What is Restless Legs Syndrome?
Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a common, long-term disorder where individuals feel a strong need to move their legs. RLS often comes with unusual, but not painful, feelings in the legs that usually start when relaxing and are eased by movement. The symptoms usually get worse at night. Not only does it impact sleep but it is also related to involuntary leg twitching during sleep, called periodic leg movements of sleep. More than three million people a year in the United States are affected by this condition.
Unfortunately, RLS is often not diagnosed, leading to significant delays in recognizing and managing it. Even though it can start during childhood, it’s usually not diagnosed until someone is in their 30s. The symptoms of RLS are generally more severe when resting or sleeping. Modern treatments for this condition include certain medications.
What Causes Restless Legs Syndrome?
Restless legs syndrome (RLS) comes in two kinds: primary and secondary. Primary RLS often comes from problems within the brain itself. In 25-75% of these cases, it appears to run in families, possibly passed down from parents to their children. People with family history of RLS usually start experiencing symptoms before the age of 45 and the disease tends to worsen slowly over time. There’s also a pattern where each generation starts showing signs of the disease earlier, a phenomenon known as genetic anticipation. Stress, mental health issues, and fatigue can often make RLS symptoms worse.
Secondary RLS happens as a result of other medical conditions such as iron deficiency, kidney disease in its final stage, diabetes, rheumatism, vein problems, nerve damage in the limbs, deficiencies in folate or magnesium, amyloidosis (an abnormal protein build-up), nerve root disease in the lower back, fibromyalgia, celiac disease. Certain medications may also trigger or worsen RLS. These include drugs for managing Parkinson’s disease or psychosis, diphenhydramine, tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, alcohol, caffeine, lithium, and beta-blockers.
About a third of pregnant women experience RLS, but the good news is that the symptoms usually disappear within a few weeks after giving birth. However, women who had RLS during pregnancy are four times more likely to have chronic (ongoing) RLS later in life compared to women who didn’t experience RLS while pregnant.
RLS is also quite common in people with end-stage kidney disease, affecting 25-50% of these patients. The discomfort tends to get worse during dialysis. It’s been observed that anxiety, high blood phosphate levels, and how people cope with stress can independently contribute to RLS in these patients. Undergoing a kidney transplant may help get rid of RLS in these cases.
Risk Factors and Frequency for Restless Legs Syndrome
Restless legs syndrome is a condition that affects around 5% to 15% of people. It can start at a young age, especially in cases of familial restless legs syndrome, but can also affect people older than 90 years. There are some groups more likely to have restless legs syndrome:
- It’s more common in women than men.
- White individuals are more often affected than African Americans.
- Pregnant women are particularly susceptible, with 11% to 29% of them affected. The frequency is three times higher in pregnant women than non-pregnant ones, and it is most common in the third trimester.
Additionally, 25% to 50% of people with end-stage renal disease may also experience restless legs syndrome, particularly during their hemodialysis treatments.
Signs and Symptoms of Restless Legs Syndrome
Restless legs syndrome (RLS) causes people to experience sensations like creeping, pulling, itching, and stretching, deep within their legs, rather than on their skin. Unlike painful neuropathies, these feelings aren’t described as painful or tingly. There’s also no sensitivity to touch. The severity of these symptoms can vary greatly between patients, with some having minor discomfort, while others suffer from sleep disruptions and a reduction in their quality of life.
These symptoms are usually more severe later in the day, and often appear quickly when the patient lies down to rest or sleep. In extremely severe cases, symptoms may even occur when the patient is seated during the day, creating difficulties for activities like attending meetings or going to the movies. For temporary relief, patients may fidget, move around in bed, or massage their legs. While it’s more uncommon, the arms can be affected as well. Those with severe symptoms may feel the need to walk around or pace to alleviate their discomfort.
Another symptom of RLS is involuntary jerking of the foot while asleep. These movements can last between half a second to five seconds and repeat every 20 to 40 seconds during sleep. Some patients may also experience limb twitching. These symptoms can be seen in about 80% of those with restless legs syndrome.
