Restless legs syndrome

Restless Legs Syndrome (RLS), also called Willis-Ekbom disease (WED), is a common movement disorder characterized by an irresistible urge to move the legs. This can be accompanied by symptoms such as painful or burning sensations in the calves and/or legs as well as pins and needles. These symptoms tend to occur most during quiet wakefulness, for example when watching television or when drifting off to sleep, or during sleep. This is known as periodic limb movement during sleep (PLMS) and periodic limb movement while awake (PLMW).

RLS is a fairly common neurological movement disorder, occurring in 5 to 15 percent of adults. The exact cause, however, remains unclear. It can occur at any age but tends to be more frequent with increasing age. It is thought to arise from abnormalities in the dopamine and iron systems in the brain, including the basal ganglia and spinal cord. Additionally, alterations in the central nervous system are thought to affect biological processes relating to our 24-hour cycle (circadian rhythm) and the way various neurotransmitters work. There seems to be a genetic link, although no specific genes have been identified so far. RLS also appears to be strongly linked with an iron deficiency in the body.

How is RLS diagnosed?

A diagnosis of RLS is made if a person displays all five primary clinical features set out in 1995 and amended in 2014 by the International Restless Legs Syndrome Study Group (IRLSSG):

  1. An urge to move the legs usually but not always accompanied by, or felt to be caused by, uncomfortable and unpleasant sensations in the legs.
  2. The urge to move the legs and any accompanying unpleasant sensations begin or worsen during periods of rest or inactivity such as lying down or sitting
  3. The urge to move the legs and any accompanying unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.
  4. The urge to move the legs and any accompanying unpleasant sensations during rest or inactivity only occur or are worse in the evening or night than during the day.
  5. The occurrence of the above features is not solely accounted for as symptoms primary to another medical or a behavioral condition (e.g. myalgia, venous stasis, leg edema, arthritis, leg cramps, positional discomfort, habitual foot tapping).

In addition, other features that may suggest a diagnosis of RLS are:

  • periodic limb movements when asleep
  • sleep disturbances, particularly difficulty in falling asleep
  • dyskinesia when awake, almost always during periods of rest or inactivity
  • an improvement of symptoms when dopamine is taken
  • a family history of RLS
  • exclusion of other possible underlying causes
  • a progressive nature of the condition, with periods of remission occasionally.

If RLS is diagnosed, your doctor should also check that you are not taking drugs which make RLS worse (such as certain antidepressants, anti-allergy drugs or alcohol at night). You may also be referred for a neurological examination to see whether inflammation of the nerves in the legs is causing the movement and uncomfortable sensations.

If a diagnosis is still uncertain, or your symptoms do not respond to treatment, then you may be asked to stay overnight in a sleep laboratory so that you can be observed further and tests can be carried out during your sleep cycle.

Parkinson's and RLS

It is difficult to confirm exactly how Parkinson’s can affect RLS or vice versa. It is a condition in its own right, occurring in people both with and without Parkinson’s – although it is thought to be almost twice as likely to occur in people with Parkinson’s.

RLS can also be difficult to diagnose in Parkinson's as it may come and go and can be confused with other symptoms of the condition such as akathisia (a restlessness caused by dopaminergic medications), internal tremor, or by ‘wearing off’. RLS can also cause night time pain which may be mistaken for arthritis in people with Parkinson's.

One of the main consequences of RLS in Parkinson’s is sleep disruption and insomnia. At best, sleep disruption can lead to daytime tiredness and possible irritability. At worst, it can lead to anxiety and depression, although more research is needed into this. RLS may also affect your sleeping partner if you experience periodic limb movement (PLM). For this reason many people with this condition find it easier to sleep alone.

What treatment is available?

RLS is a condition that is treatable and generally susceptible to pharmacologic therapy. Here, a wide range of different treatment options is available, including dopaminergic agents, drugs that modulate certain calcium-channels, opioids, and benzodiazepines. However, the medical condition most commonly associated with RLS is iron deficiency so your doctor should first check your ferritin levels (a protein that binds iron in the blood). If levels are low you will be given an iron supplement. For some people increasing the ferritin levels will eliminate or reduce the RLS symptoms.

Some Parkinson's medications can make RLS worse and should be avoided. For example, some people who take levodopa complain that RLS symptoms occur during the day, as well as evenings, and may also involve the arms. These symptoms typically worsen late in the night as the medication wears off. It is therefore often preferable to use dopamine agonists such as cabergoline (Cabaser), pramipexole (Mirapexin) or ropinirole (Requip) instead of levodopa when treating Parkinson’s and RLS. A night time dose of Stalevo may also be helpful or a rotigotine skin patch which provides a slow release of medication throughout the night.

If you are already taking dopamine agonists to manage Parkinson's symptoms and you still experience RLS symptoms, then your doctor may suggest you try other medications, such as clonazepam, gabapentin or strong painkillers, although these may or may not be licenced to treat RLS in your country. In severe cases, an apomorphine infusion can be given during the night but this is only available in specialist centres.

How can I help myself?

There are many ways you can help yourself – but it does depend on how disruptive the symptoms are and what changes you are willing to make.

First, review your lifestyle and see what changes you can make to reduce or eliminate RLS symptoms. Suggestions include:

  • Establish the right level of exercise - too much worsens it, too little may trigger RLS. Some people find a few minutes of exercise just before bedtime is particularly effective, although others find exercise in an evening worsens the symptoms.
  • Avoid stimulants, such as caffeine, alcohol and smoking, particularly in the evening.
  • Eliminate from your diet foods that trigger RLS – these may include sugar, triglycerides (a form of dietary fat found in meats, dairy produce and cooking oils), gluten, sugar substitutes (aspartame), or following a low-fat diet. Experiment to see what works for you – but before significantly changing your diet, always check with your doctor or a dietician first.
  • Create a peaceful, cool sleeping environment.
  • Discuss with your doctor adding supplements such as potassium, magnesium, B-12, folate, vitamin E, and calcium to your diet. Whilst it has not been clinically proven, there is anecdotal evidence to suggest these supplements can ease RLS symptoms.

To relieve the symptoms, you could try:

  • stretching and massaging the legs
  • applying a hot – or cold – compress to the muscles in the leg
  • taking a warm bath before going to bed
  • drinking more water. Dehydration may cause the urge to move the legs, so some people find drinking a glass of water stops the urges for a short while
  • soaking your feet in hot water just prior to going to sleep
  • wearing compression stockings or tights in bed
  • placing a pillow between your knees or thighs when lying in bed
  • massage and chiropractic spinal manipulation
  • distracting your mind – read a book or switch on the TV.

These are simply suggestions and what works for some people, won’t for others. If you have any concerns talk to your doctor or healthcare professional first.

Acknowledgement

Our thanks to Parkinson’s UK for permission to use the following source:

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