Restless Leg Syndrome

I have run this mile countless times, not around the neighborhood nor the local track, but simply in my bed each night as I try to fall asleep. The nagging need to move my legs beneath the sheets is overwhelming. I get out of bed. I walk through the house. I try running water over my feet and legs. I hang my legs over the edge of the bed and dangle my feet. Pacing the floor again, I try sleeping on the sofa. I have tried a variety of medications and have avoided certain foods and drinks prior to bed. My symptoms go away for a while. Some nights I simply fall asleep due to exhaustion. This scene repeats itself and to varying degrees of aggravation.

What is this sleep malady and why am I affected by the inability to relax and fall asleep peacefully? I am not alone in this affliction. It is called Restless Leg Syndrome or simply RLS. Approximately 10% of the population is affected. The syndrome is characterized by the urge to move the legs and usually manifests during periods of inactivity and at night prior to falling asleep. Women are affected nearly twice as often as men. Women who are multiparous (who have had more than one child) are primarily affected and the symptoms tend to worsen with subsequent pregnancies.

The syndrome often becomes worse with age and is frequently diagnosed in middle age. RLS often can be a secondary symptom of conditions that cause iron deficiencies. This is perhaps why RLS presents itself during pregnancy when iron deficiencies can occur. End stage renal disease and neuropathies can also cause RLS symptoms. The severity of symptoms range from mild to uncomfortably irritating to painful. Management of RLS, depending on the severity, can involve simple lifestyle changes, such as diet and exercise or in severe cases medications that can be prescribed by a family physician.

Diagnosis usually is based on the subjective information of the recipient. Are the symptoms alleviated by moving the limbs? Is there a family history of RLS? Do certain types of medications help to alleviate or aggravate symptoms? When are symptoms most noticeable? Are there problems with falling asleep and staying asleep? Is there an anemia or an iron deficiency present? Is there an underlying disease present that would cause RLS? The answers to these questions help make the diagnosis.

Often times the victim may present with a normal physical exam. Typically the patient’s main complaint is fatigue and lack of sleep. Their sleep problems are often described as an uncomfortable, creeping, nagging sensation in their legs that does not allow for falling asleep. The feeling is uncomfortable enough to cause the person to “have to” move their legs in order to rid themselves of the sensation. The arms can sometimes be involved as well. The symptoms are alleviated as long as the legs continue to move. Once movement has stopped the uncomfortable sensation begins again. So goes the pattern. The severity varies from night to night and the symptoms may dissipate for several weeks to several months and then return.

The symptoms can also occur during any period of inactivity, whether it is sitting down to read, watch TV, or travel or any time the body is required to sit still. Eighty percent of those affected experience Periodic Limb Movement Disorder or PLMD. This is a jerking motion of the limbs that occur throughout the night and disrupts the sleep cycle. PLMD is different from RLS in that the movements are totally involuntary. The diagnosis of PLMD is made by a sleep study at medical facilities that do sleep monitoring. In either case, the cause of the disorder is not known. It is believed that the chemical neurotransmitter dopamine, which carries information to the nerve cells, is possibly not functioning correctly and therefore an imbalance of this substance contributes to the development of RLS.

Interestingly enough, although it is diagnosed frequently in middle age there are those who are affected early in life. Genetics definitely is a factor in determining early onset of the syndrome. Those with family members affected can have symptoms present as infants. In my particular case, my mother suffers from RLS and my symptoms appeared in my early teens. The fact that I have had four children has made the symptoms even more pronounced. It is estimated that 50% of those with RLS have a genetic predisposition. Others develop RLS as a secondary symptom of other disorders. Again, those with anemia or low iron levels can develop RLS. It is important to have your physician perform a serum ferritin and iron level to determine if iron deficiency exists. Once anemia is corrected the symptoms of RLS are usually alleviated.

Those suffering from kidney failure, diabetes, Parkinson’s disease and peripheral neuropathies often exhibit RLS. Again treating the underlying condition will usually resolve the RLS. Pregnancy is a tremendous contributing factor particularly in the last trimester. Once delivery has occurred the symptoms lessen. However, as mentioned previously multiple pregnancies tend to cause the symptoms to remain. Medications also can be a contributing factor. Antinausea, antipsychotic, and some cold and allergy medications can reek havoc on the RLS sufferer. At one point my sleep was so disrupted that I resorted to nightly sleep aids containing diphenhydramine. Little did I know this was contributing to my RLS. Once I stopped the over the counter sleep aid, my nightly occurrences of the “jimmy legs” stopped as well.

RLS can affect our daily productivity. Lack of concentration, lack of motivation and memory loss are all byproducts of sleep disruption. RLS is often underdiagnosed or misdiagnosed. Common misdiagnoses are depression, insomnia, arthritis, neuropathies and night cramps. Discuss your symptoms with your physician. Identifying a problem is often half the battle. If there is a positive family history, if you experience the urge to move your limbs voluntarily or involuntarily throughout the night and are experiencing sleep interruptions its quite possible that RLS is present. If involuntary, periodic limb movement disorder is suspected, be aware that there are lifestyle changes that can help tremendously.

Pharmacotherapy includes dopaminergic drugs. Levodopa is a first line standard therapy for this disorder. Pergolide (Permax®) is another medication that is used. The FDA has approved the drug Ropinirole (Requip®) as a treatment for RLS. The drug Cabergoline (Dostinex) is yet another agent but less is know about it. Other pharmaceuticals used with varying affect are opiates, tramadol (Ultram®), benzodiazepines and anticonvulsants. There is even a drug called Rotigotine (NeuproTM®) in the form of a patch that is in trial.

Some non-pharmaceutical treatments include exercise. Reduction in caffeine consumption, particularly in early afternoon and early evening. It is not necessary to eliminate caffeine but reduce its use and never late in the evening. Eliminate the use of tobacco, that’s a no brainer. We are fully aware of the detrimental effects of tobacco. Reduce the stress in one’s life, for example try meditation or yoga to keep the mind and body in tune. Strive for a healthy diet. Obesity is rampant in our society and makes management of this disease difficult. Manage your medications. If you feel that certain medications may be triggering your RLS discuss the problem with your physician. There are also drugs out in the market that help in the treatment of RLS. Lastly, once it has been determined that anemia is present ask your doctor about vitamin supplements.

Reference:

Allen, RP., et. al., “Restless Legs Syndrome: A Kickoff”, The Movement Disorder Society, Feb. 2006.

By: JP Saleeby, MD

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