Restless Leg Syndrome
What is Restless Leg Syndrome?
restless legs syndrome?
The most distinctive or unusual aspect of the condition is that lying down and trying to relax activates the symptoms. Most people with RLS have difficulty falling asleep and staying asleep. Left untreated, the condition causes exhaustion and daytime fatigue. Many people with RLS report that their job, personal relations, and activities of daily living are strongly affected as a result of their sleep deprivation. They are often unable to concentrate, have impaired memory, or fail to accomplish daily tasks. It also can make traveling difficult and can cause depression.
As many as 10 percent of the U.S. population may have RLS. Several studies have shown that moderate to severe RLS affects approximately 2-3 percent of adults (more than 5 million individuals). An additional 5 percent appears to be affected by a milder form. Childhood RLS is estimated to affect almost 1 million school-age children, with one-third having moderate to severe symptoms. Some people with RLS will not seek medical attention, believing that they will not be taken seriously, that their symptoms are too mild, or that their condition is not treatable. Some physicians wrongly attribute the symptoms to nervousness, insomnia, stress, arthritis, muscle cramps, or aging.
RLS occurs in both men and women, although the incidence is about twice as high in women. It may begin at any age. Many individuals who are severely affected are middle-aged or older, and the symptoms typically become more frequent and last longer with age.
RLS is classified as a movement disorder, as individuals are forced to move their legs in order to gain relief from symptoms.
More than 80 percent of people with RLS also experience a more common condition known as periodic limb movement of sleep (PLMS). PLMS is characterized by involuntary leg twitching or jerking movements during sleep that typically occur every 15 to 40 seconds, sometimes throughout the night. The symptoms cause repeated awakening and severely disrupted sleep. Although many individuals with RLS also develop PLMS, most people with PLMS do not experience RLS. People who have PLMS and do not have RLS or another cause for the PLMS may be diagnosed with periodic limb movement disorder (PLMD). PLMD may be a variant of RLS and thus respond to similar treatments.
What are common signs and symptoms of restless legs?
People with RLS feel uncomfortable sensations in their legs, especially when sitting or lying down, accompanied by an irresistible urge to move the affected limb. These sensations less commonly affect the arms, trunk, or head. 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.
A classic feature of RLS is that the symptoms are worse at night with a distinct symptom-free period in the 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 theater, long-distance flights, immobilization in a cast, or relaxation exercises. Many individuals also note a worsening of symptoms if their sleep is further reduced by events or activity.
RLS symptoms may vary from day to day and in severity and frequency from person to person. Individuals with mild RLS may have some disruption of sleep onset and minor interference in daytime activities. In moderately severe cases, symptoms occur only once or twice a week but result in significant delay of sleep onset, with some disruption of daytime function. In severe cases of RLS, the symptoms occur more than twice a week and result in burdensome interruption of sleep and impairment of daytime function.
Individuals with RLS can sometimes experience remissionsspontaneous improvement over a period of weeks or months before symptoms reappearusually during the early stages of the disorder. In general, however, symptoms become more severe over time.
People who have both RLS and an associated medical condition tend to develop more severe symptoms rapidly. In contrast, those who have RLS that is not related to any other condition and experience onset at an early age show a very slow progression of the disorder; many years may pass before symptoms occur regularly.
What causes restless legs syndrome?
In most cases, the cause of RLS is unknown. However, it may have a genetic component; RLS is often found in families where the onset of symptoms is before age 40. Specific gene variants have been associated with RLS. Evidence indicates that low levels of iron in the brain also may be responsible for RLS.
Considerable evidence suggests that RLS is related to a dysfunction in the brains basal ganglia circuits that use the neurotransmitter dopamine, which is needed to produce smooth, purposeful muscle activity and movement. Disruption of these pathways frequently results in involuntary movements. Individuals with Parkinsons disease, another disorder of the basal ganglias dopamine pathways, often have RLS as well.
RLS also appears to be related to the following factors or conditions, although researchers do not yet know if these factors actually cause RLS:
Alcohol and sleep deprivation also may aggravate or trigger symptoms in some individuals. Reducing or completely eliminating these factors may relieve symptoms, but it is unclear if this can prevent RLS symptoms from occurring at all.
How is restless legs syndrome diagnosed?
There is no specific test for RLS. The four basic criteria for diagnosing the disorder are:
Physicians should focus largely on the individuals descriptions of symptoms, their triggers and relieving factors, as well as the presence or absence of symptoms throughout the day. A neurological and physical exam, plus information from the individuals medical and family history and list of current medications, may be helpful. Individuals may be asked about frequency, duration, and intensity of symptoms as well as their tendency toward daytime sleep patterns and sleepiness, disturbance of sleep, or daytime function.
Laboratory tests may be performed to rule out other conditions. Blood tests can identify iron and vitamin deficiencies as well as other medical disorders associated with RLS. In some cases, sleep studies such as polysomnography (a test that records the individuals brain waves, heartbeat, breathing, and leg movements during an entire night) may identify the presence of other causes of sleep disruption (e.g., sleep apnea), which may impact management of the disorder.