Generally, a physical examination of a patient with RLS shows no abnormalities. This examination is undertaken to rule out secondary causes for the symptoms.
- Strong, uncontrollable urge to move the lower limbs, often accompanied by uncomfortable sensations.
- Growing urge to move the limbs during the evening and nighttime, as well as during rest or sleep.
- Movement or leg stretching can sometimes relieve these urges. Continuing the activity can help keep symptoms at bay.
- Severe night-time symptoms can disrupt sleep, leading to daytime fatigue.
- These symptoms are not caused by other health issues, such as tardive dyskinesia, leg cramps, muscle spasms, or discomfort from the position.
During sleep, the legs may jerk or twitch involuntarily, often with sudden foot movements that may last between one to five seconds, and reoccur every 30 to 40 seconds. A positive family history is common in children with this condition.
Physical examinations generally come back normal. However, it’s still important to rule out potential underlying causes of these symptoms, such as neurological disorders, nerve root disease (radiculopathy), or Parkinson’s disease.
Testing for Restless Legs Syndrome
There are no dedicated tests that can directly diagnose restless legs syndrome or RLS. However, there are several tests that help rule out other conditions that could be causing similar symptoms, which could indirectly lead to an RLS diagnosis. These include blood tests, and in some cases, electromyography (EMG) and nerve conduction studies. These studies are particularly useful if the doctors suspect damage or disease in the nerves (neuropathy) or nerve root (radiculopathy). There’s also Polysomnography, a sleep study test often done to measure frequency of leg movements and analyze sleep patterns.
One significant test for patients with suspected RLS is called iron studies. Iron studies help understand how your body is processing iron. Necessary tests would include measurements of serum iron, transferrin saturation, ferritin (a protein that stores iron), and total iron-binding capacity. If these precise tests can’t be done, doctors usually at least check ferritin levels. Because if you have low ferritin, it could be contributing to RLS symptoms.
In a situation where patients have experienced temporary relief then a reoccurrence or increase in RLS symptoms, their iron levels should be rechecked. The symptom increase is often referred to as “augmentation” and may include symptoms occurring earlier in the evening, intensifying in the morning, or spreading to the upper body.
If doctors suspect that your RLS is due to another health condition, they may also test for levels of substances such as blood urea nitrogen (BUN), fasting blood glucose, creatinine, magnesium, vitamin B-12, thyroid-stimulating hormone (TSH), and folate through various lab tests including complete blood count (CBC).
Focusing on nerves, even if they appear normal upon initial inspection, if the doctors think it is likely that there is nerve root disease (radiculopathy) or nerve disease (polyneuropathy), then nerve conduction studies and a procedure called needle electromyography (EMG) might be requested. These tests can help doctors see how well your nerves are functioning.
Treatment Options for Restless Legs Syndrome
For those with Restless Legs Syndrome (RLS), a condition causing an irresistible urge to move your legs, treatment may not always be necessary. If the symptoms are sporadic or mild, your primary care provider or a neurologist may recommend monitoring the condition instead of immediate treatment.
Treatment often involves a combination of medication and non-medical measures. These treatments are customized based on your symptoms.
In 2014, an innovative device designed to improve sleep for people with RLS received US Food and Drug Administration (FDA) approval. It works by sending vibrations to the patient’s legs. Two random tests showed that it was more effective in improving sleep than a placebo pad.
To manage RLS, patients are usually advised to avoid substances and situations that could worsen the condition. This includes caffeine, certain antidepressants and antipsychotics, and medications that block dopamine or act centrally on antihistamines. Non-medical remedies such as short daily dialysis for patients with kidney failure, iron supplements, exercise, massage, and applying heat can all help alleviate symptoms.
Certain medications like dopamine agonists — pramipexole, ropinirole, rotigotine, and cabergoline — can decrease symptoms, enhance sleep quality, and improve overall quality of life. However, some such as pramipexole and ropinirole may have adverse effects, including gambling addiction and significant weight gain.
