Restless Legs Syndrome
What is restless legs syndrome
Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a chronic condition that causes strong, unpleasant feelings in the legs, resulting in an overwhelming need to move them. Moving the legs relieves the unpleasant sensations.
Restless legs syndrome is considered a condition of the nervous system, sometimes referred to as a neurological disorder. Because RLS can seriously affect some people’s sleep patterns, it can also be classed as a sleep disorder.
Around 8 percent of the population of the United States and up to 10 percent of the population of the U.K., is thought to be affected by restless legs syndrome. RLS symptoms often begin at around 40 to 45 years of age, more often affecting women than men.
Restless legs syndrome cannot be cured. However, there are various treatments, including home remedies, lifestyle changes and natural treatments, that can lessen the severity of symptoms. If RLS is triggered by a specific condition or medication, treating that condition can eliminate RLS.
Symptoms of restless legs syndrome
The main symptom of restless legs syndrome is an overwhelming urge to move the legs because of uncomfortable and unpleasant feelings in one or both legs.
- Feeling the urge to move
- Causing discomfort
- Having an electric current
Some people may experience the feelings as painful, but most people feel the sensations as an ache rather than something sharp and causing immediate pain.
- Lying down
- In bed
- In a restricted space, like on a plane or at the movies
Symptoms improve in the mornings, and when the person starts to move or walk around. Moving around as a remedy can be difficult when the person is trying to go to sleep.
Symptoms can vary in severity, from mild discomfort to being so disruptive and painful they affect day-to-day life. Sleep can be so disturbed that people have difficulty functioning during the day and can commonly lead to depression and anxiety.
Periodic limb movement in sleep (PLMS)
Periodic limb movement in sleep causes limbs, commonly the legs but also sometimes the arms, to jerk or twitch involuntarily during sleep. It can be so severe as to wake the sleeper and disturb anyone sharing the bed. Limb movements may also occur during waking hours.
Most people with restless legs syndrome have PLMS, but many people with PLMS do not also have restless legs syndrome.
Causes of restless legs syndrome
In most cases, it is not known what causes restless legs syndrome . This is called primary, or idiopathic, RLS.
Sometimes restless legs syndrome is caused by another health condition. This is known as secondary RLS.
Primary restless legs syndrome
There is research that suggests restless legs syndrome is connected to problems with a part of the brain called the basal ganglia, which uses dopamine to control muscle movement. If this part of the brain becomes damaged, it can result in muscle spasms and jerky movements.
Secondary restless legs syndrome
There are a number of other conditions that appear to be linked to causing restless legs syndrome. These may include:
Iron deficiency anemia
A lack of iron in the body, leading to iron deficiency anemia, appears to be linked to restless legs syndrome. Iron helps dopamine to function in the brain. Iron levels in the body also dip towards the end of the day, which corresponds with RLS symptoms becoming worse.
See the resource on iron deficiency for more information.
Restless legs syndrome and pregnancy
Pregnant women may develop restless legs syndrome, with symptoms more common in the final trimester. Between 10 percent and 25 percent of pregnant women are thought to experience symptoms.
Nobody is quite sure why pregnancy can trigger restless legs syndrome. There are suggestions it is connected to:
- Low iron levels
- Low folate levels
- Circulation problems
- Increase in estrogen
Restless legs syndrome that develops during pregnancy generally goes away within a month after birth.
Other health conditions
- End-stage kidney disease, particularly when needing dialysis
- Nerve damage, including that caused by diabetes
- Spinal cord disease
- Multiple sclerosis
- Parkinson’s disease
- Rheumatoid arthritis
- Antidepressants, particularly selective serotonin reuptake inhibitors and tricyclic antidepressants
- Anti-nausea medication, particularly metoclopramide
- Antipsychotic medications, such as haloperidol and phenothiazines
- Lithium, used to treat bipolar disorder
- Antihistamines, found in cold and allergy medications
- Calcium channel blockers, used to treat high blood pressure
- Beta blockers, used to treat blood pressure and heart conditions
- Caffeine and alcohol
- Smoking to excess
Diagnosing restless legs syndrome
These are the diagnostic criteria for RLS, published by the International Restless Legs Syndrome Study Group (IRLSSG). All five criteria are required for the diagnosis:
- An urge to move the legs, usually caused by uncomfortable and unpleasant sensations in the legs. Sometimes the urge to move is present without the sensations, and sometimes the arms or other body parts are involved as well as the legs
- The urge to move or sensations in the limbs begin, or become worse while resting
- The urge to move or sensations in the limbs are partially or totally eased by moving. Relief lasts as long as the movement continues
- The urge to move or sensations in the limbs are worse in the evening or night, or only happen in the evening or night
- Symptoms are not explained by another medical or behavioral condition
A doctor will diagnose based on a description of symptoms and triggers. A physical and/or neurological exam may be done, a family history taken and possibly blood tests to look for underlying factors.
A sleep study may be helpful to check for sleep disruption and periodic limb movement in sleep. (See Periodic limb movement in sleep (PLMS)
The Restless Legs Syndrome Foundation produces an RLS Symptom Diary which can be printed off and used to track symptoms, activities and sleep patterns. RLS-UK has a tool to help affected people monitor symptoms and medication.
Restless leg syndrome in children
There is thought to be a genetic link with restless legs syndrome. The Restless Legs Syndrome Foundation reports that 35 percent of people with the condition say they first experienced symptoms before the age of 20, and that 1.5 million children and adolescents in the United States are believed to be affected.
Children with restless legs syndrome are likely to be tired during the day, due to disturbed sleep. This can affect their performance in school.
