Restless legs syndrome RLS is an unusual condition of the nervous system characterised by the compelling need to move the legs. It is usually worse in the evening and can be a problem when trying to sleep. The strange sensation in the calves has been described as a type of cramp, soreness or a creeping, crawling feeling.
Some liken the sensation to shooting darts of electricity or even squirming insects inside the legs. The same symptoms can also be caused by other conditions including diabetes, iron deficiency anaemia, alcoholism and some forms of arthritis. It is relatively common in pregnancy. Around five out of every people will experience RLS at some time. Usually both legs are affected, but it is not uncommon to experience the unpleasant sensations in only one leg.
The symptoms can be mild, moderate or severe. In severe cases, the person may be unable to sleep. No one knows what causes RLS. It can begin at any age, including childhood although this is thought to be underreported.
There is a strong genetic link. Iron deficiency is the most important risk factor. Restless legs syndrome can affect anyone Restless legs syndrome can affect people of any age, but certain groups of people tend to be more susceptible, including: Middle-aged and elderly people Pregnant women Those with a parent who experiences RLS which suggests a genetic link Those who have another sleep disorder called periodic limb movement disorder People on antidepressant medication. Iron supplements are available over-the-counter.
A common side effect is upset stomach, which may improve with use of a different type of iron supplement. Because iron is not well-absorbed into the body by the gut, it may cause constipation that can be treated with a stool softeners such as polyethylene glycol. Others may require iron given through an IV line in order to boost the iron levels and relieve symptoms. Anti-seizure drugs.
Anti-seizure drugs are becoming the first-line prescription drugs for those with RLS. The FDA has approved gabapentin enacarbil for the treatment of moderate to severe RLS, This drug appears to be as effective as dopaminergic treatment discussed below and, at least to date, there have been no reports of problems with a progressive worsening of symptoms due to medication called augmentation.
Other anti-seizure drugs such as the standard form of gabapentin and pregabalin can decrease such sensory disturbances as creeping and crawling as well as nerve pain. Dizziness, fatigue, and sleepiness are among the possible side effects. Recent studies have shown that pregabalin is as effective for RLS treatment as the dopaminergic drug pramipexole, suggesting this class of drug offers equivalent benefits.
Dopaminergic agents. These drugs, which increase dopamine effect, are largely used to treat Parkinson's disease. They have been shown to reduce symptoms of RLS when they are taken at nighttime.
These drugs are generally well tolerated but can cause nausea, dizziness, or other short-term side effects. Levodopa plus carbidopa may be effective when used intermittently, but not daily.
Although dopamine-related medications are effective in managing RLS symptoms, long-term use can lead to worsening of the symptoms in many individuals. With chronic use, a person may begin to experience symptoms earlier in the evening or even earlier until the symptoms are present around the clock. Over time, the initial evening or bedtime dose can become less effective, the symptoms at night become more intense, and symptoms could begin to affect the arms or trunk.
Fortunately, this apparent progression can be reversed by removing the person from all dopamine-related medications. Another important adverse effect of dopamine medications that occurs in some people is the development of impulsive or obsessive behaviors such as obsessive gambling or shopping. Should they occur, these behaviors can be improved or reversed by stopping the medication.
Drugs such as methadone, codeine, hydrocodone, or oxycodone are sometimes prescribed to treat individuals with more severe symptoms of RLS who did not respond well to other medications. Side effects include constipation, dizziness, nausea, exacerbation of sleep apnea, and the risk of addiction; however, very low doses are often effective in controlling symptoms of RLS.
These drugs can help individuals obtain a more restful sleep. However, even if taken only at bedtime they can sometimes cause daytime sleepiness, reduce energy, and affect concentration. Benzodiazepines such as clonazepam and lorazepam are generally prescribed to treat anxiety, muscle spasms, and insomnia. Because these drugs also may induce or aggravate sleep apnea in some cases, they should not be used in people with this condition. These are last-line drugs due to their side effects.
Although the sensations can occur on just one side of the body, they most often affect both sides. Because moving the legs or other affected parts of the body relieves the discomfort, people with RLS often keep their legs in motion to minimize or prevent the sensations. They may pace the floor, constantly move their legs while sitting, and toss and turn in bed. PLMD is characterized by involuntary leg twitching or jerking movements during sleep that typically occur every 10 to 60 seconds, sometimes throughout the night.
