Restless Legs Syndrome
What is restless legs syndrome?
Restless legs syndrome (RLS) is a disorder related to sensation and movement. People with restless legs syndrome have an unpleasant feeling or sensation in parts of their bodies when they lie down to sleep. Most people also have a very strong urge to move, and moving sometimes makes them feel better. But all this movement makes it hard or impossible to get enough sleep.
Restless legs syndrome usually affects the legs. But it can cause unpleasant feelings in the arms, torso, or even a phantom limb (the part of a limb that has been amputated).
When you don't get enough sleep, you may start to have problems getting things done during the day because you're so tired. You may also be sleepy or have trouble concentrating. So it's important to see your doctor and get help to manage your symptoms.
What causes restless legs syndrome?
Usually there isn't a clear reason for restless legs. The problem often runs in families. Sometimes there is a clear cause, like not getting enough iron. If that's the case, treating the cause may solve the problem.
Women sometimes get restless legs while they are pregnant.
Other problems that are sometimes linked to restless legs syndrome include kidney failure, rheumatoid arthritis, diabetes, nerve damage, anemia, and Parkinson's disease. But most people who seek treatment do not have any of these other problems.
What are the symptoms?
Restless legs syndrome makes you feel like you must move a part of your body, usually your legs. These feelings are often described as tingling, "pins and needles," prickling, pulling, or crawling.
Moving will usually make you feel better, at least for a short time. This problem usually happens at night when you are trying to relax or go to sleep.
After you fall asleep, your legs or arms may begin to jerk or move. These movements are called periodic limb movements. They can wake you from sleep, which adds to your being overtired. Although periodic limb movement is considered a separate condition, it often happens to people who have restless legs syndrome.
How is restless legs syndrome diagnosed?
One of the hardest things about having restless legs syndrome is getting to the diagnosis. Often doctors don't ask about sleep or don't ask about the symptoms of restless legs. If you're not sleeping well, or if you think you may have restless legs syndrome, tell your doctor.
Your doctor will talk with you about your symptoms to make sure that the feelings you describe are typical of restless legs syndrome and are not caused by some other problem.
You may have blood tests to rule out other problems that could be causing your symptoms. In some cases, the doctor may order tests of your nerves to be sure there is no nerve damage. Your doctor may also order a sleep study called a polysomnography. This test records how often your legs jerk or move while you sleep.
How is it treated?
If your symptoms are mild, a few lifestyle changes may be enough to control your symptoms. Some changes that may help:
- Avoid tobacco, alcohol, and caffeine.
- Keep your bedroom cool, quiet, and comfortable, and use it only for sleeping, not for watching TV.
- Get regular exercise.
- Massage the leg or the arm, or use heat or ice packs.
When symptoms are more severe, medicines may help control the urge to move and help you sleep. There are different types of medicine, and you may have to try a few to find the one that works best.
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The main symptom of restless legs syndrome (RLS) is an irresistible urge to move because of uncomfortable and sometimes painful sensations deep within a part of your body. The feelings usually affect the legs but can also affect the arms, torso, or a phantom limb (the part of a limb that has been amputated). Some people describe the sensations as aching, creeping, crawling, or prickling. Symptoms usually begin about 15 minutes after you lie down to sleep or to relax or when you have not moved for long periods, such as when traveling in a car or airplane. Symptoms that occur frequently can result in significant sleep loss, fatigue, and problems with daily functioning.
After they are asleep, most people with RLS also have involuntary or jerking leg movements called periodic limb movements. These movements can interrupt your sleep, which adds to problems with fatigue. Periodic limb movements may also occur during the day, although most people move around after their legs begin to bother them. As a result, the periodic limb movements that people have when they are awake may not be noticed except under unusual circumstances.
Restless legs syndrome and periodic limb movements also often disturb the sleep of a bed partner. This can cause fatigue for both people and can strain the relationship.
Symptoms may start during infancy or any time during your life. At first, your symptoms may be mild and occur only once in awhile. Typically, symptoms get worse with age. After age 50, many people with this condition have daily symptoms and suffer from significant sleep loss. Severe insomnia, fatigue, anxiety, depression, and lack of social activity can become a problem and cause a decline in quality of life.
Restless legs syndrome may start or become worse during pregnancy, especially after week 20.
Exams and Tests
A doctor diagnoses restless legs syndrome by asking questions about your symptoms. A physical exam may be done to look for other possible problems that could be causing your symptoms.
Restless legs syndrome is diagnosed by your doctor based on the following four criteria:
- You have an urge to move a part of your body, usually because of uncomfortable sensations such as tingling, "pins and needles," prickling, crawling, or pain. In some cases, you may not feel any unpleasant sensations but still feel the urge to move your legs or your arms.
