The Complete Guide to Restless Legs Syndrome
Restless Legs Syndrome – also called Willis-Ekbom disease – is a form of neurological disorder. The disorder is characterized by the irresistible urge to move caused by unpleasant or cold sensations that only go away with movement. The disorder regularly interferes with sleep and can get worse at night, leading many to categorize it as a form of sleep disorder.
Despite the name, RLS can also affect other extremities including the arms, head, torso, and other areas. The uncomfortable feeling is temporarily eliminated by moving the affected body part, but it can come back if people stop moving.
While between 5-15% of people in the United States are said to be affected by RLS, the condition remains largely misunderstood to the point of ridicule. It is one of the “spectrum” conditions, meaning that it affects different people to a different degree. Some people have minor symptoms while others can find it intolerable and are unable to sleep at all.
What Causes Restless Legs Syndrome?
For the most part, the specific causes of RLS are unknown. There is evidence that the condition could be genetic though. It is more likely to appear in people who have a family history of developing the condition and some gene variants have been linked to RLS. Evidence suggests that it could also be caused by an iron deficiency.
There has been considerable evidence to suggest that RLS is connected to a dysfunction in the part of the brain responsible for movement (the basal ganglia) which uses dopamine for fuel. Dopamine is required to create smooth muscle movement. If these pathways are disrupted it can cause involuntary movements like those associated with RLS. People with diseases that affect the basal ganglia, such as Parkinson’s, are more likely to develop RLS.
Sleep deprivation, sleep apnea, and other sleep conditions have also been connected to RLS. Reducing and eliminating risk factors like these can offer some relief to RLS sufferers.
Risk Factors for Restless Legs Syndrome
There has been more and more evidence to suggest that people are born with a genetic predisposition towards developing Restless Legs Syndrome, especially for early-onset Restless Legs Syndrome, which sets in before 40. Around half of all RLS cases are thought to be related to genetics.
Another risk factor of RLS is a central dopaminergic dysfunction. To put it simply, it means there are problems in the pathways that allow for dopamine to move through the brain. Given that dopamine is needed for muscle movement, disruption to these pathways can be a big factor in RLS. Another major risk factor for RLS is a deficiency of iron in the brain. Even people with regular levels of iron can develop RLS is their brain in particular doesn’t have enough of this vital micronutrient.
RLS can be worsened by some other conditions, in particular low-density lipoprotein apheresis, end-stage renal disease, and pregnancy. Those who smoke, don’t exercise, or are obese are also at greater risk of developing RLS. Certain medications have also been connected to RLS including some anti-psychotics, anti-depressants, anti-nausea medications, and non-selective antihistamines.
Restless Leg Syndrome and Diabetes
There is a connection between diabetes and restless leg syndrome. The excessively high blood sugar levels of diabetics can cause nerve damage, known as diabetic peripheral neuropathy. Nerve damage in the legs and feet caused by peripheral neuropathy can contribute to developing restless leg syndrome.
Studies have shown that there is a major correlation between the two conditions and that people with diabetes are more likely to develop RLS. Diabetes itself causes enough sleep-related problems for sufferers as improper glucose metabolization can interfere with sleep.
Diagnosing and Testing for Restless Legs Syndrome
Unfortunately, there is no official test for detecting RLS. A physician will examine a patient and make a decision based on their evaluation and their discussion with the patient. The five key elements of a clinical diagnosis of RLS are:
- The overwhelming urge to move legs characterized by an uncomfortable or unpleasant sensation
- The urge to move the legs gets worse if they aren’t moved
- The urge is temporary and is partially/fully relieved with movement
- The urge for movement is worse during the night
- The above factors are not caused by another behavioral or medical condition the patient has
Physicians will rely heavily on the individual’s own description of their symptoms, triggers, and relieving factors. They will also consider how symptoms appear and disappear during the course of a day. They may also conduct a physical and neurological exam and consider the medical and family history of a patient for a more effective diagnosis.
Individuals will likely be asked for information about the frequency and intensity of their symptoms; if the symptoms are alleviated by movement; how long it takes them on average to fall asleep; if their symptoms are painful; if they are likely to sleep during the day; and any possible impairment of sleep and regular daytime functioning.
Ruling Out Potential Causes
The signs and symptoms of Restless Leg Syndrome may be connected to other health issues. A physician will want to rule these out for a more accurate diagnosis. Laboratory tests can be used to rule out factors such as iron deficiency anemia (a separate condition caused by an iron deficiency), kidney failure, and pregnancy. Blood tests may help to identify medical disorders or iron deficiencies associated with restless leg syndrome.
Sleep studies may be used to find another cause for the sleep disturbance. For example, a polysomnography test, which measures brain activity, breathing, heart rate, and movement during sleep, can help to identify sleep apnea. These tests can also help to support the RLS diagnosis but these symptoms are not exclusive to RLS and are not necessarily RLS indicators.
Restless Legs in Pregnancy
It’s estimated that up to 25% of pregnant women suffer from restless leg symptoms.
