RESTLESS LEG SYNDROME
Restless Leg Syndrome?
Restless Leg Syndrome?
- When sitting or lying down, do you have unpleasant or creepy-crawly sensations in your legs (and sometimes in other parts of your body), tied to a strong feeling or urge to move?
- Do the sensations and urge to move during periods of rest or inactivity and relieved by movement?
- Do the sensations and urge to move bother you more in the evening and at night rather than the day?
- Do you often have trouble falling asleep or staying asleep?
- Does your bed-partner tell you that you jerk your legs (or your arms) when you are asleep; do you sometimes, have involuntary leg jerks when you are awake?
- Are you frequently tired or fatigued during the day?
- Do you have family members who experience these same sensations and urge to move?
- Have medical tests not revealed a cause for your sensations and urge to move?
If you do have restless legs syndrome (RLS), you are not alone. Up to 8% of the U. S. population may have this neurologic condition. Many people have a mild form of the disorder, but RLS severely affects the lives of millions of individuals.
Features of RLS
Adults with RLS will typically have all four of these primary features.
- The bothersome, but usually not painful, sensations deep in the legs produce an irresistible urge to move. Some words used to describe these sensations include creeping, itching, pulling, creepy-crawly or tugging. (These sensations may only involve a strong urge to move the legs. They may also occasionally occur in the arms. )
- Symptoms are worse or exclusively present when the afflicted individual is at rest, and the sensations are typically lessened by voluntary movement of the affected extremity.
- Symptoms are worse in the evening and at night, especially when the individual lies down.
- Movements of the toes, feet, or legs (known as restlessness) are typically seen when the afflicted individual is sitting or lying down in the evening. This restlessness may be seen as fidgetiness or nervousness.
Associated Features of RLS
RLS symptoms can cause difficulty in falling and staying asleep. Approximately 80% of people with RLS will also have periodic limb movements of sleep, which are jerks that typically occur every 20 to 30 seconds on and off throughout the night, often causing partial arousals that disrupt sleep.
Because you may experience difficulties with falling and staying asleep at night, you may be abnormally tired or even sleepy during waking hours. Chronic sleep deprivation and its resultant daytime sleepiness can affect your ability to work, participate in social activities, and partake in recreational pastimes and can cause mood swings, which can affect your personal relationships.
Research into the cause of RLS is ongoing and answers are limited, but we do think that RLS may have different but perhaps overlapping causes. RLS often runs in families. Researchers are currently looking for the gene or genes that may be responsible for this form of RLS, known as primary or familial RLS.
RLS may be the result of another condition, which, when present, worsens the underlying RLS. This is called secondary RLS. During pregnancy, particularly during the last few months, up to 15% of women develop RLS. After delivery, their symptoms often vanish. Anemia and low levels of iron in the blood are associated with symptoms of RLS, as are chronic conditions such as peripheral neuropathy (damage to the nerves in the hands and feet) and kidney failure. Recent literature also points toward an association between RLS and symptoms of attention-deficit hyperactivity disorder. If you have no family history of RLS and no underlying or associated conditions causing the disorder, your RLS is said to be idiopathic, meaning without a known cause.
Age of Onset
Though RLS is diagnosed most often in people in their middle years, many individuals with RLS, particularly those with primary RLS, can trace their symptoms back to childhood. These symptoms may have been called growing pains or the children may have been thought to be hyperactive because they had difficulty sitting quietly.
With its classic symptoms, RLS is diagnosed by reviewing your medical history. After ruling out other medical conditions as the cause of your symptoms, your healthcare provider can make the diagnosis of RLS by listening to your description of the sensations. No laboratory test exists that can confirm your diagnosis of RLS. However, a thorough physical examination, including the results of necessary laboratory tests, can reveal temporary disorders, such as iron deficiency, that may be associated with RLS. Some people (including those with periodic limb movements of sleep and without the abnormal sensations of RLS) will require an overnight testing of sleep to determine other causes of their sleep disturbance.
The goal of any medical treatment, including the treatment of RLS, is to achieve the greatest benefit while incurring the fewest risks. Sound treatment strategy, therefore, involves weighing these risks and benefits and beginning with the least-risky treatments. Low-risk therapies involve treating symptoms that are caused by underlying disorders and making lifestyle changes.
If an underlying iron or vitamin deficiency is found to be the cause of your restless legs, supplementing with iron, vitamin B12, or folate (as indicated) may be sufficient to relieve your symptoms. Because the use of even moderate amounts of some minerals (such as iron, magnesium, potassium, and calcium) can impair your body’s ability to use other minerals or can cause toxicity, you should use mineral supplements only on the advice of your health-care provider. Current recommendations include checking a serum ferritin level (to evaluate iron-storage status) and supplementing with iron if your ferritin level is less than 50 mcg/L.
The use of some medications seems to worsen the symptoms of RLS. These drugs include calcium-channel blockers (used to treat high blood pressure and heart conditions), most antinausea medications, some cold and allergy medications, major tranquilizers, phenytoin, and most medications used to treat depression.
Lifestyle changes involve determining, on an individual basis, which habits and activities worsen or improve your symptoms of RLS. A healthy balanced diet is important in reducing the severity of your RLS. Though caffeine consumption may initially appear to relieve your symptoms, the use of caffeine most likely only delays, and often intensifies, your symptoms to a time later in the day. The best solution is to avoid all caffeine-containing products, including chocolate and caffeinated beverages such as coffee, tea, and soft drinks. The consumption of alcohol increases the span or intensity of symptoms for most individuals; again, refraining from the use of alcohol is your best solution.
