Restless leg syndrome (RLS)

Overview

Restless legs syndrome (RLS), also called Willis-Ekbom Disease, causes unpleasant or uncomfortable sensations in the legs and an irresistible urge to move them.  Symptoms commonly occur in the late afternoon or evening hours, and are often most severe at night when a person is resting, such as sitting or lying in bed.  They also may occur when someone is inactive and sitting for extended periods (for example, when taking a trip by plane or watching a movie).  Since symptoms can increase in severity during the night, it could become difficult to fall asleep or return to sleep after waking up.  Moving the legs or walking typically relieves the discomfort but the sensations often recur once the movement stops.  RLS is classified as a sleep disorder since the symptoms are triggered by resting and attempting to sleep, and as a movement disorder, since people are forced to move their legs in order to relieve symptoms.  It is, however, best characterized as a neurological sensory disorder with symptoms that are produced from within the brain itself.

RLS is one of several disorders that can cause exhaustion and daytime sleepiness, which can strongly affect mood, concentration, job and school performance, and personal relationships.  Many people with RLS report they are often unable to concentrate, have impaired memory, or fail to accomplish daily tasks.  Untreated moderate to severe RLS can lead to about a 20 percent decrease in work productivity and can contribute to depression and anxiety.  It also can make traveling difficult.

It is estimated that up to 7-10 percent of the U.S. population may have RLS.  RLS occurs in both men and women, although women are more likely to have it than men.   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.

More than 80 percent of people with RLS also experience periodic limb movement of sleep (PLMS).  PLMS is characterized by involuntary leg (and sometimes arm) twitching or jerking movements during sleep that typically occur every 15 to 40 seconds, sometimes throughout the night.  Although many individuals with RLS also develop PLMS, most people with PLMS do not experience RLS.

 Fortunately, most cases of RLS can be treated with non-drug therapies and if necessary, medications.

Symptoms

People with restless legs syndrome have unusual feelings in their legs (like itching, crawling, pulling, aching, throbbing, or pins and needles) and a powerful urge to move their legs to make the sensations go away. The condition can also happen in other areas like the arms, chest, or head. The feelings usually happen on both sides of the body. They can also happen on only one side, or they might start on one side and then move to the other.

RLS symptoms range from mild to unbearable. They might come and go, and the intensity can vary between episodes. They’re generally worse in the evening and at night.

Symptoms almost always go away in the early morning, so people who have RLS can often sleep well then.

The severity of RLS symptoms ranges from mild to intolerable. Symptoms can come and go and severity can also vary. The symptoms are generally worse in the evening and at night. For some people, symptoms may cause severe nightly sleep disruption that can significantly impair their quality of life.

Causes

Doctors don’t know what causes most cases of restless legs syndrome, but your genes might play a role. Nearly half of the people with RLS also have a family member with the condition.

It might also be tied to:

• Chronic diseases. Certain long-term medical conditions include RLS symptoms, including iron deficiency, Parkinson’s disease, kidney failure or renal disease, diabetes, and peripheral neuropathy.
• Medications. Some drugs might make symptoms worse, including anti-nausea meds, antipsychotics, some antidepressants, and cold and allergy medications that have antihistamines.
• Pregnancy. Some women have RLS during pregnancy, especially in the last trimester. Symptoms usually go away within a month after delivery.
• Lifestyle. A lack of sleep or another sleep disorder like apnea can trigger symptoms or make them worse. So can alcohol, tobacco, and caffeine use.

Diagnosis

Since there is no specific test for RLS, the condition is diagnosed by a doctor’s evaluation.  The five basic criteria for clinically diagnosing the disorder are:

• A strong and often overwhelming need or urge to move the legs that is often associated with abnormal, unpleasant, or uncomfortable sensations.
• The urge to move the legs starts or get worse during rest or inactivity.
• The urge to move the legs is at least temporarily and partially or totally relieved by movements. 
• The urge to move the legs starts or is aggravated in the evening or night.
• The above four features are not due to any other medical or behavioral condition.

A physician will focus largely on the individual’s 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 person’s medical and family history and list of current medications, may be helpful.  Individuals may be asked about frequency, duration, and intensity of symptoms; if movement helps to relieve symptoms; how much time it takes to fall asleep; any pain related to symptoms; and any tendency toward daytime sleep patterns and sleepiness, disturbance of sleep, or daytime function.  Laboratory tests may rule out other conditions such as kidney failure, iron deficiency anemia (which is a separate condition related to iron deficiency), or pregnancy that may be causing symptoms of RLS.  Blood tests can identify iron deficiencies as well as other medical disorders associated with RLS.  In some cases, sleep studies such as polysomnography (a test that records the individual’s 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.  Periodic limb movement of sleep during a sleep study can support the diagnosis of RLS but, again, is not exclusively seen in individuals with RLS.

Diagnosing RLS in children may be especially difficult, since it may be hard for children to describe what they are experiencing, 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.

Treatment

There’s no cure for restless legs syndrome itself, but treatments can help control it so you can get a good night’s sleep.

If another condition is causing your restless legs, such as an iron deficiency, your doctor will treat it.

Treatment for RLS itself will target your symptoms. If your RLS is mild or moderate, some small changes to your everyday life might help: getting regular exercise; following a sleep schedule; and avoiding caffeine, alcohol, and tobacco.

Other ways to treat RLS without drugs include:

• Leg massages
• Hot baths
• Heating pads or ice packs on your legs
• A vibrating pad called Relaxis

Medications help some people. But a drug that eases symptoms in one person may make them worse in another, or a drug that works for a while may stop working.

Drugs to treat RLS include:

• Dopaminergic drugs, which act on the neurotransmitter dopamine in your brain. The FDA has approved pramipexole (Mirapex), ropinirole (Requip), and rotigotine (Neupro) for moderate to severe RLS.
• Benzodiazepines, a type of sedative, may help with sleep, but they can cause daytime drowsiness.
• Narcotic pain relievers
• Anticonvulsant or antiseizure drugs, such as carbamazepine (Tegretol), gabapentin (Neurontin), gabapentin enacarbil (Horizant), and pregabalin (Lyrica)

Restless Legs Syndrome Prognosis

Restless legs syndrome is a lifelong condition that might get worse with age. But some people go into remission and don’t have symptoms for days to years.

Keep your doctor updated on how you’re doing. If you start to feel worse, they might suggest different lifestyle changes or medications.

It can help to talk to other people who know what you’re going through, whether it’s a family member who has RLS or a support group.