A National Institutes of Health consensus panel in 2003 determined that a diagnosis of restless legs syndrome requires four basic criteria:
- an urge to move the limbs because of abnormal or uncomfortable sensations
- symptoms that get worse when the person is in bed or resting
- improvement of symptoms with physical activity
- worsening of symptoms at night.
The sensation is described by patients as a need to move, crawling, tingling, restless, cramping, creeping, pulling, electric, tension, discomfort and itching. Doctors believe the symptoms follow a circadian pattern–more likely to occur during evening hours rather than simply during periods of inactivity.
It’s important to distinguish restless legs syndrome from periodic limb movements during sleep (PLMS), defined as repetitive jerking movements during sleep. Restless legs make it difficult to get to sleep. Periodic limb movements lead to frequent awakenings and fragmented sleep.
About 80 percent of RLS patients–and particularly seniors with the disorder–also have periodic leg movements during sleep–a double dose of trouble. But it’s not a necessary symptom for diagnosis. RLS is a primary disorder in its own right. Similar symptoms may be brought on by other conditions such as anemia, kidney failure, diabetes and Parkinson’s disease or by medications such as antihistamines, anti-nausea, anti-seizure, anti-psychotic and antidepressant medications.
Recent research indicates that the symptoms are usually related to a low level of iron in the central nervous system. Also playing a key role is the neurotransmitter dopamine. Dopamine drugs have traditionally been used in treatment. A medication was recently approved by the Food and Drug Administration for treatment of the disorder. Ropinirole (Requip), a dopamine agonist (or a drug that activates dopamine receptors).
Initially, it’s important to look for non-drug treatments. Mild to moderate symptoms can often be relieved by cutting back on alcohol and caffeine and ceasing to smoke. Medications, including over-the-counter cold and allergy remedies, should be evaluated to see if they may be contributing to the problem. Exercise, a regular sleeping pattern, hot baths, massage and heat or ice packs for the legs may also help.
When symptoms are severe, dopamine agonists are usually the first line of treatment. In most cases, they bring about immediate improvement of symptoms. Prior to approval, ropinirole was found effective in three large, placebo-controlled studies. The effectiveness of other dopamine agonists such as pramipexole and pergolide has also been demonstrated.
Side effects of dopamine agonists include nausea, light-headedness, drowsiness and postural hypotension. There are also concerns about long-term cardiovascular effects, so the drugs are not to be taken lightly. Patients taking dopamine medications also often develop augmentation–needing larger doses or alternative treatments to counter an increased intensity of symptoms.
Other drug treatments include benzopdiazepines, opioids and anticonvulsants. When symptoms are severe enough to result in significant sleep deprivation, RLS can have a devastating effect on thinking, attention, mood and overall health. About 67 percent of RLS patients have a diagnosis of depression. The disrupted sleep associated with restless legs could help bring on depression. Depression also affects sleep and might make RLS symptoms worse.
Self Help for Restless Legs
- Mild to moderate cases of restless legs may be managed with self help measures.
- Maintain a regular sleep schedule.
- Keep the bedroom free of distractions.
- Reduce caffeine, alcohol and tobacco intake.
- Practice relaxation techniques.
- Stretch and massage the leg muscles.
- Wear long socks to bed.
- Apply a hot water bottle or cold compresses to affected areas of the legs.
- Take a hot bath or shower.
- Get regular exercise.
Over the long term, poor sleep is associated with heart disease, hypertension and an increased risk of early death. So if your legs are keeping you awake at night, it’s important to do what you can to quiet them down.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director, Richmond Apothecaries, Inc