Diagnosing RLS in children may be especially difficult, since it may be hard for a child to describe where it hurts, when and how often the symptoms occur, and how long symptoms last. Pediatric RLS can sometimes be misdiagnosed as "growing pains" or attention deficit disorder.
How is restless legs syndrome treated?
RLS can be treated, with care directed toward relieving symptoms. Moving the affected limb(s) may provide temporary relief. Sometimes RLS symptoms can be controlled by finding and treating an associated medical condition, such as peripheral neuropathy or diabetes.
Certain lifestyle changes and activities that may reduce symptoms in persons with mild to moderate symptoms include decreased use of caffeine, alcohol, and tobacco; supplements to correct deficiencies in iron, folate, and magnesium; changing or maintaining a regular sleep pattern; a program of moderate exercise; and massaging the legs, taking a hot bath, or using a heating pad or ice pack. A trial of iron supplements is recommended only for individuals with low iron levels. Although many people find some relief with such measures, rarely do these efforts completely eliminate symptoms.
Medications are usually helpful but no single medication effectively manages RLS for all individuals. Trials of different drugs may be necessary. In addition, medications taken regularly may lose their effect over time, making it necessary to change medications periodically.
Common drugs prescribed to treat RLS include:
Dopaminergic agents (drugs that increase dopamine), largely used to treat Parkinson's disease, have been shown to reduce symptoms of RLS and PLMS when they are taken at bedtime and are considered the initial treatment of choice. The U.S. Food and Drug Administration (FDA) has approved ropinirole, pramipexole, and rotigotine to treat moderate to severe RLS. Both drugs are generally well tolerated but can cause nausea, dizziness, or other side effects. Good short-term results of treatment with levodopa plus carbidopa have been reported.
Although dopamine-related medications are effective in managing RLS, long-term use can lead to worsening of the symptoms in many individuals. This apparent progressive worsening is referred to as augmentation. With chronic use, a person may begin to experience symptoms earlier in the evening than in the afternoon until finally the symptoms are present around the clock. The initial evening or bedtime dose becomes less effective, the symptoms at night become more intense, and symptoms begin to affect the arms or trunk. Fortunately, this apparent progression is reversible 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 reversed by stopping the medication.
The FDA has approved gabapentin enacarbil, which metabolizes in the body to become gabapentin, for the treatment of moderate to severe RLS.
Other medications may be prescribed off-label (not specifically designed to treat RLS) to relieve some of the symptoms of the disorder.
Benzodiazepines can help individuals who have mild or intermittent symptoms obtain a more restful sleep. However, even if taken only at bedtime they can sometimes cause daytime sleepiness. Benzodiazepines such as clonazepam and diazepam 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.
Opioids such as codeine, propoxyphene, or oxycodone may be prescribed at night to diminish pain and help to relax individuals with more severe symptoms. Side effects include dizziness, nausea, exacerbation of sleep apnea, and the risk of addiction.
Anticonvulsants such as gabapentin and pregabalin can decrease the sensory disturbances such as creeping and crawling sensations and nerve pain. Dizziness, fatigue, and sleepiness are among the possible side effects.
The Relaxis pad, which the person can place at the site of discomfort when in bed and provides 30 minutes of vibrations (counterstimulation) that ramp off after 30 minutes, has been approved by the FDA for individuals with RLS.
What is the prognosis of people with restless legs?
RLS is generally a lifelong condition for which there is no cure. Nevertheless, current therapies can control the disorder, minimizing symptoms and increasing periods of restful sleep. Symptoms may gradually worsen with age, although the decline may be somewhat faster for individuals who also suffer from an associated medical condition. In addition, some individuals have remissionsperiods in which symptoms decrease or disappear for days, weeks, or monthsalthough symptoms usually eventually reappear. A diagnosis of RLS does not indicate the onset of another neurological disease, such as Parkinsons disease.
What research is being done?
The National Institute of Neurological Disorders and Stroke (NINDS), a component of the National Institutes of Health, is the primary Federal sponsor of research on brain and nervous system disorders. The NINDS seeks to increase scientific understanding of RLS, find improved methods of diagnosing and treating the syndrome, and discover ways to prevent it.
NINDS-supported researchers are investigating the possible role of dopamine function in RLS. Researchers suspect that impaired transmission of dopamine signals may play a role in the disorder. Additional research should provide new information about how RLS occurs and may help investigators identify more successful treatment options.
Workshops and conferences sponsored by the NINDS as well as nongovernment organizations have emphasized the need for further research on animal models and the complex roles of dopamine interaction with iron levels. For example, serum ferritin, an index of iron deficiency, has been shown to predict the severity of RLS symptoms in older individuals.
In other related research, NINDS scientists are conducting studies to better understand the physiological mechanisms of PLMS associated with RLS.
Where can I get more information?