Transdermal patches with rotigotine can be used and are generally well-tolerated. They also have a very low chance of making the symptoms of RLS worse. A large study involving 3286 participants demonstrated that pramipexole improved symptoms in people with moderate-to-severe primary RLS. Rotigotine also had a positive effect in another small study on end-stage renal disease (ESRD) patients.
Medications like gabapentin or pregabalin, which are alpha2-delta calcium-channel ligands, can be very helpful for patients who seriously struggle with sleep, have insomnia, anxiety, pain, or a past history of impulse control disorder.
All treatments, although effective, must be monitored for adverse effects that may make patients less likely to stick to the treatment. Nowadays, the choice of first-line treatment is often between an alpha2 delta calcium channel ligand and a dopamine receptor agonist. Iron supplements are recommended for patients with low levels of ferritin in their blood, a protein that binds to iron.
RLS symptoms in pregnant women typically disappear after delivery. Exercise can also help many patients, although it may not be a practical solution during the night.
The International Restless Legs Syndrome Study Group (IRLSSG) created a guide for treating RLS in the long-term. They found:
* Pregabalin – Effective for up to a year in treating RLS
* Ropinirole, pramipexole, and rotigotine – Effective for up to six months
* Gabapentin enacarbil for 1 year, levodopa for 2 years, and rotigotine for 5 years – Generally effective for durations between 1 and 5 years
* Pergolide and cabergoline – Not used due to safety concerns
All patients with less than 50 ng/mL of ferritin should get iron supplements. If iron-deficient, 325 mg of ferrous sulfate could be given with 250 mg of vitamin C. It should be taken on an empty stomach and no food should be consumed for at least 60 minutes afterwards to ensure maximum absorption. Sometimes, intravenous iron might be required in treating RLS due to iron deficiency.
Non-medical measures include maintaining good sleep hygiene, regular exercise, taking hot or cold baths, massaging your limbs, stimulating your feet with vibrations or electricity, and avoiding caffeine before bedtime.
What else can Restless Legs Syndrome be?
When trying to diagnose restless legs syndrome, some conditions might have similar symptoms and should be considered. These are:
- Tardive dyskinesia (a side effect of certain medications)
- Akathisia (a movement disorder)
- Leg cramps
- Vascular disease (issues related to blood vessels)
- Muscle spasms
- Radiculopathy (pinched nerve in the spine)
What to expect with Restless Legs Syndrome
Approximately 70% of people who suffer from this condition notice their symptoms gradually become moderate to severe. While the condition usually affects the legs, some people may also start to experience similar discomforts in their arms. These symptoms typically aren’t as bad in the morning but tend to worsen later in the day and at night. For some, these symptoms can become so uncomfortable that they disrupt sleep and make them feel tired during the day.
Research indicates that people with this condition, often referred to as Restless Legs Syndrome (RLS), are more likely to experience high blood pressure, headaches, and sleep problems. It generally results in a lower quality of life for most of those affected.
By the time people reach around 50 years of age, the effects of RLS tend to intensify and interrupt sleep on a daily basis, leading to tiredness during the daytime. Dealing with such prominent symptoms often leads to a poorer quality of life.
Possible Complications When Diagnosed with Restless Legs Syndrome
The problems associated with the disease itself primarily affect a person’s quality of life, due to things like disturbed sleep and constant tiredness. For many patients, these symptoms become worse over time, leading to serious issues with their everyday wellbeing.
Potential Impacts on Quality of Life:
- Disturbed sleep
- Constant tiredness
- Deterioration of symptoms over time
- Significant impacts on everyday wellbeing
Preventing Restless Legs Syndrome
It’s crucial for patients to understand that their condition tends to worsen over time. However, there are several non-medication based treatments that can help to ease the symptoms. Here are some things that patients can do at home to help themselves feel better:
* Self-massage or get someone to massage their legs
* Use heating pads or take a warm bath to soothe their legs
* Stay away from medicines that can exacerbate Restless Legs Syndrome (RLS)
* Maintain an active mind during the day, for instance, by doing crossword puzzles
* Regularly engage in moderate exercises
These suggestions aim to help manage the symptoms and improve the patient’s quality of life.