Because fatigue and drowsiness tend to worsen the symptoms of RLS, implementing a program of good sleep hygiene should be a first step toward resolving your symptoms.
Ideally, sleep hygiene involves having a cool, quiet, and comfortable sleeping environment, going to bed at the same time every night, arising at the same time every morning; and obtaining a sufficient number of hours of sleep to feel well rested. Some people with RLS find that going to bed later and arising later in the day helps them to obtain an adequate amount of sleep. Good sleep hygiene also involves a program of regular, moderate exercise. Typically, sleep experts recommend exercise should take place at least six hours before bedtime to avoid an adverse impact on your sleep, however, many people with RLS find that exercising, using a stationary bike or a treadmill, immediately before bedtime is useful.
You may find that you achieve your best sleep later in the 24-hour cycle, for example, sleeping from 2 AM until 10 AM may work best for you. Some people find that performing isometric exercises for a few minutes before bed is helpful.
Self-directed activities that counteract your symptoms of RLS appear to be very effective, although temporary, solutions to managing the disorder. You may find that walking, stretching, taking a hot or cold bath, massaging your affected limb, applying hot or cold packs, using vibration, performing acupressure, and practicing relaxation techniques (such as biofeedback, meditation, or yoga) may help reduce or relieve your symptoms. You may also find that keeping your mind actively engaged through activities such as a participating in a stimulating discussion or argument, performing intricate needlework, or playing video games helps during times that you must stay seated, such as when you are traveling.
Unfortunately, in many cases, the symptoms of RLS either initially do not resolve with the treatment of underlying disorders and the implementation of lifestyle changes or, over time, progress so that relief is insufficient with these methods. In either case, the use of medications (pharmacologic therapy) may become necessary.
No drugs have been approved by the U. S. Food and Drug Administration for the treatment of RLS, but several drugs have undergone clinical studies in RLS and have been approved for other conditions. These medications fall into four main classesâ€”dopaminergic agents, sedatives, pain relievers, and anticonvulsants. Each drug or class of drugs has its own benefits, limitations, and side-effect profile. The choice of medication is dependent upon the timing and severity of your symptoms.
The primary and first-line treatment for RLS is with dopaminergic agents: primarily dopamine-receptor agonists like Mirapex (pramipexole), Permax (pergolide), and Requip (ropinirole), but also drugs like Sinemet (carbidopa/levodopa) that add dopamine to the system. Although dopaminergic agents are used to treat Parkinsonâ€™s disease, RLS is not a form of Parkinson’s disease. All of these drugs should be started at low doses and increased very slowly to decrease potential side effects.
Of the dopaminergic agents, Sinemet has been used the longest, but it has recently been found to cause a serious problem, known as augmentation, in the vast majority of patients who take it for the treatment of RLS. If you are taking Sinemet, you need to be aware of this problem and should discuss it with your physician. Also, you should not take Sinemet within two hours after eating a high-protein meal.
Sedative agents are most effective for relieving the nighttime symptoms of RLS. They are used either at bedtime in addition to a dopaminergic agent or for individuals who have primarily nighttime symptoms. The most commonly used sedative is clonazepam (Klonopin).
Pain-relieving drugs are used most often for people with severe relentless symptoms of RLS. Some examples of medications in this category include codeine, Darvon or Darvocet (propoxyphene), Dolophine (methadone), Percocet (oxycodone), Ultram (tramadol), and Vicodin (hydrocodone).
These drugs are particularly effective for some, but not all, patients with marked daytime symptoms, particularly people who have pain syndromes associated with their RLS. Gabapentin (Neurontin) is the anticonvulsant that has shown the most promise in treating the symptoms of RLS.
By arming yourself with information, you have taken the first step toward defeating RLS. Your optimum treatment plan requires a close interaction between you and your healthcare provider. Choosing a healthy lifestyle, eliminating symptom-producing substances, taking vitamin and mineral supplements as necessary, and engaging in self-directed activities will all work toward reducing or eliminating the need for pharmacologic intervention.
If you do need medications, careful trials are typically necessary to find the best medication and the best dosage for you. Many patients report that a combination of medications works best, and some find that a medication that has worked for an extended period of time suddenly becomes ineffective and another medication must be substituted. Quite clearly, you must be cautious when combining a variety of medications and should only do so under the supervision of your healthcare provider.
Because no single treatment for RLS is entirely effective for everyone, continued research is of vital importance. Until we find the cause of RLS and a cure, working closely with your healthcare provider, interacting with a local support group, and exploring non-drug treatments as well as pharmacologic therapy will help you find the answer to living a happy productive life in spite of having RLS.
Living with Restless Leg Syndrome
- Talk about RLS Sharing information about RLS will help your family members, friends, and coworkers understand when they see you pacing the halls at night, standing at the back of the theater, or walking to the water cooler many times throughout the day.
- Don’t fight it if you attempt to suppress the urge to move, you may find that your symptoms only get worse. Get out of bed. Find an activity that takes your mind off of your legs. Stop frequently when traveling.
- Keep a sleep diary if you can’t sit to write, dictate into a small tape recorder. Keep track of the medications and strategies that help or hinder your battle with RLS, and share this information with your healthcare provider.
- Occupy your mind keeping your mind actively engaged may lessen your symptoms of RLS. Find an activity that you enjoy to help you through those times when your symptoms are particularly troublesome.
- Rise to new levels you may be more comfortable if you elevate your desktop or bookstand to a height that will allow you to stand while you work or read.
- Stretch out your day Begin and end your day with stretching exercises or gentle massage.
- Help others Support groups bring together family members and people with RLS. By participating in a group, you cannot only help yourself, but your insights may help someone else.
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