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)
- 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.
- RLS symptoms occur or become worse at rest.
- 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.
- 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.
