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.[1][2][3]

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.[4][5]

Around 8 percent of the population of the United States[6] and up to 10 percent of the population of the U.K.[7], 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.

Other conditions, such as pregnancy, iron deficiency anemia[1] or Parkinson’s disease[8] may cause restless legs syndrome.

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.[2]

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.

The sensations in the legs and, in severe cases, the arms are variously described as:[1][9][10]

  • Crawling
  • Itching
  • Aching
  • Throbbing
  • Pulling
  • Burning
  • Painful
  • Fizzing
  • Tickling
  • Tingling
  • Feeling the urge to move
  • Cramping
  • Restlessness
  • Creeping
  • Causing discomfort
  • Tense
  • 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.[2]

Symptoms occur when the person is at rest or inactive, such as:[6][9]

  • Lying down
  • Sitting
  • 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.[1] 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.[1][7][10]

Periodic limb movement in sleep (PLMS)

Periodic limb movement in sleep (PLMS), also known as periodic limb movement disorder (PLMD)[3], is experienced by 80 percent of people with restless legs syndrome.[11]

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.[11]

Most people with restless legs syndrome have PLMS, but many people with PLMS do not also have restless legs syndrome.[12]

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

Primary restless legs syndrome tends to begin slowly, around the age of 40. This is earlier than most secondary RLS cases. RLS also runs in families, suggesting a genetic link.[7][13]

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.[1]

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[14], appears to be linked to restless legs syndrome.[15] 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.[16]

Nobody is quite sure why pregnancy can trigger restless legs syndrome. There are suggestions it is connected to:[16]

  • 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.[1]

Other health conditions

There are several conditions that can cause restless legs syndrome as a complication, such as:[2][13][10]

  • End-stage kidney disease, particularly when needing dialysis
  • Nerve damage, including that caused by diabetes
  • Spinal cord disease
  • Multiple sclerosis
  • Fibromyalgia
  • Parkinson’s disease
  • Rheumatoid arthritis

Triggers

Many medications and other substances can make restless legs syndrome worse, such as:[2][13][17][18]

  • 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:[10]

  • 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.[2]

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[6] produces an RLS Symptom Diary[19] 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.[20]

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.[21]

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.[22]

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.

If restless legs syndrome is caused by a condition or medication, symptoms may go and not return if the condition is cured or medication is stopped. For example:[2][23]

  • 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

Iron supplements

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.[1][24]

The NHS notes that side effects of taking more than 20mg of iron a day can include:[25]

  • Constipation
  • 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.

Lifestyle management

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.[1][2][26][27]

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

Certain activities can ease restless legs syndrome symptoms, such as:[26][27]

  • 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

Medical devices

The U.S. Food and Drug Administration has approved devices to treat restless legs syndrome[1], including a foot wrap[28] and a vibrating pad. This pad, called Relaxis, has been found to improve quality of sleep.[29]

Dopamine agonists

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.[30]

Three types of dopamine agonists have been approved to treat restless legs syndrome:[1][31]

  • Ropinirole
  • Pramipexole
  • Rotigotine, taken as a skin patch

Side effects of these drugs can include:

  • Nausea
  • Sleepiness
  • Headaches
  • Dizziness
  • 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.[32]

Levodopa

Levodopa is a drug that the body converts into dopamine. It is usually taken alongside a drug called carbidopa, which stops levodopa being converted into dopamine before reaching the brain.[33][34]

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.[34]

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.

Anti-seizure medication

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.[24]

A long-release form of gabapentin enacarbil is used to treat restless legs syndrome. The medication decreases the uncomfortable, creeping feelings in the legs.[1][35]

Possible side effects, which lessen over time, of gabapentin enacarbil include:[35]

  • Fatigue
  • 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: [24][10]

  • 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.[24]

Sleep aids

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.[24]

Benzodiazapines can include:[1][24]

  • Temazepam
  • Clonazepam
  • Lorazepam
  • Zaleplon
  • Eszopiclone

These drugs are not recommended for long-term use because of their various side effects, which include:[1][36]

  • 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.[37]

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.[38]

Ending the treatment will relieve signs of augmentation. However, coming off the drugs may be difficult as withdrawal symptoms can occur.[31]

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.[31][38]

As with augmentation, rebound can be halted and reversed by stopping taking the medication. Rebound can also be counteracted with longer-acting medication.