For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute's Brain Resources and Information Network (BRAIN) at: BRAIN, P.O. Box 5801, Bethesda, MD 20824, 800-352-9424, www.ninds.nih.gov
Information also is available from the following organizations:
National Heart, Lung, and Blood
"Restless Legs Syndrome Fact Sheet", NINDS, Publication date September 2010, NIH Publication No. 10-4847
NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient's medical history.
All NINDS-prepared information is in
the public domain and may be freely copied. Credit to the
NINDS or the NIH is appreciated.
Syndrome (Constant Urge to Move Legs)
What is restless leg syndrome?
Restless leg syndrome, often simply referred to as RLS, is a condition where a person finds it difficult to not move their legs when sitting or lying down. In other words, a person with RLS has to move their legs or they experience an uncomfortable sensation in the legs. This prompts a person to stand up, move around or just change position and sometimes kick around during sleep. Restless leg syndrome (RLS) is a type of nerve disorder associated with muscle movement and since it persists during sleep, often disturbing normal sleep patterns, it is also known as a parasomnia.
Restless leg syndrome affects up to 15% of Americans. It is not a life threatening condition but has been associated with diseases such as headaches, migraines and hypertension (high blood pressure). The reason for this link is not always clear. Patients with restless leg syndrome may also experience difficulty concentrating, poor memory and even slight personality changes but this seems to be largely due to the disturbance of sleep. Most RLS patients experience significant psychological stress as a result of the condition disturbing the quality and duration of sleep.
Restless Leg Syndrome Causes
The exact cause of restless leg syndrome is unknown. It tends to occur more frequently in patients with anemia and during pregnancy but these are not causes. Even the exact disease process is not known but it appears that the root of the problem does not always lie in the legs, but rather in the brain. It appears to be linked to dopamine, a type of brain hormone. There is some evidence to suggest that the problem may lie with the dopamine receptors rather than just the hormone dopamine on in its own. Similarly a problem with the iron levels have been detected yet the mechanism by which it may contribute to restless syndrome is unclear.
Primary Restless Leg Syndrome
Primary RLS is where the condition occurs on its own and no abnormality can be found. The cause appears to be genetic as there is a familial tendency to inherit restless leg syndrome. In these instances the onset of restless leg syndrome may occur much earlier in life.
Secondary Restless Leg Syndrome
Secondary RLS is when the condition arises as a result of some underlying diseases or factors. Even in these cases, the way the abnormality or disease leads to RLS is not fully understood. However, most of these underlying diseases either affect iron levels in the body or cause nerve diseases known as peripheral neuropathy. These conditions include :
Restless Leg Syndrome in Pregnant Women
RLS may also occur in pregnancy. This may be in part due to changes in the iron levels and hormone changes with pregnancy. However, RLS usually subsides within weeks after delivery although there is a greater chance of these women developing permanent RLS later in life.
Medication Causing Restless Leg Syndrome
The following medications may be associated with restless leg syndrome. However, it is unclear whether these medication causes, triggers or exacerbates existing RLS. Only certain types of these medication may be responsible for RLS.
Restless Leg Syndrome Symptoms
The two main symptoms are strange sensations in the leg and an irresistible urge to move the legs.
Abnormal Leg Sensations
Most RLS patients have difficulty clearly describing the abnormal sensation they experience in the legs. It is almost never a pain of sorts nor is it muscle cramps. However, some patients may find that the words pain and cramps are the only way to describe the sensation despite it not being an actual pain or cramp. Some of the more common descriptions of the sensation includes :
Urge to Move Legs
The uncontrollable desire to move the legs is the other main symptom that is reported in restless leg syndrome. Features associated with this urge includes :
Wriggling of the legs during sleep is not the same as muscle twitching. RLS may occur with a twitching disorder known as periodic leg movement disorder where there is involuntary leg muscle movements.
Restless Leg Syndrome Diagnosis
Restless leg syndrome is usually diagnosed by the patients report of the symptoms. Various tests may be conducted to either find a cause or connection with other disorders where the restless leg syndrome may be secondary. Blood tests will assess micronutrients levels (vitamins and minerals), kidney function and thyroid activity. Other tests are also done to exclude certain disorders which may be mistaken with restless leg syndrome as is the case with period leg movement disorder. Nerve and muscle testing specific for these disorders will also be considered.
Restless Leg Syndrome Treatment
Where restless leg syndrome is associated with other conditions (secondary RLS), the treatment will be directed at the underlying disease. Restless leg syndrome may then ease or even subside once these existing diseases are effectively treated and managed. With primary RLS, where there is no link to other diseases, the main option is lifestyle changes such as :
If any causative medication is identified as a possible cause, then this should also be attended to either by stopping the medication or changing the type of drug. This should only be done under the strict supervision of a doctor.
Restless Leg Syndrome Medication
Medication to treat primary restless leg syndrome is only considered once lifestyle measures have failed to provide relief and the loss of sleep is causing severe adverse effects on the patients life. These drugs include :