Restless Leg Syndrome: Conditions, Causes, Cautions and Control

Restless Leg Syndrome: Separating fact from fiction
Restless Leg Syndrome: Separating fact from fiction

A Twitch in Time


There you are, ready to go to sleep. You turn the lights down, slide under your sheets and close your eyes, hoping for some peace and rest. Just as your body begins to relax and you're about to slip into the arms of slumber, you notice some unpleasant sensations in your legs.

This could be an itch, a nagging ache, tingling, a sensation of something crawling, numbness or a feeling of water running down your legs. You close your eyes tight and wish it would go away. It doesn't. There is a overwhelming urge to move your legs. You try to shake it off by moving your legs about. You sigh, get out of bed, stretch and pace around. Soon the feeling has gone. You get back into bed, hoping to finally get some sleep.

But just as you begin to relax, it starts all over again.

This is not just one night. It happens with increasing frequency every week, much to your ( and your loved one's) despair.

If this sounds familiar, you have come to the right place. You may have a condition called Restless Leg Syndrome.


Restless Leg Syndrome is a name used freely to indicate all manner of things. There are a lot of innocent reasons for your legs feeling restless, equally there are all manner of other diseases that can make your legs uncomfortable and cause similar symptoms. Not every restless leg has RLS - but this doesn't mean we can't have a treatment plan for them all.

Chaos and Confusion

The internet is rife with information on RLS ( as it is affectionately known) People have spent small fortunes on dubious therapies trying to get rid of it. So, what, you ask me, is different about this article?


For one, I am not trying to sell you anything. I am also a medic with years of experience in diagnosing and treating this condition. I have seen many frustrated and fed up patients who have done the rounds and tried a hundred different treatments. I find that the biggest problem is not with treatment but in making an accurate diagnosis and isolating the underlying cause. Some Doctors and therapists are very good at throwing everything they've got at the symptoms and hope something would stick. I feel this can be a frustrating journey for the patient who may slowly lose faith in the system.


I tell my patients is that Restless Leg Syndrome is a name used freely to indicate a spectrum of problems. There are a lot of innocent reasons for your legs to feel restless. There are also other diseases that can make your legs uncomfortable and cause similar symptoms - but not all of them are RLS.

Not every restless leg has RLS - but this doesn't mean we can't treat them all.


The RLS that is also known as Willis-Ekbom disease (WED) is a distinct entity. It helps to separate the facts from fiction so you can identify RLS accurately, treat it and feel better.


So here we not only discuss the distinct neurological condition called RLS, we will also discuss all the other culprits that can cause similar symptoms. a thorough and accurate history and evaluation will go a long way to help you.

ICD10 Classification

G25. Other extrapyramidal and movement disorders

G 25.8 Other specified extrapyramidal and movement disorders

Restless legs syndrome



What is RLS?

Back in 1945 Swedish Neurologist Karl Axel-Ekbom described Restless Leg Syndrome as a neurological movement disorder.

Understandably during Dr Ekbom's time although medicine was going through rapid paces of change, a lot of the technology that is available to us was not available then. This somewhat limited Dr Ekbom's ability to delineate some of the allied diseases that could cause the same or similar symptoms.


From a diagnostic point of view RLS can be primary or secondary.

Primary RLS ( also known as Idiopathic) is the one when all other underlying diseases have been eliminated, and what is left is a pure sleep/movement disorder. The exact cause for idiopathic RLS has not been fully described, however there is a lot of evidence pointing to a disorder of the nerve pathway and an imbalance in the chemicals that transmit nerve signals (neurotransmitters).


Secondary RLS is where the patients experience all the symptoms of RLS to varying degrees, but have underlying treatable conditions that can mimic or contribute to the symptoms. In many cases it is not a single contributing factor. As it is often the case in medicine, a combination of reasons can cause the problem.


We have to remember that individually these symptoms can happen to all us at some time, it is the collective nature of these symptoms and simultaneous presence that helps us to narrow down to RLS.

Symptoms and Signs

As with many diseases the symptoms and signs may vary with individuals in terms of frequency and severity.