- The sensations and the urge to move begin or get worse during periods of rest or inactivity, such as when you are sitting or lying down.
- The sensations and the urge to move are partially or totally relieved by movement. But relief may be temporary and only last while you are walking, stretching, or moving.
- The urge to move and the sensations are worse in the evening or at night. But some people may have severe sensations and urges to move throughout the day and night.
Other factors that may support a diagnosis include:
- Having a family history (in a parent or sibling) of restless legs syndrome.
- Having periodic limb movements—involuntary jerking or movement of your legs—while you are awake or asleep.
- Showing improvement when the medicine dopamine is used.
A sleep study called a polysomnography may be done to help your doctor diagnose restless legs syndrome or rule out other sleep disorders. This test records the electrical activity of your brain, eye movements, muscle activity, heart rate, breathing, air flow through your nose and mouth, and blood oxygen levels.
Although this test is not essential, it provides details of limb movement symptoms. These details may help evaluate the severity of your symptoms. The severity ranges from people who have restless legs syndrome occasionally, with only mild difficulty falling asleep, to those who have it frequently, with repeated interruptions of sleep. Serious sleep problems can greatly affect your ability to function during the day.
Common problems with diagnosing restless legs syndrome
Many cases go undiagnosed because:
- Many people do not seek a doctor's help when they have symptoms.
- Most people visit a doctor during the day, when symptoms are not present or are only mild.
- Some doctors do not recognize the condition and may believe that the symptoms are caused by other conditions, such as insomnia, stress, muscle cramps, or arthritis.
Restless legs syndrome does occur in children but it is hard to diagnose for the same reasons. Children often are not able to describe their symptoms. A parent's observations of the child's behavior and sleep may be helpful. Knowing that a parent or other close relative has restless legs syndrome can also help the doctor make a diagnosis of restless legs syndrome in the child.
Other conditions to consider
Polysomnography and related sleep study tests may also be done to help identify problems that can interfere with sleep. You may be evaluated for other conditions with symptoms similar to restless legs syndrome. These conditions include varicose veins, arthritis, or intermittent claudication (a tight, aching, or squeezing pain in the calf, foot, thigh, or buttock that occurs during exercise).
You also may be asked about behaviors, habits, and physical traits that may be related, such as:
- Lack of regular, moderate exercise.
- Being overweight and having a high body mass index.
You may also have tests to check for other diseases or health conditions—such as diabetes, peripheral neuropathy, pregnancy, kidney problems, or iron deficiency anemia—that can cause your symptoms. Tests will vary depending on what your doctor identifies as likely problems.
Treatment for restless legs syndrome is based on the type of symptoms you have and how bad your symptoms are. Getting regular exercise and enough sleep may relieve mild symptoms. Medicines may be tried when symptoms are severe and interfere with sleep and daily functioning. If your symptoms are being caused by another medical condition (such as iron deficiency anemia), that condition can be treated first.
Changing your daily routine is sometimes enough to control your symptoms. Stretching, walking, exercising regularly, taking a hot or cold bath, using massage, losing weight if you are overweight, and avoiding smoking, alcohol, and caffeine may reduce or control your symptoms.
If your symptoms are caused by another medical condition such as diabetes or iron deficiency anemia, you will be treated for that condition first. For example, if iron deficiency is causing restless legs syndrome, you will be prescribed iron supplements.
For restless legs syndrome that starts during pregnancy, your doctor may recommend conservative treatment, such as regular exercise and stretching, to relieve symptoms. Your condition may be reevaluated if it doesn't go away after you have given birth.
Children who have restless legs syndrome are not usually treated with drugs right away. First regular, moderate exercise and regular sleep routines are tried. If this treatment is not effective, the doctor may prescribe medicine.
If your symptoms do not improve, drugs may be used to control the urge to move and help you sleep, such as:
- Dopamine agonists, such as ropinirole (for example, Requip).
- Anticonvulsants, such as gabapentin (for example, Neurontin) or gabapentin enacarbil (Horizant).
In some cases, your doctor may recommend an opioid pain medicine.
If your doctor recommends medicine, make sure that you discuss expectations and understand the potential benefits and risks of the drug. Let your doctor know about all of the other drugs you are taking. Drugs taken for other conditions sometimes contribute to restless legs syndrome. For example, antidepressants improve restless legs syndrome in some people but make it worse in others.
Treatment if the condition gets worse
Over time, treatment of RLS with a dopamine medicine may not work as well as it did at first. This is called augmentation.