The good news is that restless legs in pregnancy is mostly a temporary concern. The symptoms will generally peak during the third trimester and will disappear entirely by the time te baby is born – or within a month after birth. Women that get pregnant while suffering from RLS may find their condition gets worse during pregnancy. Women who are taking medication to manage their RLS should stop taking the medication prior to getting pregnant.
It’s currently unknown why women can develop RLS during pregnancy even if they have no history of the condition. There are several theories about it though; iron deficiency, hormonal changes, circulatory changes, and folate deficiency are all potential causes of pregnancy restless legs syndrome.
Around two-thirds of women who suffer from restless legs during pregnancy are affected by pregnancy-induced RLS. The risk factors and predictors of women developing RLS during pregnancy are having a family history of RLS, having developed RLS during an early pregnancy, a personal history of RLS, and a reduced blood cell count.
While pregnancy-induced RLS comes with a generally short-term prognosis, there is still the risk of developing long-term chronic RLS. Women who develop it in pregnancy are more likely to have the condition when they get older than women who don’t. This, along with a family history of restless leg in women with pregnancy-induced RLS, could suggest that there is a genetic predisposition that is brought to light due to the pregnancy.
Many of the drugs used to treat RLS have yet to be tested and studied with pregnant women. There isn’t enough data available to assess the risk medications may present to a developing baby.
Be sure to talk to your physician or midwife about using supplements such as vitamin B12, iron, magnesium, and folate supplements. Your doctor could advise you against taking more supplements based on prenatal vitamin levels. Also talk to a doctor before taking any kind of over-the-counter supplements and medications. It’s likely that your doctor will advise you to avoid strong medications until after you give birth.
Some women find relief from RLS by stretching, using hot and cold treatments, getting a massage, having a warm – not hot – bath, and practicing relaxation techniques. Consider asking your partner to rub or massage your legs as you fall asleep.
Drinking and smoking should be avoided during pregnancy. As well as the obvious risks to fetal development, they have been shown to be risk factors for RLS in pregnancy and they also disturb sleep patterns.
Restless Legs in Children
While there is no specific known cause for RLS, we do understand the role that genetics can play for many sufferers. Studies have shown that that between 63% and 92% of people who have primary RLS (when RLS isn’t caused by other conditions) have a family history of the condition.
It’s becoming obvious that children can develop restless legs syndrome as much as adults can. The symptoms of RLS – and problems associated with it – in children bear a strong similarity to Attention Deficit Hyperactivity Disorder (ADHD). As such, many children with RLS are misdiagnosed as having ADHD.
Research from sleep specialists suggest that up to 25% of children who have been diagnosed with ADHD could actually be suffering from Restless Legs Syndrome, Periodic Limb Movements, or some combination of these two conditions.
Much like adults, children dealing with restless legs will try to ease their discomfort through movement. They may fidget, stretch, walk, run, rock themselves, and move around a lot while trying to sleep. These issues may also be confused with more generic “growing pains” with parents and doctors assuming that they are just having trouble dealing with their body growing. When children are at school their movements could be mistaken for being signs of hyperactivity or inattentiveness.
Make no mistake about it though; restless legs syndrome is a very real medical condition that requires care and attention. One difference between RLS in children and RLS in adults is that children complain of symptoms during the day more than the night.
Diagnosing children with RLS can be difficult because they can have trouble explaining where the pain comes from, how often symptoms appear, and how long they last.
Children with restless legs syndrome don’t sleep as much as they should and are more likely to be hyperactive or overtired during the day. While some studies into ADHD and RLS have been conducted, further research is needed for definitive answers to help children get the diagnosis they need and deserve.
If you are worried that your child might have restless legs syndrome you should take them to see a neurologist rather than a primary care physician.
Restless Legs in Elderly
Restless legs syndrome is generally broken down into primary and secondary restless legs syndrome. Primary RLS affects people under 40 and is likely genetic, while secondary RLS develops over time and is more likely to affect elderly people.
Restless legs in elderly people is associated with several things that can intensify symptoms, including chronic health conditions such as diabetes, iron deficiency, peripheral neuropathy, kidney failure, Parkinson’s Disease, and an underactive thyroid are associated with restless legs. These are all conditions that develop over time and are more likely to strike older people.
It is more likely for elderly women to be diagnosed over elderly men, but there’s definitely an increased risk factor for elderly people in general.
Restless Legs Syndrome Treatments
Treatments for restless legs and feet are primarily aimed at reducing the symptoms of the condition. Moving limbs can offer some temporary relief. It’s also possible to control the symptoms by dealing with underlying medical conditions associated with RLS, such as neuropathy and anemia.
Some medications have proven effective for some sufferers, but there has yet to be a universal remedy that helps everyone suffering from restless legs syndrome. Regular medications can also become less effective over time and so you may need to adjust your dosage or medication entirely.
The treatment options for RLS include;
- Lifestyle Changes for Restless Legs
Making some lifestyle changes can offer some relief for those with mild-to-moderate restless leg symptoms. The lifestyle changes for restless legs include reducing/cutting out tobacco and alcohol use, maintaining a regular sleeping pattern, getting regular exercise, having leg massages, having a warm – but not – hot bath, and using hot and cold treatments.