However variable the symptoms can be, to make a diagnosis of RLS there needs to be some common features:


Discomfort of the Legs:

A nagging discomfort that could be tingling, numbness, ache, altered skin sensations such as creeping or crawling, pulling, perception of warmth or cold, itching or sense of pressure. In rare occasions symptoms have been known to affect the arms and even the head/neck area.


Symptoms triggered by rest:

Unlike other causes of discomfort where activity makes the symptoms worse, in RLS it is rest that triggers the symptoms. Rest as in sitting or lying down can bring on the above mentioned symptoms


Nocturnal Symptoms:

Typically in RLS symptoms get worse at night. The problem mainly comes on when trying to sleep.


Movement helps to relieve:

Twitching, restless movements help to relieve this discomfort. Also pacing, walking can help. Symptoms tend to return when the movement stops. Massage helps too.


Urge to move:

Sometimes the urge to move the limb may occur even without the discomfort or unpleasant sensation.


More likely to affect both legs:

RLS is more likely to affect both legs at the same time.

Symptom Poll

Do you suffer from any of the following symptoms?

  • Uncontrollable urge to move legs when at rest
  • Uncontrollable discomfort in both legs
  • Leg symptoms worse at night
  • Movement relieves symptoms
  • All of the above
See results without voting
Diagnostic criteria for RLS
Diagnostic criteria for RLS

The primary RLS is a purely neurological disorder thought to be due to an imbalance in the brain pathway involving Dopamine ( a neurotransmitter). The latter is linked to control muscle activity in movement and at rest. Some research has shown this is linked to the Basal Ganglia of the brain- the same area affected in Parkinson's disease. Restless legs is one of the common features in advanced Parkinson's disease.


It is important to rule out all the secondary causes including lifestyle issues that can produce restless leg symptoms before narrowing it down as primary idiopathic. The main causes of RLS are listed below.

Causes

Cause
Notes
Primary Idiopathic
a neurological disorder possibly caused by neurotransmitter imbalance as well as altered pathways of sensory perception
 
 
Secondary causes
 
Diabetes Mellitus
Usually through Perpiheral neuropathy
Peripheral Neuropathy
Alcohol, Vitamin B12 deficiency etc.
Kidney failure
 
Parkinson's Disease
Associated restless limbs and movements
Sleep deprivation
 
Pregnancy
usually in the last trimester- thankfully transient
Obesity
Carrying a lot of weight especially in the middle
Sedentary lifestyle
 
Heavy Smoking
 
Varicose Veins
venous insufficiency causing stasis of blood
Iron deficiency
 
Lymphoedema
Thick swelling in the skin compressing the nerves
Drugs
see separate table
The nerve pathway involved in RLS symptoms
The nerve pathway involved in RLS symptoms

Drugs that can worsen RLS

Drug category
Examples
 
 
Antihistamines
certain cold/allergy medicines such as Benadryl,NyQuil, Dimetapp
Antidepressants
Prozac, Efexor, Cipralex etc)
Antipsychotics
those used for psychosis, schizophrenia, bipolar illnesses
Anti-nausea medications
Dramamine, Compazine, antivert etc.)
Calcium channel blockers
Nifedipine, Amlodipine, Felodipine etc.
Over the counter sleep aids
those that contain chlorpheniramine, chlorpromazine

Direct marketing, seeding internet sites with information linking to their drug, convincing gullible patients and medical professionals that the 'syndrome' is being under-diagnosed and capitalising on the patient frustration is rife with this condition.

Treatment Options

There have been some unscrupulous attempts to push drug therapy as first line for RLS. This type of syndrome-mania is common among Drug companies attempting to sell their specific products.

For mild to moderate RLS symptoms simple lifestyle modifications and therapy options alone will suffice. The drugs that are used to treat severe uncontrolled RLS can carry their own hefty side effects. So one has to weigh the benefits and risks.

In the absence of a clear diagnosis and sensible advice, it is likely that sufferers may get frustrated and feel drug therapy is the only option. It is always worth revisiting the diagnosis and ensuring other conditions and options have been explored with support and understanding.

