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Restless Legs Syndrome (RLS)

Definition

Restless legs syndrome (RLS) is a sleep-related movement disorder in which the person feels a strong urge to move the lower limbs during periods of rest.

What is Restless Legs Syndrome?

Restless legs syndrome (RLS) is a sleep-related movement disorder in which the person feels a strong urge to move the lower limbs during periods of rest. Also called Ekbom Syndrome and Willis-Ekbom disease, RLS results in a “pins and needles” sensation in the limbs that can be a painful deterrent to sleep.

RLS sensations typically:

  • Occur during periods of inactivity
  • Become more sensitive in the evening and at night
  • Are relieved by movement of the limbs
  • Often delay sleep onset due to the strong sensations felt in the limbs and the need to continue movement for relief
  • May cause involuntary jerking of the limbs during sleep or sleep onset (Periodic Limb Movement Disorder)

According to the National Institute of Neurological Disorders and Stroke, symptoms can be variable from day to day both in frequency of occurrence and severity. Some may only experience symptoms once or twice a week while others with more severe cases can experience symptoms 3 or more times a week, which can lead to significant changes in quality of life due to sleep deprivation and excessive daytime sleepiness.

Symptoms of Restless Legs Syndrome

People with RLS may experience myoclonus, or sudden, involuntary muscle contractions or jerks at sleep onset or during sleep. According to the International Restless Legs Syndrome Study Group (IRLSSG), people with RLS experience:

  • An urge to move the lower limbs
  • The urge is accompanied with pain or unbearable sensations which get worse when the person rests or lies down
  • These sensations may include a creepy-crawling feeling, a throbbing or burning sensation, or an itching in the legs
  • Some relief from the urge results from walking or stretching
  • The symptoms become worse at night or during rest
  • No other obvious cause for these symptoms

How Common is Restless Legs Syndrome?

The Restless Legs Syndrome Foundation reports that up to 8 percent of adults have RLS. For around 3 percent, the disorder creates sleep disturbances severe enough to negatively impact quality of life. The disorder is twice as common in women than men and more common during certain life stages, including pregnancy. Up to a quarter of pregnant women experience RLS, which usually resolves after pregnancy. Additionally, RLS is underdiagnosed in children and is increasingly recognized as an underlying factor in some childhood sleep problems.

What Causes Restless Legs Syndrome?

Restless legs syndrome is a neurological disorder related to abnormalities in the regulation of certain neurotransmitters and nutrients. RLS not caused by another disorder is called primary or idiopathic RLS. Primary RLS is thought to result from several overlapping factors.

The first factor involves the area of the brain’s regulation of dopamine. Dopamine is a neurotransmitter involved in movement and mood regulation. Excess dopamine is thought to play a role in RLS symptoms.

The second factor involved in primary RLS is the regulation of iron. Brain imaging and autopsies have revealed low concentrations of iron in the brains of individuals afflicted with restless legs syndrome. Over 80 percent of children affected by RLS have low stored iron (ferritin).

The third factor is genetics. Researchers have identified several genetic variants associated with RLS; each variant increases RLS risk by more than 50 percent. Biochemically, the protein tyrosine phosphatase receptor type delta is highly prevalent in people with RLS.

Secondary RLS occurs as the result of another disorder or condition, or from taking certain medications.

Although RLS may produce a “pins and needles” sensation in the limbs, it is worth noting that it is not a circulation disorder. RLS is not associated with increased risk of cardiovascular disease.

Diagnosis

Physicians use a combination of medical history and self-reported signs and symptoms to diagnose RLS. While there is no blood test to diagnose RLS, physicians may request lab tests to measure iron levels. Polysomnography can help monitor sleep patterns to determine whether an underlying sleep disorder is contributing to RLS.

Treatment

According to the American Academy of Sleep Medicine, chronic RLS with two or more occurrences per week qualifies for treatment, as does intermittent RLS with severe symptoms.

A popular home remedy for restless legs syndrome involves a bar of soap in bed. Evidence pointing to the benefits of this approach is anecdotal, but it can’t hurt to try.

When RLS symptoms are mild or moderate, symptoms are usually managed with lifestyle changes and good sleep hygiene. These changes include:

  • Maintaining a consistent sleep routine
  • Keeping the bedroom dark, quiet and cool
  • electronics and other distractions from the bedroom
  • Avoiding lying in bed awake for long periods of time

People who experience severe restless legs syndrome symptoms most nights may consider medications to relieve discomfort and improve sleep. Dopamine agonists, commonly used to treat Parkinson’s disease, are FDA-approved for treating RLS. These medicines include pramipexole (Marapex), pergolide, and levodopa.

If iron deficiency is present, iron supplementation can reverse the symptoms. The anticonvulsant medication gabapentin has also been prescribed.

The benzodiazepine clonazepam is prescribed in some countries for RLS. It is not approved by the US FDA for this condition, and US doctors do not often prescribe it. Opioids are sometimes prescribed in severe cases.

Periodic Limb Movement of Sleep (PLMS) or Periodic Limb Movement Disorder (PLMD)

Those with RLS may develop PLMD, but the reverse is not necessarily true.  Most with PLMD do not complain of RLS symptoms or episodes. Though they appear to be identical in nature (both involve frequent leg movements) they are in fact different.

To begin, PLMD occurs while the patient is asleep and is involuntary; most of those experiencing PLMD are unaware that they even have such muscle activity while sleeping. PLMD typically is seen within the first half of the night, and occurs in a rhythmic pattern. As seen on an overnight polysomnogram, PLMD occurs in a series of 4 or more limb movements.  Severe cases can see upwards to a hundred or more limb movements. Studies indicate that nearly 4 percent of adults suffer from PLMD and it is more commonly found in females.

Similar to RLS, periodic limb movements can cause excessive daytime sleepiness and fatigue. PLMD can disrupt a person’s sleep by causing arousals or brief interruptions while sleeping, leaving the person feeling unrested upon waking. Treatment is similar to that of someone with RLS, and given that many people with RLS have PLMD it is often already part of the treatment plan.

Diagnosis

There are 5 main benchmarks used in diagnosing patients with restless leg syndrome in addition to subjective descriptions/symptoms from the patient.  The benchmarks include

  • Strong and overwhelming urge or need to move the limbs with associated uncomfortable sensations
  • The urge increases when inactive or while resting
  • The urge can be relieved or partially alleviated by movement of the limbs
  • The urge to move limbs begins in the evening or at night
  • The urge occurs independent of other medical or behavioral conditions

A polysomnography can be helpful in reviewing sleeping patterns and to help determine if there is the presence of sleep disordered breathing.  A polysomnogram also can provide insight as to whether the person also experiences periodic limb movement disorder which may worsen sleep quality.  Polysomnography acts as another piece to the diagnostic puzzle giving the physician a clearer picture.

There is not a specific blood test for RLS, but the blood work that is often ordered is done as a means to check a person’s iron levels since iron deficiency in the blood is a major risk factor for RLS.

Additional Resources:

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