Restless leg syndrome

Definition

The condition known as restless leg syndrome (RLS) is a movement disorder caused by an irresistible urge to move the legs due to unpleasant sensations. It occurs primarily during times of relaxation, such as when the patient is trying to go to sleep.

Description

Most frequently, RLS troubles people over age 40. Almost half of patients over age 60 who complain of insomnia are diagnosed with RLS. Those who have a family history of it may have trouble with it as younger adults, or even as children. It is not usually described as painful, although some may complain of a disagreeable creeping, tugging, or aching sensation. A related condition, experienced by as many as 80% of RLS sufferers, is known as periodic limb movements of sleep (PLMS), or nocturnal myoclonus. In PLMS, jerky leg movements occur about every 20–40 seconds during sleep, and the arms may be affected as well.

Causes & symptoms

Although RLS appears to be familial in some cases, other causes should be ruled out and treated before starting medication. Certain diseases and conditions are more highly associated with RLS. People experiencing symptoms should be examined and tested for anemia, uremia, and imbalances of electrolytes and vitamins. Renal failure is a major predisposing factor. RLS can also be associated with pregnancy. As many as one in seven women may experience it to some degree. It usually disappears after delivery, but it can recur with subsequent pregnancies or later in life.

Many medications can induce or worsen the symptoms of RLS. A prescribed medication should not be stopped without consulting a health care provider. Medications that may cause problems for some patients include some antidepressants, antihistamines, most antinausea medications, phenothiazine tranquilizers, sinemet, some calcium channel blockers used for hypertension, and a few psychiatric drugs. Patients with RLS or PLMS should have a health care provider ask whether alternative medications are available if one is prescribed that may worsen RLS symptoms.

Most sufferers of RLS experience mild symptoms. They may lie down to rest at the end of the day and, just before sleep, will experience discomfort in their legs that prompts them to stand up, massage the leg, or walk briefly. Eighty-five percent of RLS patients either have difficulty falling asleep or wake several times during the night; almost half experience daytime fatigue or sleepiness. It is common for the symptoms to be intermittent. They may disappear for several months and then return for no apparent reason. Two-thirds of patients report that their symptoms become worse with time. Some older patients claim to have had symptoms since they were in their early 20s, but were not diagnosed until their 50s. Suspected under diagnosis of RLS may be attributed to the difficulty experienced by patients in describing their symptoms. An estimated 2–15% of the population has some degree of RLS symptoms.

Diagnosis

A careful history enables the physician to distinguish RLS from similar types of disorders that cause nighttime discomfort in the limbs, such as muscle cramps, circulatory diseases, and damage to nerves that detect sensations or cause movement (peripheral neuropathy).

The most important tool the doctor has in diagnosing RLS is the history obtained from the patient. Several common medical conditions are known to either cause or to be closely associated with RLS. The doctor may link the patient's symptoms to one of these conditions, which include anemia; diabetes; disease of the spinal nerve roots (lumbosacral radiculopathy); Parkinson's disease; late-stage pregnancy; kidney failure (uremia); and complications of stomach surgery. In order to identify or eliminate such a cause, blood tests may be performed to determine the presence of serum ferritin, folate, vitamin B12, creatinine, and thyroid-stimulating hormones. The physician may also ask if symptoms are present in any close family members, since it is common for RLS to run in families and this type is sometimes more difficult to treat.

Treatment

It is likely that the best alternative therapy will combine both conventional and alternative approaches. Levodopa may be combined with a therapy that relieves pain, relaxes muscles, or focuses in general on the nervous system and the brain. Any such combined therapy that allows a reduction in dosage of levodopa is advantageous, since this approach will reduce the likelihood of unacceptable levels of drug side effects. Of course, the physician who prescribes the medication should monitor any combined therapy.

Acupuncture

Patients who also suffer from rheumatoid arthritis may especially benefit from acupuncture to relieve RLS symptoms. Acupuncture is believed to be effective in arthritis treatment and may stimulate those parts of the brain that are involved in RLS. It is also thought to benefit RLS patients who do not have rheumatoid arthritis.

Homeopathy

Homeopaths believe that disorders of the nervous system are especially important because the brain controls so many other bodily functions. The remedy is tailored to the individual patient and is based on individual symptoms as well as the general symptoms of RLS.

Reflexology

Reflexologists claim that the brain, head, and spine all respond to indirect massage of specific parts of the feet.

Nutritional supplements

Supplementation of the diet with vitamin E, calcium, magnesium, and folic acid may be helpful for people with RLS.

Allopathic treatment

If causes related to diet, metabolic abnormalities, and medication have been excluded or treated, therapeutic medications may be helpful. Some medications, including those mentioned above, may cause symptoms of RLS. Patients should check with a health care provider about these possible side effects, especially if symptoms first occur after starting a new medication.

In some people whose symptoms cannot be linked to a treatable associated condition, drug therapy may be necessary to provide relief and restore a normal sleep pattern. Prescription drugs that are normally used for RLS may include dopaminergic agents (such as levodopa and/or carbidopa, used to treat Parkinson's syndrome), dopamine agonists, opioids, benzodiazepines, anticonvulsants, iron (for anemic patients), and clonidine. Patient response is variable, so it is best to consult a health care provider to determine the best medication or combination regimen for the individual circumstances. Careful monitoring of side effects and good communication between patient and doctor can result in a flexible program of therapy that minimizes side effects and maximizes effectiveness.

Expected results

RLS usually does not indicate the onset of other neurological disease. It may remain static, although two-thirds of patients get worse with time. The symptoms usually progress gradually. Treatment with dopamine agonists is effective in moderate to severe cases that may include significant PLMS. These drugs, however, produce significant side effects, including sleepiness and nausea. An individually tailored treatment plan is optimal. The prognosis is usually best if RLS symptoms are recent and can be traced to another treatable condition that is associated with RLS.

Prevention

Diet is one factor that can prevent symptoms of RLS. A helpful diet will include an adequate intake of iron and the B vitamins, especially B12 and folic acid. Strict vegetarians should take vitamin supplements to obtain sufficient vitamin B12. Ferrous gluconate may be easier on the digestive system than ferrous sulfate, if iron supplements are prescribed. Caffeine, alcohol, and nicotine use should be minimized or eliminated. Even a hot bath before bed has been shown to prevent symptoms for some sufferers.

Resources

BOOKS

The Editors of Time-Life Books. The Medical Advisor. The Complete Guide to Conventional and Alternative Medicine. Alexandria, VA: Time-Life Books, 1997.

Long, James W., and James J. Rybacki. The Essential Guide to Prescription Drugs. New York: Harper Perennial, 1995.

Mills, Simon, and Stephen J. Finando. Alternatives in Healing. New York: New American Library, 1989.

National Institutes of Health. Restless Legs Syndrome: Detections and Management in Primary Care. Bethesda, MD: NIH, 2000.

PERIODICALS

O'Keeffe, Shaun T. "Restless Legs Syndrome: A Review." Archives of Internal Medicine 56 (Feb 12, 1996): 243-246.

ORGANIZATIONS

Restless Legs Syndrome Foundation. 1904 Banbury Road. Raleigh, NC 27608-4428. (919) 781-4428. http://www.rls.org.

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