The symptoms cause repeated awakening and severely disrupted sleep. Most people find the symptoms of RLS to be less noticeable during the day and more pronounced in the evening or at night, especially during the onset of sleep.
For some people, the symptoms disappear by early morning, allowing for more refreshing sleep at that time. Other triggering situations are periods of inactivity such as long car trips, sitting in a movie theatre, long-distance flights, immobilisation in a cast, or relaxation exercises.
American research suggests that about five out of every people will suffer from RLS at some time. Usually, both legs are affected, but it is not uncommon to experience the unpleasant sensations in only one leg. RLS can affect anyone of any age, although the disorder is more common with increasing age. It occurs in both genders, although the incidence may be slightly higher in women. Sometimes people will experience spontaneous improvement over a period of weeks or months.
Although rare, spontaneous improvement over a period of years also can occur. Nausea may be especially common. In rare cases, dopaminergic drugs can cause hallucinations or lung disease. Long-term treatment with levodopa can also lead to drug-induced dyskinesia, a condition characterized by exaggerated involuntary movements or uncontrolled muscle contractions.
Because these drugs may cause daytime drowsiness, people should be extremely careful while driving or performing tasks that require concentration.
Long-term use of dopaminergic drugs can lead to tolerance, in which the drugs become less effective. Rebound effect, augmentation, and tolerance can reduce the value of dopaminergic drugs in the treatment of RLS. Using the lowest dose possible can minimize these effects.
Patients who withdraw from these drugs typically experience severe RLS symptoms for the first 2 days after stopping. RLS eventually returns to pre-treatment levels after about a week. The longer a patient uses these drugs, the worse their withdrawal symptoms. Withdrawal from dopamine precursors or dopamine agonists can lead to a serious, potentially life-threatening condition called Neuroleptic Malignant Syndrome.
This disorder causes muscle stiffness and breakdown, fever, rigidity, and confusion. One should never abruptly stop these medications without first talking to their doctor. Dopamine receptor agonists also called dopamine agonists mimic the effects of dopamine by acting on dopamine receptors in the brain.
They are now generally preferred to L-dopa see below. Because they have fewer side effects than L-dopa, these drugs may be used on a daily basis. As the newer drugs are taken for longer periods and at higher doses, however, their augmentation rates may become closer to those of L-dopa.
Because they take longer to take effect, these drugs are not as useful to relieve symptoms once they have begun. Other dopamine agonists that have been tested in small studies include alpha-dihydroergocryptine, or DHEC Almirid , and piribedil Trivastal. Benzodiazepines, such as clonazepam Klonopin , are known as sedative hypnotics. Doctors prescribe them for insomnia and anxiety.
They may be helpful for RLS that disrupts sleep, especially in younger people. Clonazepam may be particularly helpful for children with both PLMD and symptoms of attention deficit hyperactivity disorder. The medicine also may be helpful for people with RLS who are undergoing dialysis. There is insufficient evidence that this class of medications is effective in treating RLS. Older people are more susceptible to side effects.
They should usually start at half the dose prescribed for younger people, and should not take long-acting forms. Side effects may differ depending on whether the benzodiazepine is long-acting or short-acting. Benzodiazepines are potentially dangerous when used in combination with alcohol. Some drugs, such as the ulcer medication cimetidine, can slow the breakdown of benzodiazepine. Withdrawal symptoms usually occur after prolonged use and indicate dependence. They can last 1 to 3 weeks after stopping the drug and may include:.
Rebound insomnia, which often occurs after withdrawal, typically includes 1 to 2 nights of sleep disturbance, daytime sleepiness, and anxiety. The chances of rebound are higher with the short-acting benzodiazepines than with the longer-acting ones.
Narcotics are pain-relieving drugs that act on the central nervous system. They are sometimes prescribed for severe cases of RLS.
They may be a good choice if pain is a prominent feature, but chronic narcotic administration should be done carefully due to a high risk of abuse and dependence. The use of such drugs may be beneficial when included as part of a comprehensive pain management program. Such a program involves screening prospective patients for possible drug abuse and regularly monitoring those who are taking narcotics.
