Restless Leg Syndrome

In order for a diagnosis of Restless Leg Syndrome (RLS) to be made in an adult, each of four features is required.

Primary Features of Restless Leg Syndrome(RLS)

  1. The primary RLS symptoms involve a strong, almost irresistible urge to move the legs. This urge to move the legs is usually associated with uncomfortable sensations in the legs. Affected individuals describe this sensation as uncomfortable and use words such as creeping, pulling, gnawing, creepy-crawly, itchy, grabbing or tugging. These feelings usually involve the legs, but may occasionally occur in the arms or other body parts.
  2. RLS symptoms occur or become worse at rest.
  3. RLS symptoms are reduced by voluntary movement of the affected extremities. The relief can be partial or complete and usually starts soon after the onset of activity and persists as long as the motor activity continues. Increased motor activity can occur during periods of rest and sleep.
  4. RLS symptoms are worse in the evening and at night, especially when lying down.

Associated Features of Restless Leg Syndrome (RLS)

RLS symptoms may cause difficulty falling or staying asleep. About 80% of people with RLS also have periodic limb movements of sleep (PLMS). These limb movements during sleep may be associated with arousals or brief partial awakenings which disrupt sleep. The disruption of sleep causes sleep deprivation associated symptoms such as excessive daytime somnolence, difficulty concentrating, irritability or mood swings.

Treatment

The goal of treatment is to achieve the greatest clinical benefit with a minimum of risk.

Lifestyle changes such as reduced caffeine intake and a healthy, balanced diet are often beneficial. Caffeine should be avoided in all forms, including coffee, tea, soft drinks and chocolate. Alcohol may increase the intensity of symptoms. Good sleep hygiene is important. Sometimes exercise before bed may be helpful.

Self-directed activities such as stretching, walking, use of vibration, hot or cold packs, or relaxation techniques may be useful.

Some patients benefit from iron, vitamin B12 or folate supplementation. Iron supplementation should not be done without physician supervision. RLS patients should be screened with a measure of iron storing status called a ferritin level and supplemented if the ferritin level is less than 50 mcg/L.

Many medications are associated with worsening of RLS symptoms and may need to be avoided. These medications include calcium-channel blockers, anti-nausea medications, some cold and allergy medications, major tranquilizers, phenytoin, and many antidepressants.

Pharmacologic Therapy

There are no medications which have been approved by the U.S. Food and Drug Administration for the treatment of RLS. However, there are drugs which have undergone clinical testing for treatment of RLS and have been found to be helpful. These drugs fall into four major categories: dopaminergic agents, sedatives, pain relievers and anticonvulsants.

Dopaminergic Agents

These are the first-line treatment of RLS. These drugs were developed to treat a different movement disorder, Parkinson's disease. RLS is not a form of Parkinson's disease but does seem to respond to some of the same medications. Drugs used include carbidopa/levodopa (Sinemet), pergolide (Permax), pramipexole (Mirapex) and ropinirole (Requip). Carbidopa/levodopa (Sinemet) has been used longest but has been associated with a serious problem known as augmentation.

Sedatives

Sedatives are most effective for improving sleep quality. They are usually used alone or in association with a dopaminergic agent. Drugs used include clonazepam (Klonopin), temazepam (Restoril), or triazolam (Halcion).

Pain Relievers

For patients with severe relentless RLS symptoms, narcotic pain medication may be helpful.

Anticonvulsants

These drugs are very useful for patients with marked daytime symptoms, especially if associated with painful sensory discomfort. Gabapentin (Neurontin) has shown the most promise. Other drugs from this category include valproate (Depakene) and carbamazepine (Tegretol).

Resources

Many helpful lists and resources are available through the Restless Legs Syndrome Foundation at www.rls.org.