Restless Legs Syndrome (RLS): Symptoms, Causes, & Treatment

Have you ever felt the urge to move your legs after sitting down for a long time? A lot of individuals have experienced that sensation, but for some, this can become a nuisance that leads to more serious complications.

Restless Leg Syndrome (RLS), also called the Wilis- Ekbom Disease is a chronic, multifactorial disease of the limbs where patients have the irresistible urge to move their legs. Patients with RLS also experience sleep disturbance since Restless Leg Syndrome often has a pattern where the symptoms worsen at night. RLS is often underdiagnosed thus leading to delay in treatment. (1) 

What is Restless Leg Syndrome (RLS)? 

Restless Leg Disorder starts during childhood but the diagnosis is often made in the 3^rd decade of life. In the United States, it has been estimated that 7 to 10% of the population suffers from RLS and women are more likely to be affected than men. (2) 

This condition is debilitating but thanks to the advancement in medicine, it is now treatable. 

There are 2 types of Restless Leg Syndrome: (3)

1. Primary Restless Leg Syndrome 
2. Secondary Restless Leg Syndrome

Secondary Restless Leg Syndrome is often because of other etiologies like the following:

1. Varicose veins 
2. End stage renal disease (ESRD)
3. Celiac Disease
4. Fibromyalgia
5. Amyloidosis
6. Folate or Magnesium Deficiency
7. Diabetes Mellitus either Type 1 or Type 2
8. Iron Deficiency
9. Lumbosacral Radiculopathy
10. Rheumatic Disease
11. Medications often given for depression like Tricyclic Antidepressants (TCA), Selective Serotonin Reuptake Inhibitors (SSRI) and other medications like diphenhydramine. 

What Causes Restless Leg Syndrome?

Idiopathic Restless Leg Syndrome usually stems from a problem in the dopaminergic (the hormone for happiness) systems and iron stores in the brain. There is usually a decrease in both of these thus RLS develops. Studies have suggested that RLS may be inherited from our parents since certain genes may carry the problem of RLS. 

Other causes of RLS are imbalances in vitamins and minerals such as calcium, phosphate, vitamin D and iron. 

Patients who have anemia, nerve problems, low ferritin and high estrogen levels are common in patients who are pregnant thus making them vulnerable for Restless Leg Syndrome. RLS is common in pregnant women especially in the 3^rd trimester. (4)

What are the Signs and Symptoms of Restless Leg Syndrome?

Patients who are suffering from Restless Leg Syndrome oftentimes describe a feeling of crawling, itching or stretching in the areas of the deep structures like the muscle or near the bone than in the skin. 

They complain of paresthesia (tingling or pricking sensation) even when there is no contact on the skin. These symptoms can vary from very mild to that of major impairment to the point of having disruptions in their day to day life. 

Symptoms are often worse at the end of the day and increases during the night especially when the patient is at sleep. These often occur 15 to 30 minutes prior to sleeping. For patients with symptoms that are severe, RLS occurs even when patient is just seated. The arms may also be affected in some cases. 

The leg movements are usually involuntary and forceful dorsiflexion of the foot that last from 0.5 to 5 seconds and can occur every 20 to 40 seconds during sleep. This is noted in 80% of patients with RLS. (1) 

How is Restless Leg Syndrome Diagnosed?

The diagnostic criteria for RLS is the following, and all must be met: (5)

1. An uncontrollable urge to move the lower extremities that may be accompanied by uncomfortable sensations like paresthesia.
2. The urge to move the extremities is less during daytime but progressively worsens in the evening especially when asleep. The symptoms also appear during rest or periods of inactivity. 
3. The urge to move the lower extremities may be partially or completely relieved by the movement of the legs. While there is continued activity, the symptoms are often absent or mild.
4. The urge to move the lower extremities is often worse during nighttime and makes sleep impossible. Patients often feel fatigued during the day because of the lack of sleep. 
5. These symptoms must not be because of other behavioral conditions like leg cramps, muscle cramps, discomfort from certain positions or tardive dyskinesia. 

Tests that will be taken are often done to rule out other causes because no specific test can diagnose Restless Leg Syndrome.  An EMG or electromyography may also be requested to rule our neuropathies or muscle disorders. 

What are the Treatments for Restless Leg Syndrome?