Perhaps some Physicians who may not have the skill and patience in counselling, communicating the disease spectrum and exploring options or simply find it hard to reach to the patient may resort to drug options early.

Similarly assertive patients who are impatient for a quick-fix may force the Doctors to prescribe. It is important to take a considered opinion and evaluate the severity first through proper investigations.

If other easily treatable causes such as iron deficiency, varicose veins or vitamin deficiency are found, they can be resolved quickly.

An ideal therapeutic evaluation should include some or all in step by step approach ( simple tests first and more complex tests only if needed):


Lifestyle Therapy


  • Cut back on Cola, Caffeine, Fizzy drinks
  • Reduce Weight
  • Exercise in moderation
  • Reduce or stop Alcohol/ Smoking
  • Relaxation techniques


Before resorting to meds


  • Be honest and evaluate whether you have made the necessary lifestyle changes
  • Weigh up benefits and risks
  • Check if the drugs interfere with other medications you may take
  • Plan the dosage and regular review with your Doctor
  • Have a plan for objective evaluation before and after therapy
  • Don't let frustration cloud your mind


Treat any underlying disease

If any of the secondary causes ( Diabetes, Neuropathy, Vitamin or iron deficiency) are identified they need to be treated promptly and effectively.


Lifestyle Modifications

It is silly to expect RLS to resolve quickly without making any necessary lifestyle modifications as much as we can. While this can be long drawn out and frustrating, it should hopefully also be a motivation. Even if medication is prescribed, lifestyle changes can help reduce dosage and duration of treatment.


Dietary changes and Supplements

There are certain supplements such as trace minerals ( Zinc, Magnesium) , Vitamin B12, iron that have been known to help relieve the symptoms. Discuss with your Doctor first.


Drug Therapy

Dopaminergic agents:

Currently three drugs have been licensed by FDA for treating advanced RLS when all of the above have failed. All three also also anti-parkinson's drugs and do carry a long list of side effects. It is important to weight the benefits vs risks.


  • Pramipexole (Mirapex)
  • Ropinirole (Requip)
  • Rotigotine transdermal system (Neupro)


Benzodiazepines:

Small doses of benzodiazepines such as Diazepam, Temazepam, Clonazepam in a planned treatment schedule ( to avoid addiction) have been shown to help.


Opiates:

Certain opioid pain relief agents such as Codeine, Vicodin, Percoset, Tramadol may help in severe cases. These are also highly addictive so caution needs to be exercised o avoid dependancy.


Anti-Convulsants:

Some anti-epileptics such as Gabapentin and Pregabalin are now licensed to treat nerve pain. These can be tried to see if they help in severe cases of RLS.


List of Medications used and their side effects
List of Medications used and their side effects

In Summary

Restless Leg Syndrome can be frustrating, demoralising and always impacting the quality of life. This along with lack of considered advice can make us vulnerable to seeking treatments anyone and everyone may suggest.

It is important to be systematic and considered in our approach right from diagnostic assessment to treatment. I know this can be hard when you haven't been sleeping for days and when it is affecting your mood and relationships.

Let's not fall prey to snake oil salesmen. Hopefully this article can help somewhat in understanding the problem and dealing with it to get the best and safe outcome.


© Mohan Kumar 2013

Thank You!

Thank you for reading this article and hope you found the information useful. Do leave some comments and feedback below. Please do vote as appropriate!

If you like what you read share it with friends and family on Facebook/Twitter/ Pinterest / Google+ or similar.

Appreciate your time and interest, dear reader.

Do come again.

Docmo

© Mohan Kumar 2013

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Comments 24 comments

always exploring profile image

always exploring 3 years ago from Southern Illinois

Thak goodness i don't have this condition, but i do have celiac disease..Boy! what i would give for a cheeseburger on a Sarah Lee bun. I hope you will write on this. Thank you.


Daisy Mariposa profile image

Daisy Mariposa 3 years ago from Orange County (Southern California)

Mohan (Docmo),

Thanks for publishing this very informative article.

