Is it a sleep disorder, or a movement disorder? Well, it depends what type of neurologist you may be talking to. One thing is clear though; it is a neurological disorder, affecting sleep and presenting with abnormal movements. Contrary to some beliefs, it is not a matter of phantom imagination. The problem is real.

In Restless Leg Syndrome (RLS), the patient has an uncontrollable urge to move a body part, usually a leg. If the patient tries to suppress this urge or not move the leg, strong emotional tension builds up resulting in very uncomfortable feeling, with no choice left but to move the leg. Patient typically feels better after moving the limb or getting up and walking.

What are the symptoms of RLS?

The main symptom is the urge to move a body part, as described above. Patient may also feel a creepy-crawly feeling in the leg, which is not pain but is equally bothersome. Symptoms are not much noticeable during daytime, and typically appear at rest, usually in the evening, and especially at bedtime. Not able to sleep, patient may develop significant insomnia, which may lead to stress, anxiety, depression, and forgetfulness.

What exactly causes RLS?

Exact cause is unknown. General understanding is that the problem resides in the brain, and has something to do with iron deficiency in the brain, even when blood iron levels are normal.

What are the risk factors for RLS?

Common risk factors for RLS are: Family history, iron deficiency, kidney failure, pregnancy, migraine, stroke, Parkinson disease, liver cirrhosis, multiple sclerosis, depression, anxiety, ADHD, polyneuropathy, and use of certain medicines. RLS is more common in Caucasians than in Asians, and is more common in Asians than African Americans.

How is RLS diagnosed?

It is diagnosed by its typical history. There is no specific test. But patients are tested for certain conditions that may cause RLS, e.g., Iron deficiency, or kidney failure. A sleep study is not needed to make a diagnosis of RLS.

Is RLS a genetic disorder?

There is strong genetic tendency for RLS. At least some genes for RLS have already been identified. A test to check for abnormal genes is not required or done in clinical settings, as it does not make any difference in management.

What age group is affected by RLS?

RLS may start at very young age. Some infants are known to be restless, crying, and not able to sleep until someone massages their legs. This phenomenon has long been known, and people have called it, “growing pains.” The suffering infant, unable to verbalize, likely suffers from RLS. It affects all age groups, and its risk increases with age.

What symptoms may suggest RLS in children?

Other than its typical symptoms described above, which infants and children are not able to verbalize, it is important to consider RLS in children with following situations:

A: Infant getting especially cranky at sleep time
B: ADHD type symptoms
C: Anxiety disorder
D: Depression

Is there a cure for RLS?

Not at this time.

Is RLS a new disease?

Not really, except that until about 1990s, it was not described or defined as well.

What medicines can make RLS worse?

There are many medicines that may cause RLS or make it worse. Some are as follows:

A: Antihistamines, like diphenhydramine (Benadryl).
B: Serotonin reuptake inhibitors (SSRIs), like fluoxetine (Prozac)
C: Serotonin-norepinephrine reuptake inhibitors, like venlafaxine (Effexor)
D: Dopamine antagonists, like haloperidol (Haldol)
E: Prokinetic agents, like metoclopramide
F: Tricyclics, like amitryptiline

How is RLS treated?

Before any treatment, one should find any factor that may be controlled to avoid RLS. This includes, stopping an offending medicine, treating anemia, or any other medical condition that may be causing it, or making it worse. Following medicines can help with RLS:

A: Iron salt, such as ferrous sulfate
B: Anticonvulsants, such as gabapentin, gabapentin enacarbil, and pregabilin
C: Dopaminergic drugs, such as ropinirole, pramipaxole, and rotigotine
D: Presynaptic alpha2-adrenergic agonists, such as clonidine, and tizanidine
E: Benzodiazepines, such as clonazepam, and lorazepam
F: Opioids

Iron is used in patients with low ferritin level, either alone or with another medicine. Opioids are avoided as much as possible. The medicine may not have to be taken every night. As much as possible, patients are advised to avoid using the medicine during daytime hours, and use the smallest effective dose about an hour or two before sleeping.

What is the issue of augmentation of RLS?

For some patients, there seems to be a threshold dose of medicines, if that threshold is crossed, RLS symptoms may worsen instead of getting better. They may involve new body areas, start appearing earlier in the day, or may last all day. Its treatment is not easy. Completely stopping the offending medicine, and trying a smaller dose of a different class of medicine may help. This is one of the reasons that, as much as possible, higher doses and daytime med use are avoided.

Are medicines for RLS harmful for long-term use?

Every medicine is a chemical and it is best to avoid it much as possible. If it is needed, smallest effective dose is recommended. Above described meds for RLS are reasonably safe but may still have some risks.

Following are some common issues:

Gabapentin may cause leg edema, unsteadiness, and has some abuse potential
Dopamine agonists may cause sedation, and compulsive behavior
Benzodiazepines have sedative effect, and potential abuse issues
Alpha agonists may be sedating
Opioids have significant abuse potential

Is medicine the only way to manage RLS? Is there any other way?

Not necessarily. At least mild cases can be managed without medicines. Also, medicine can be used on as needed basis too. There are other ways to manage RLS, though not all as effective. I have rarely seen a patient satisfied and happy taking a medicine for a condition, more than a really suffering patient of RLS. Following measures are potentially useful for all patients with RLS:

a. Review all prescription and non-prescription meds/supplements and, as much as possible, remove or minimize use of any possible trigger.

b. If anemic, get appropriate treatment.

c. Avoid dessert or sugar intake for 4-5 hours before sleep.

d. Avoid prolonged nap during the day. Keep afternoon nap to not more than a few minutes.

e. Heavy physical exercise or activity during the evening hours may also help; activity at work, and in the bed does not count.

f. Avoid caffeine for 5-6 hours before sleep.

g. Avoid any activity that may stress or overly activate your mind 4-5 hours before sleep. This includes watching news, or any type of emotionally charged media.

h. Avoid eating for 4-5 hours before sleep.

i. Keep yourself hydrated but most of the hydration should be upon waking up in am, during daytime hours, and not during 4-5 hours before sleep. This includes alcohol.

j. If you live in a noisy home or an environment, consider a noisemaker, like a small fan for sleeping.

k. Minimize alcohol intake. Avoid drugs of abuse.

l. If all fails and you like to try something mild, try a small serving of tonic water at bedtime.

m. There is a more effective approach of an FDA approved vibrating device for legs, Relaxis, which may be an option as stand-alone or in addition to medicines.

Where can I get more information about RLS?

American Academy of Neurology
American Academy of Sleep Medicine
Center for Disease Control and Prevention