Here is a list of things that may help Restless Leg Syndrome:

1. Avoid caffeine if you can or decrease intake of caffeine and caffeine- containing medication.
2.  Avoid medications like antidepressants, antipsychotics, anti-emetics and centrally acting antihistamines. 
3. Exercise daily.
4. For patients with renal failure, short daily dialysis is recommended. 
5. Massage and heat or warm compress may help alleviate symptoms. 
6. The use of medications like pramipexole, ropinirole, rotigotine and cabergoline may help decrease symptoms and improve sleep and quality of life of patients with RLS. 
7. Rotigotine transdermal patch is also effective and is well tolerated.
8. Using gabapentin or pregabalin can be used for initial treatment of patients with severe disturbance of sleep and insomnia. It is also used for patients with pain, anxiety and impulse control disorder. 
9. Radiofrequency Ablation is a minimally invasive procedure of removing varicose veins and may help if you are experiencing Restless Leg Syndrome due to varicose veins. 

The drugs mentioned above are effective from 1 to 5 years but may have adverse effect or may be contraindicated in certain patients, which is why, prior to using these medications, it is important to have yourself checked by your physician. 

For patients with RLS secondary to problems in vitamins or minerals, adding these vitamins and minerals may be beneficial. 

Pregnant women with RLS often improve after delivery.

Exercise is very important and benefits a lot of patients suffering from RLS but is generally not helpful for patients with RLS happening in the middle of the night. 

Medication for Restless Legs Syndrome

Anti-seizure Drugs – FDA has approved gabapentin enacarbil for treatment of moderate to severe RLS. The drug has similar effects as dopaminergic treatment (covered below).

Recent studies have shown pregabalin (another anti-seizure drug) is effective for RLS treatments as the dopaminergic drug pramipexole. Side effects may vary so it’s important to consult your physician before taking any medication.

Dopaminergic agents are drugs that increase dopamine effects. They are used to treat Parkinson’s disease, however, they have been shown to reduce the symptoms of RLS when they are taken at nighttime. 

The FDA has approved ropinirole, pramipexole, and rotigotine to treat moderate to severe RLS. Side effects may include nausea, dizziness, and other short-term side effects. 

Long term use of dopaminergic agents is not recommended as they can worsen symptoms. Stopping the medication can reverse the progression. 

Opioids such as methadone, codeine, hydrocodone, and oxycodone may be prescribed in low doses to individuals with more severe symptoms of RLS. 

Side effects can include constipation, dizziness, nausea, exacerbation of sleep apnea, and risk of addiction. 

Benzodiazepines such as clonazepam and lorazepam are drugs that are generally prescribed to treat anxiety, muscle spasms, and insomnia. They can help obtain more restful sleep. 

Side effects may include daytime sleepiness, reduced energy and affect concentration. They should not be used for individuals with sleep apnea. 

Complications of Restless Leg Syndrome

70% of patients with RLS may have symptoms that are moderate to severe. Some patients may also have the same symptoms in the upper extremities. 

As mentioned, the symptoms are typically less severe in the morning especially when there are activities but worsens during night time especially at the time of sleep. 

It is disabling and interrupts their sleep thus causing fatigue all throughout the day. Because of this, patients are fatigue and because of the symptoms, depression can also occur. 

Conclusion

Because Restless Leg Syndrome can be debilitating and can significantly affect the quality of life of patients, it is important that when managing these patients, their disease is explained to them and supportive care is given. 

RLS is a complicated and devastating illness. The underlying problems in secondary Restless Leg Syndrome should be treated immediately. 

If you think you or a loved one has Restless Leg Syndrome and may need further treatment, do not hesitate to click here to book a free consultation.

References

1. Mansur A, Castillo PR, Rocha Cabrero F, et al. Restless Leg Syndrome. [Updated 2020 Apr 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430878/
2. Restless Legs Syndrome Fact Sheet. (n.d.). Retrieved from https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/restless-legs-syndrome-fact-sheet
3. Pratt D. P. (2016). Restless Legs Syndrome/Willis-Ekbom Disease and Periodic Limb Movements: A Comprehensive Review of Epidemiology, Pathophysiology, Diagnosis and Treatment Considerations. Current rheumatology reviews, 12(2), 91–112. https://doi.org/10.2174/1573403×12666160223120340
4. Prosperetti, C., & Manconi, M. (2015). Restless Legs Syndrome/Willis-Ekbom Disease and Pregnancy. Sleep medicine clinics, 10(3), 323–xiv. https://doi.org/10.1016/j.jsmc.2015.05.016
5. Guo, S., Huang, J., Jiang, H., Han, C., Li, J., Xu, X., Zhang, G., Lin, Z., Xiong, N., & Wang, T. (2017). Restless Legs Syndrome: From Pathophysiology to Clinical Diagnosis and Management. Frontiers in aging neuroscience, 9, 171. https://doi.org/10.3389/fnagi.2017.00171