthur, M.D. Sleep Thief, Restless Legs Syndrome, Galaxy Books, Inc. 1996. Soft-cover and hard-cover editiions.