I know someone who has both Restless Leg Syndrome and peripheral neuropathy, plus some other related problems. Your explaining things to non-medical personnel in a way they can easily understand, without your talking down to them, is greatly appreciated. I'm going to send my friend the link to your article.


kat11 profile image

kat11 3 years ago from Illinois

Thank you very informative. I have neuropathy from an accident 28 years ago. At night my legs want to move and they twitch severely at times. At the end of February of this year I had to have another cervical fusion. I sometimes walk and stretch but it sometimes doesn't help. I have used heat which sometimes works. Voting up and keep up the excellect information.


Twilight Lawns profile image

Twilight Lawns 3 years ago from Norbury-sur-Mer, Surrey, England. U.K.

Mohan, my highly esteemed friend. I am a sufferer And have actually published a hub On this dreadful condition.

After years of putting up with it I'm a c very little light at the end of the tunnel. dictating this on a smartphone might mean that there will be a bit of rubbish return roger I will have a look at my pc when I return.

Regards,

Ian


my_girl_sara profile image

my_girl_sara 3 years ago from Georgia

My mom suffers from this condition and needs to read this very informative blog.


Twilight Lawns profile image

Twilight Lawns 3 years ago from Norbury-sur-Mer, Surrey, England. U.K.

Hello, again, Mohan.

Well, that above was sort of what I wanted to say.

Ropinerole is the medication which helps me at night, but I have found that when I feel it coming on during the daytime, then co-codamol helps "push it back" quite successfully, but of course, codeine interferes with peristalsis and we all know what can happen then!

Cheers again,

Ian


Vellur profile image

Vellur 3 years ago from Dubai

Thank you for this information, now I know what it is all about. Very clearly explained. Voted up.


Docmo profile image

Docmo 3 years ago from UK Author

@Ruby: thank you. sorry to hear about your coeliac, it must be so difficult with the restrictive diet. I will write some info on it, when I can.

@Daisy: thank you, I hope your friend finds this info useful.

@kat11: neuropathy produces similarly distressing symptoms- in case of straight forward neuropathy- the drugs mentioned especially pregabalin or gabapentin may be of use.


Docmo profile image

Docmo 3 years ago from UK Author

@Ian: good to hear from you. Hope you found this info useful. If ropinorole alone doesn't control the symptoms

adding analgesia + benzodiazepine/ mild tricyclics helps.

@my_girl_sara: hope this is of some use to your mom. thanks for visiting.

@Nithya: thank you very much.


suzettenaples profile image

suzettenaples 3 years ago from Taos, NM

Great hub! I love how you have presented this. My father and aunt (both deceased now) both suffered from this. I had no idea it was a neurological condition so I certainly learned something new here. So far, I have not suffered from it, but because my dad and his sister did, I suppose I could at any time. This information is so helpful and interesting. I will now know how to combat it if I should ever get it. Quite an interesting hub and thank you for informing us about an annoying condition to say the least.


drbj profile image

drbj 3 years ago from south Florida

I can C, Mohan, that U R an X-pert not only in the treatment of RLS but in explaining succinctly in an EZ to understand fashion, the 4 Cs (Conditions, Causes, Cautions and Control) pertaining to this uncomfortable syndrome. Thank U for your impeccable research and sharing it with us - your fervent fans. Voted Up, Up, Up!


nybride710 profile image

nybride710 3 years ago from Minnesota

I defintely have RLS, but I have never been to a doctor for it. This was very informative and give me a good direction to go in with pursuing treatment.


Pamela99 profile image

Pamela99 3 years ago from United States

My sister suffers from this disorder. This was a very thorough description of the RLS in language anyone can understand. This disorder seems to be much more prevalent than we know as it seems many people don't seek out treatment for the symtpoms. Voted up, useful and interesting.


jlpark profile image

jlpark 3 years ago from New Zealand

Thanks for this article. I have Idopathic Restless LIMB Syndrome - yup, not just my legs. Requip (Ropinerole) has been a god-send - works a treat for me at a reasonably small dose. However, Ropinerole is not useful when you are pregnant due to being a dopamine agonist.

It was difficult to get someone to listen when I was asking for something else to use as I was trying to get pregnant. I had to research it all myself, and had to take the information with me. Tramadol works a treat, but can be addictive - however, in 50mg doses ONCE a day - its not likely to be a problem.