You might notice that your symptoms:
- Begin earlier in the day.
- Become more intense.
- Spread to another part of your body.
If you are taking a dopamine medicine for RLS and your symptoms change, tell your doctor. Do not stop taking your medicine without talking to your doctor first. You can work with your doctor to decide what treatment is the best one for you.
If you continue to have symptoms even though you are receiving treatment with drugs and are exercising regularly, eating right, and not smoking, drinking alcohol, or using caffeine, your symptoms may need to be reevaluated. Many other conditions can cause the sensations found in restless legs syndrome, including several vitamin and mineral deficiencies.
Your doctor may recommend different drugs or a combination of drugs. Follow up with your doctor if your symptoms do not improve.
Your doctor may have you try other treatments. Examples are:
- A pneumatic compression device, which pumps air in and out of sleeves to make them tight and loose around your legs while you are resting.
- Vibrating pads (Relaxis), which send vibrations to your legs as you lie in bed. The vibrations have been shown to improve sleep for some people with RLS.
There are ways to improve your symptoms of restless legs syndrome at home.
- Exercise. Regular, moderate exercise may reduce symptoms. Avoid long periods between activity and avoid sudden bursts of intense activity. Talk to your doctor before you start an exercise program.
- Heat or cold. Your symptoms may be relieved by bathing in hot or cold water. Or try a heating pad, hot water bottle, or ice bag. Keep a cloth between the heating pad, hot water bottle, or ice bag and your skin. Do not use a heating pad with children.
- Good sleeping habits. Fatigue can make your symptoms worse. So it is important to establish good sleep habits. Keep your bedroom cool, quiet, and comfortable. Use it only for sleeping, not for watching TV. Try to go to bed and get up at the same time every day.
- Stretching and massage. You may be able to control your symptoms by gently stretching and massaging your limbs before bed or as discomfort begins.
- Caffeine, tobacco, and alcohol. These may make your symptoms worse.
- Certain medicines. Some prescription and over-the-counter (OTC) medicines (such as cold and sinus medicines) can make symptoms of RLS worse. If you think your symptoms get worse after you take a certain medicine, talk to your doctor.
- Being confined for long periods. Try to plan for times when you will need to remain seated for long stretches. For example, if you are traveling by car, plan to make some stops so you can get out and walk around.
- Excessive exercise. Although moderate exercise may help relieve symptoms, unusually intense workouts may make them worse. Try to figure out at what level exercise helps and at what point it triggers restless legs syndrome.
See your doctor if your symptoms do not improve, if they become worse, or if they significantly interfere with your sleep and daily functioning.
Other Works Consulted
- American Academy of Sleep Medicine (2005). Restless legs syndrome. In International Classification of Sleep Disorders, Diagnostic Coding Manual, 2nd ed., pp. 178–181. Westchester, IL: American Academy of Sleep Medicine.
- Aurora RN, et al. (2012). The treatment of restless legs syndrome and periodic limb movement disorder in adults—An update for 2012: Practice parameters with an evidence-based systematic review and meta-analyses. Sleep, 35(8): 1039–1062. Also available online: http://www.aasmnet.org/practiceparameters.aspx?cid=119.
- Esteves AM, et al. (2009). Effect of acute and chronic physical exercise on patients with periodic leg movements. Medicine and Science in Sports and Exercise, 41(1): 237–242.
- Garcia-Borreguero D, et al. (2010). Treatment of restless legs syndrome with pregabalin: A double-blind, placebo-controlled study. Neurology, 74(23): 1897–1904.
- Pack AM (2010). Neurologic disease during pregnancy. In LP Rowland, TA Pedley, eds., Merritt's Neurology, 12th ed., pp. 1043–1050. Philadelphia: Lippincott Williams and Wilkins.
- Voon V, et al. (2011). Frequency of impulse control behaviours associated with dopaminergic therapy in restless legs syndrome. BMC Neurology. Published online: September 28, 2011. (doi: 10.1186/1471-2377-11-117). Available online: http://www.biomedcentral.com/1471-2377/11/117.
- Weintraub D, et al. (2010). Impulse control disorders in Parkinson disease. Archives of Neurology, 67(5): 589–595.
Current as of: August 4, 2020
Author: Healthwise Staff
Anne C. Poinier MD - Internal Medicine
E. Gregory Thompson MD - Internal Medicine
Adam Husney MD - Family Medicine
Martin J. Gabica MD - Family Medicine
Kathleen Romito MD - Family Medicine
Karin M. Lindholm DO - Neurology
Current as of: August 4, 2020
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