Doses should be adjusted as necessary to achieve an acceptable balance between pain relief and side effects. People on long-term opiate therapy should also be monitored periodically for sleep apnea, a condition that causes breathing to stop for short periods many times during the night.
Sleep apnea may worsen symptoms of RLS, insomnia, and other complaints. Antiseizure drugs, such as gabapentin Neurontin , valproic acid valproate, divalproex, Depakote, Depakene , and carbamazepine Tegretol are being tested for RLS. Common side effects included mild sleepiness and dizziness.
Gabapentin enacarbil Horizant is an extended-release prodrug form of gabapentin that is one of the few drugs approved by the FDA specifically for the treatment of moderate to severe RLS. All antiseizure drugs have potentially severe side effects. Therefore, people should try these medications only after non-drug methods have failed. Side effects of many anti-seizure drugs include nausea, vomiting, heartburn, increased appetite with weight gain, hand tremors, irritability, and temporary hair thinning and hair loss.
Taking zinc and selenium supplements may help reduce this last effect. Some anti-seizure drugs can also cause birth defects and, in rare cases, liver toxicity. Gabapentin may have fewer of these side effects than valproic acid or carbamazepine. Recently, there has been concern that gabapentin may also be prone to abuse, especially when used in conjunction with opiates.
Bupropion Wellbutrin , a newer antidepressant, may be helpful for RLS, at least in the short-term. Bupropion is a weak dopamine reuptake inhibitor, it causes a slight increase in the availability of dopamine in the brain. The drug is not addictive and does not have the severe side effects of other RLS drugs, but more research is needed to determine if it is useful. Clonidine Catapres , a drug used for high blood pressure, is helpful for some people and may be an appropriate choice for people who have RLS accompanied by hypertension.
It also may help people with RLS who are undergoing hemodialysis. The anti-spasm drug baclofen Lioresal appears to reduce intensity of RLS although not frequency of movements.
Pregabalin Lyrica is approved for the treatment of diabetic neuropathy, postherpetic neuralgia, and fibromyalgia, and may also be helpful in the treatment of RLS. These electrical devices are either placed under the legs or worn by the patient during sleep and work by delivering vibrations through the skin that are supposed to improve the quality of sleep.
Better studies are needed on the effectiveness of these devices for RLS. DBS requires surgery to place wire electrodes into the brain and a small battery under the skin in the chest.
Because this requires brain surgery, it is only used after many other treatments have failed. Cannabis has also been shown to help some people. Local laws may prevent some people from access. American Academy of Sleep Medicine -- aasm. Restless legs syndrome and periodic limb movements during sleep. Principles and Practice of Sleep Medicine. Philadelphia, PA: Elsevier; chap Update to the AASM clinical practice guideline: The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for practice parameters with an evidence-based systematic review and meta-analyses.
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Highlights Overview Restless legs syndrome RLS is a condition in which one has feelings of "pulling, searing, drawing, tingling, bubbling, or crawling" beneath the skin, usually in the calf area. Specific characteristics of RLS include: Uncomfortable feelings of "pulling, searing, drawing, tingling, bubbling, or crawling" beneath the skin, usually in the calf area, causing an irresistible urge to move the legs.
These sensations occur mostly in the lower legs, but they can sometimes affect the thighs, feet, and even in the arms. These may be the first symptoms of RLS in some people.
Semi-rhythmic movements during sleep known as periodic limb movement disorder PLMD , which occurs in about 4 out of 5 patients with RLS. See description below. Itching and pain, particularly aching pain. Symptoms usually occur at night when people are most relaxed, with their legs at rest, lying down.
In more severe cases, symptoms also occur during the day while sitting. Movement relieves the symptoms. RLS episodes usually occur between 10 p. Symptoms are often worse shortly after midnight and disappear by morning. If the condition becomes more severe, people may begin to have symptoms during the day, but the problem is always worse at night. Disturbed nighttime sleep due to the unpleasant sensations and strong urge to move the legs.
Resisting the urge to move the legs usually leads to tension build up until the legs jerk uncontrollably. People who experience daytime symptoms may find it difficult to sit during air or car travel, or through classes or meetings. People may feel excessively tired during the daytime as a result of inadequate or poor sleep.
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