Shared, as I think this is a very informative article.


midget38 profile image

midget38 3 years ago from Singapore

Wow. My husband's colleague suffers from this.....I will need to forward it to him and he'll really appreciate this comprehensive information! Thanks for sharing!


tillsontitan profile image

tillsontitan 3 years ago from New York

Written like a true doctor...not one of these quacks! You do a tremendous service to those of us on hubville by providing the true facts. This is a wonderful article and will hopefully help many people.

You can tell always exploring that I have Celiac as well and have written a few hubs about it. However, I am sure your hub would be more comprehensive. Can you tell I'm a fan?

Voted up, useful, interesting and shared.


Trinity M profile image

Trinity M 3 years ago

Hi Docmo! What a wonderful, fully comprehensive article! My father-in-law was a diabetic and suffered with RLS until we put him on Vit. B. Presently my father is suffering from CLL and is on anti-depressants, anti-psychotics and sleep medication and is obviously suffering from anaemia caused by the CLL. He has severe RLS and we have been unable to help him. Thank you SO MUCH for this useful article. I will be implementing some of your tips the soonest possible.

Voted up and useful!


Vinaya Ghimire profile image

Vinaya Ghimire 3 years ago from Nepal

Hello Mohan,

I have seen people with restless legs, but did not know this was a disorder. Thanks for this comprehensive article on RLS.

Cheers


Sharkye11 profile image

Sharkye11 3 years ago from Oklahoma

An amazingly useful, in-depth article. My husband has the peripheral neuropathy due to diabetes, and he often complains of the symptoms of restless legs. I had it when I was pregnant (luckily transient!) but my health care providers wouldn't listen (nor would they hear me out about the SPD symptoms) They just said, "you are supposed to be uncomfortable when you are pregnant." I figured it was my payback for sometimes being impatient with my husband's nighttime leg laments! I am definitely giving this to my husband to read, so that maybe he will mention it to his doctor. Thanks for such a well-written, objective article!


Emma Harvey profile image

Emma Harvey 3 years ago from Berkshire, UK

Thank you so much for all of this very useful information. Your article gives clear explanations of RLS - something my husband suffers with. I must ask him to read this also - you have made this a very engaging and clear article and he should hopefully make sense of it all now.


Alecia Murphy profile image

Alecia Murphy 3 years ago from Wilmington, North Carolina

This is great information. I feel like sometimes I have RLS but am never completely sure. I know next time I visit the doctor to bring this up for a definitive answer. Thanks for sharing!


Daisy Mariposa profile image

Daisy Mariposa 2 years ago from Orange County (Southern California)

Mohan (Docmo),

I returned to read your very informative article another time. Thanks for taking the time to explain RLS in easy-to-understand terms.


DzyMsLizzy profile image

DzyMsLizzy 2 years ago from Oakley, CA

Ah, I wish I'd been able to read this 20 years or more ago. My mother suffered from this, and and would lie in bed night after night, about to fall asleep, when she would suddenly just HAVE to stretch her legs out, then just a suddenly, HAVE to bend them...etc., etc. Her doctor was among the mystified, and told her to take quinine. (I doubt it helped, but I don't know: mother wasn't one for complaining.) But, she passed away in 1998, so she no longer has the problem..but, if I'd been able to have this info back then, I could have pressured her doctor, to perhaps at least consult a specialist....

Voted up, interesting, useful, shared and pinned.


Twilight Lawns profile image

Twilight Lawns 2 years ago from Norbury-sur-Mer, Surrey, England. U.K.

Hello DzyMsLizzy (and Mohan).

Yay!

After far too many years to mention, I have, at last, been the correct dosage of Ropinerole which allows me to sleep all night long. What a relief.

Sometimes, in the evening, when sitting too long; either at the cinema, or watching DVDs, I have a little trouble (but only in my left foot) but I can cope with it when I am awake, and not trying to get to sleep.

Thank God for science, the NHS, Dr Graham and Dr Patel (Not necessarily in that order).

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