Restless Legs Syndrome (RLS): Causes, Symptoms, Diagnosis and Treatment

Restless legs syndrome (RLS), also called Willis-Ekbom disease, is a sleep disorder that causes an intense, often irresistible urge to move your legs (and even your arms or body). It occurs along with other sensations in your limbs described as pulling, creeping, tugging, throbbing, itching, aching, burning or crawling.

These sensations usually occur when lying down in bed or when sitting for long periods of time, such as while driving or while at a theater. RLS typically occurs in the evening, making it difficult to fall asleep. Often times people with RLS want to walk around and shake their legs (or arms) to help relieve the uncomfortable sensations.

Restless Legs Syndrome (RLS)

Who gets restless legs syndrome (RLS)?

People of any age, including children, can have RLS. Symptoms of RLS may begin in childhood or adulthood, but the chance of having the syndrome increases significantly with age. RLS is more common in women than in men. Up to 10 percent of the United States population has RLS.

SYMPTOMS AND CAUSES

What causes restless legs syndrome (RLS)?

Restless legs syndrome (RLS) has been found to be a genetic syndrome in some cases, meaning that parents with RLS can pass it down to their children. Up to 92% of patients with RLS have a first-degree relative with the disorder. These patients tend to develop symptoms earlier in life (before age 45) than those with RLS without the genetic link.

In addition to the genetic source, many medical problems are closely associated with the development of RLS, including:

• Low levels of iron (iron deficiency).
• Uremia (a condition associated with worsening kidney function).
• Hypothyroidism.
• Depression.
• Fibromyalgia.
• Parkinson's disease.
• Kidney disease.
• Diabetes.
• Rheumatoid arthritis.
• Peripheral neuropathy.
• Pregnancy.
• Dialysis.

Medications can also contribute to the development of RLS. Such known medications include antidepressants, allergy drugs and anti-nausea medications. Caffeine, nicotine and alcohol can also make symptoms worse.

What are the symptoms of restless legs syndrome (RLS)?

Symptoms of restless legs syndrome include:

• Leg (or arm) discomfort: These uncomfortable limb sensations are often described by adults as creeping, itching, pulling, crawling, tugging, throbbing, burning, or gnawing. These sensations usually occur at bedtime but can occur at other times of limb inactivity.
• Urge to move legs (or arms): To relieve limb discomfort, you have an uncontrollable urge to move your limbs especially when resting, such as when sitting or lying down.
• Sleep disruption: Additional time is often needed to fall asleep because of the urge to move your limbs to relieve the discomfort. Sometimes staying asleep may also be difficult.
• Bedtime behavior problems: Because of the discomfort, you may need to get out of bed to stretch your limbs to relieve the discomfort.
• Daytime sleepiness: Problems with falling asleep and staying asleep may result in daytime sleepiness.
• Behavior and work performance problems: Again, due to sleep disruption, problems may emerge in daytime behavior (irritability, moodiness, difficulty concentrating, hyperactivity, etc) and work performance.

DIAGNOSIS AND TESTS

How is restless legs syndrome (RLS) diagnosed?

Unfortunately, there is no specific test for restless legs syndrome (RLS). The diagnosis is made based on your symptoms. A medical history, complete physical and neurological exam and blood tests may be conducted to rule out any other possible health problems associated with RLS. An overnight sleep study may be recommended to evaluate for other sleep disorders, especially obstructive sleep apnea.

Your healthcare provider will ask about any family history of RLS. They will also ask if you have any sleep complaints, such as insomnia (difficulty falling asleep or staying asleep) due to your symptoms. Your healthcare provider will also ask if you have trouble staying awake during the day and ask about other behavior or work performance problems.

To confirm a diagnosis of RLS, you must meet the following five criteria:

• Have an urge or desire to move your legs (or arms), usually occurring together with uncomfortable sensations such as pulling, tugging, crawling, itching, aching, or burning.

Also, the urge to move or uncomfortable sensations:

• Begin or worsen during periods of rest or inactivity.
• Are partially or totally relieved by activities such as stretching, walking or exercising the affected muscles.
• Are worse or occur solely in the evening or at night.
• Are not solely due to another medical or behavioral problem.

MANAGEMENT AND TREATMENT

How is restless legs syndrome (RLS) treated?

Treatment of restless legs syndrome depends on the intensity of the symptoms. Treatment should be considered if quality of life is affected by insomnia and excessive daytime drowsiness. In cases of RLS due to ongoing medical disorders, specific treatment is also necessary.

Non-drug treatments. Non-drug treatments are tried first, especially if symptoms are mild. Non-drug treatments include:

• Getting regular exercise, such as riding a bike/stationary bike or walking, but avoiding heavy/intense exercise within a few hours of bedtime.
• Following good sleep habits, including avoiding reading, watching television or being on a computer or phone while lying in bed; getting 7 to 9 hours of sleep and following other healthy sleep habits. Not getting enough sleep can worsen RLS symptoms.
• Avoiding or limiting caffeinated products (coffees, teas, colas, chocolates, and some medications [check labels]), nicotine, and alcohol.
• Applying a heating pad, cold compress, or rubbing your legs to provide temporary relief to the leg discomfort. Also consider massage, acupressure, walking, light stretching or other relaxation techniques.
• Soak in a warm tub.
• Try magnesium supplements. They may be helpful.
• Reduce stress as much as possible. Try meditation, yoga, soft music or other options.

Iron supplementation. Iron deficiency is a reversible cause of RLS. If blood tests reveal you have low iron levels, your doctor may recommend taking an iron supplement.

Prescription medications. When RLS symptoms are frequent or severe, your healthcare provider will likely prescribe medications to treat the disorder. Medications options include:

• Dopamine agonists control the urge to move, sensory symptoms in the legs, and reduce involuntary leg jerks in sleep. Ropinirole (Requip®), pramipexole (Mirapex®) and the rotigotine patch (Neupro®) are the FDA-approved dopamine agonists used for RLS.
• Anti-seizure medications can slow or block pain signals from nerves in the legs. Examples include gabapentin enacarbil (Horizant®), gabapentin (Neurontin®) and pregabalin (Lyrica®). These drugs are particularly effective in patients with painful RLS due to neuropathy. Gabapentin enacarbil is the only medication in this class that is FDA-approved for RLS. However, the others may be effective.
• Benzodiazepines, clonazepam (Klonopin®) in particular, are sometimes prescribed for RLS but are usually reserved for more severe cases due to their addictive potential and side effects including daytime drowsiness.
• Opioids, such as methadone or oxycodone, can be used to relieve symptoms of RLS but because of the risk of addiction, they are usually not prescribed unless the case is severe and other medications have not been effective.