Treatment of restless legs syndrome in children

The US Food and Drug Administration has not approved any medication for treating restless legs syndrome in children. The long-term effects of treating children with medication approved for adults is unknown.[39]

Benzodiazapines, such as clonazepam, are not recommended for children because it can cause the collapse of the upper airway. Up to 20 percent of children taking levodopa and carbidopa can develop a side effect of feeling sick.[39]

Good sleep habits are recommended for treating restless legs syndrome in children, as is avoiding caffeine and antihistamines. Vitamin and mineral supplements may help, when taken in consultation with a doctor.[22][39]

Prognosis for restless legs syndrome

Primary restless legs syndrome has no cure. Although symptoms may worsen with age, treatment and therapy can bring symptoms under control and minimize disruption to everyday life.[1]

Restless legs syndrome FAQs

Q: Is restless legs syndrome painful?
A: Not generally. People tend to describe the sensations caused by restless legs syndrome as uncomfortable, such as crawling or itching. In severe cases, people may report feeling pain.

Q: What vitamin and/or mineral supplements are good for restless legs syndrome?
A: Sometimes restless legs syndrome is caused by an iron deficiency, in which case iron supplements can ease or reverse symptoms. If a person has a healthy and balanced diet, there is usually no need for supplements. A medical professional can assess whether symptoms of RLS are caused by a vitamin or mineral deficiency and can recommend supplements where necessary.

Q: Does magnesium help restless legs syndrome?
A: Although some people with restless legs syndrome report that products like magnesium oil spray has been helpful,[26] and others report magnesium supplements helped with insomnia,[40][41], Harvard Men’s Health Watch notes that studies on magnesium and sleep have, to date, been small and of short duration.[42] A scientific basis for using magnesium to help with restless legs syndrome is currently lacking.

Q: What essential oils help with restless legs syndrome?
A: Although some people report that symptoms are reduced by using essential oils, there is no scientific evidence that they have any effect. Any benefit is likely to be from massaging the legs or the placebo effect.

Q: What home remedies and natural treatments work for restless legs syndrome?
A: There are some lifestyle changes, such as good sleep hygiene, avoiding stimulants and taking exercise, that can ease symptoms of restless legs syndrome. (See Lifestyle management.) There are reports that drinking quinine tonic water, or placing a bar of soap under a bed sheet at night, will help; however, there is no scientific evidence for these activities, and any benefit is likely to be the placebo effect.

Q: What causes restless legs syndrome?
A: Nobody quite knows what causes primary restless legs syndrome. In some cases, restless legs syndrome can be triggered as a secondary condition in various cases, such as when someone is pregnant or has fibromyalgia or an iron deficiency. (See Causes of restless legs syndrome)

Q: What’s the best treatment for restless legs syndrome?
A: The best way to treat restless legs syndrome will depend on whether a cause can be found and how severe your symptoms are. For example, if your RLS is being caused by an iron deficiency, the treatment will be to take iron supplements. If you have primary RLS, but your symptoms are mild, you may be able to manage them without medication. If your symptoms are severe, there are various medications. Consult your doctor to find the right treatment for you. (See Treatment of restless legs syndrome)

Q: Will my restless legs syndrome develop into something more serious?
A: Restless legs syndrome will not develop into another condition, such as Parkinson’s disease. However, you should be aware of the effects of long-term sleep deprivation, which can include depression and diabetes.[43]

Q: Can you have restless legs syndrome in your arms?
A: Yes. In severe cases of restless legs syndrome, symptoms can affect the arms, face and trunk of the body.

Q: What exercises can I do for restless legs syndrome?
A; Regular, moderate exercise has been shown to lower the severity of restless legs syndrome symptoms.[13] Walking and stretching has also shown benefits, particularly a non-strenuous walk in the evening.[26]


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