There are several medical devices recently approved by the United States Food and Drug Administration (FDA) for treatment of restless legs. This includes a foot wrap that puts pressure on the foot and a pad that vibrates to stimulate the legs. Aerobic and stretching exercises also offer some relief for restless legs sufferers.
- Iron Supplements
Iron supplements are generally the first treatment option for people with restless legs syndrome, especially if they also have low iron levels. Iron supplements can be purchased over the counter and so are a good place to start. They do come with some side effects, including upset tummy and constipation. Some people may need to have iron given to them directly through an IV to get relief because their body is unable to properly absorb regular iron supplements.
- Anti-Seizure Medications
When it comes to prescription medication for restless legs, anti-seizure medications are the first-line option. The FDA approves the use of enacarbil for treating moderate to severe restless legs. The drug works as an effective dopaminergic treatment and there have yet to be any reported cases of the medication making symptoms worse. Other medications that full under this label, such as pregabalin and gabapentin, have also been used to reduce the symptoms of RLS such as nerve pain and the creeping sensation.
The possible side effects of taking these medications are sleepiness and fatigue as well as dizziness. Recent studies suggest that pregabalin is as effective at treating RLS as pramipexole, a dopaminergic drug. This suggests the two kinds of drugs have similar benefits for sufferers.
- Dopaminergic Medications
Dopaminergic medications or agents are drugs used to increase dopamine effect. They are used in the treatment of Parkinson’s Disease. They could also help to alleviate the symptoms of restless legs syndrome if taken before bed. The FDA approves the use of pramipexole, ropinirole, and rotigotine as treatments for restless legs. These dopaminergic agents are often tolerated quite well, but they have been shown to cause dizziness, nausea, and some other short-term side effects.
One problem with treating RLS with these medications is that they are not as effective in the long-term. They work great in the short-term but can actually make the symptoms of RLS worse in the long-term. As people use them more and more, they may notice symptoms set in earlier during the day – if not all the time. Doses also become less effective over time and the symptoms start to appear in other parts of the body. The good news is that these symptoms all go away when someone stops taking the medication and the body re-adjusts.
Opioid drugs like codeine, methadone, oxycodone, and hydrocodone have been prescribed to people suffering from severe restless legs syndrome that didn’t respond well to other medications. These medications tend to come with more side effects, including; constipation, nausea and dizziness, sleep apnea, and the potential for addiction issues.
Benzodiazepines are drugs that can help people to sleep better at night. However, they have the potential to cause daytime sleepiness even when taking at night time. They can also disrupt concentration and energy levels.
Benzodiazepines such as lorazepam and clonazepam are used to treat anxiety, insomnia, and muscle spasms. Given that the drugs have been shown to exacerbate sleep apnea for some people, they shouldn’t be used by people who have seep apnea.
Restless Legs vs Burning Feet
Burning feet syndrome and restless legs syndrome are two similar conditions that are commonly mistaken for one another. Burning feet syndrome is commonly seen with older people and it is caused by dysfunctions in peripheral neuron activity.
As the name suggests, the symptoms of this condition include the feeling of a burning sensation in feet. It can also cause numbness, aches, and a general feeling of heaviness that gets worse at night. The sensations of burning feet are more limited than RLS and are generally found only on the soles of feet.
The condition may be related to other conditions such as diabetes and hyperthyroidism. It also commonly presents with a vitamin B deficiency, which may or may not be related to the condition. Burning feet may also be a misdiagnosis of another, more serious condition such as Charcot-Marie-Tooth disease or erythromelalgia.
While burning feet can cause some neurological symptoms including reduced sense of touch and impaired pain tolerance, it doesn’t present any physical symptoms. It doesn’t cause muscle atrophy for example. Nor does it affect reflexes.
Top Tips to Manage Restless Legs Syndrome
There are several things you can do to manage restless legs syndrome and alleviate the symptoms. Here are our ten top tips on how to manage this condition;
- Avoid drinking alcohol, smoking, and having caffeine in the hours leading up to bed time
- Review any medications you take – prescription or otherwise – with a doctor
- Get regular exercise
- Stretch regularly at the start and end of the day
- Get regular leg massages (even if you have to massage yourself)
- Don’t eat any heavy meals during the evening
- Set and maintain a sleeping schedule
- Avoid napping during the day
- Only use your bed for sleep and sex
- Don’t make your bed somewhere that you do a lot of worrying; find ways to relax before bedtime
What to do if you Suspect You Might Have Restless Leg Syndrome
Restless leg syndrome is considered to be a chronic condition. If you believe that you might have it, then you should first consult your family doctor. As the condition is neurological in nature, you may be sent to a neurologist who can better test and treat the condition.
Consider making some lifestyle changes, such as those discussed above, to alleviate the symptoms. If you have an iron, folate, or magnesium deficiency then change your diet or take supplements to correct the deficiency and see if that helps.
Your doctor will be able to suggest medications you can use to manage the symptoms of restless legs. They will work with you to find the right balance of the right medications for you.