As restless legs syndrome is usually diagnosed by medical history, it can be difficult for children to express what they are experiencing and accurately report their symptom history. Children exhibiting twitching and fidgeting may be mistaken for having ADHD. There is research to suggest 25 percent of children with RLS or periodic limb movements in sleep may be misdiagnosed as having ADHD.
Treatment of restless legs syndrome
There is no cure for restless legs syndrome, though its symptoms can be managed to make the condition easier to live with.
- RLS caused by pregnancy typically ends within four weeks after giving birth
- RLS caused by iron deficiency can be treated by taking iron supplements
- RLS caused or made worse by a medication may be treated by stopping or changing medication, after consultation with a medical professional
Where restless legs syndrome is thought to be caused by a lack of iron and/or ferritin in the body, treatment with iron supplements is advised.
Discussion with a doctor will establish the appropriate amount of iron equivalent supplements per day, usually taken alongside supplements of vitamin C to help absorption. If this does not affect iron levels, an intravenous infusion may be necessary.
The NHS notes that side effects of taking more than 20mg of iron a day can include:
- Stomach ache
- Nausea and vomiting
Taking extremely high doses of iron can be dangerous. Although iron supplements are commonly available, treating restless legs syndrome with iron should be supervised by a healthcare professional.
If the symptoms of restless legs syndrome are mild, lifestyle changes may be the only treatment needed. In these cases, there are plenty of natural treatments and home remedies that can be tried.
Adopting good sleep practices can help a person with restless legs syndrome get enough sleep. Not getting enough sleep can be one of the most disruptive consequences of RLS. Good sleep habits can include:
- Going to bed and waking up at regular times
- Not napping during the day
- Making sure the bedroom is dark, cool, quiet and comfortable
- Taking electronic equipment, such as TV and phone, out of the bedroom
Changes to diet may also help with reducing symptoms of restless legs syndrome:
Avoid stimulants, like caffeine, nicotine and alcohol, particularly before bed Drink plenty of water to prevent dehydration
- Regular, moderate exercise
- Avoid being confined in places; for example, choose an aisle seat at the movies or on a plane
- Massaging the legs
- Taking a warm bath
- RLS-UK suggests hot-cold therapy: a shower of alternating hot and cold water
- Simple leg stretches may help
The U.S. Food and Drug Administration has approved devices to treat restless legs syndrome, including a foot wrap and a vibrating pad. This pad, called Relaxis, has been found to improve quality of sleep.
A class of drugs called dopamine agonists work by mimicking dopamine in the brain to stimulate a response. They are also often used to treat Parkinson’s disease.
- Rotigotine, taken as a skin patch
Side effects of these drugs can include:
- Fainting when standing up
A less common side effect of these medications is a lack of impulse control. This can lead the person taking the drugs to develop obsessions with shopping, drinking, gambling or sex. Stopping the drugs will reverse this behavior.
Sudden drowsiness and falling asleep can be a side effect of taking levodopa. It is advisable not to drive, operate machinery or take part in potentially dangerous activities until it’s clear how levodopa affects the person taking it.
Levodopa is not recommended for long term use as it can make restless legs syndrome symptoms worse. It’s generally prescribed for occasional use, when people feel symptoms coming on.
The U.S. Food and Drug Administration has approved gabapentin enacarbil for treating restless legs syndrome. Two other anti-seizure medications, pregabalin and gabapentin, are being trialled.
Possible side effects, which lessen over time, of gabapentin enacarbil include:
- Feeling dizzy
- Feeling sleepy
Gabapentin enacarbil appears to be as effective or better at treating symptoms of restless legs syndrome as the dopamine agonist pramipexole. It is of particular benefit to people with RLS, who are: 
- In pain
- Experiencing disturbed sleep as the primary symptom
- Having difficulty with impulse control
To date, gabapentin enacarbil has not been shown to cause augmentation.
One of the most disruptive effects of restless legs syndrome can be lack of sleep. Medication from the benzodiazapine class of drugs, also known as hypnotics, may be prescribed as a short-term solution to help induce sleep.
- Feeling sleepy during the day
- Lack of concentration
- Feeling sluggish
- Causing or worsening sleep apnea
- High risk of addiction
Augmentation and rebound
There are complications associated with dopamine medication used for treating restless legs syndrome.
Augmentation is the name for symptoms worsening while taking medication for restless legs syndrome. People experiencing augmentation find that symptoms start earlier in the day and the symptoms become more severe.
Augmentation is more common with levodopa use, seen in approximately 80 percent of cases as opposed to dopamine agonist use, seen in 2 percent to 35 percent of cases. It tends to occur around six months after starting a particular treatment.
Ending the treatment will relieve signs of augmentation. However, coming off the drugs may be difficult as withdrawal symptoms can occur.
Rebound occurs when restless legs syndrome symptoms appear in the morning or late at night and is related to a dose of the drug wearing off. It is differentiated from augmentation by lacking a worsening in severity of symptoms and of symptoms recurring at a different time of day; rebound occurs in the morning as opposed to evening, as seen in augmentation.
As with augmentation, rebound can be halted and reversed by stopping taking the medication. Rebound can also be counteracted with longer-acting medication.
AAST. “Treatment of Restless Leg Syndrome and Periodic Limb Movement Disorder.” March 2016. Accessed April 6, 2018. ↩
U.S. Food & Drug Administration. “Foot Wrap For Treating Restless Leg Syndrome Symptoms.” February 2018. Accessed April 8, 2016. ↩
US National Library of Medicine. [“Medical devices for restless legs syndrome – clinical utility of the Relaxis pad.]”(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4671777/) December 2015. Accessed April 8, 2018. ↩
GOV.UK. “Dopamine agonists: pathological gambling, increased libido, and hypersexuality.” August 2007. Accessed April 8. 2018. ↩