Restless Legs Syndrome
A neurological disorder causing uncomfortable sensations in the legs and an irresistible urge to move them, particularly during rest and in the evening.
What is Restless Legs Syndrome?
Restless Legs Syndrome (RLS), also known as Willis-Ekbom Disease, is a common neurological sensorimotor disorder characterized by an uncomfortable urge to move the legs, typically accompanied by unpleasant sensations. These symptoms occur primarily during periods of rest or inactivity, are worse in the evening and at night, and are at least temporarily relieved by movement. RLS significantly impairs quality of life by disrupting sleep onset and causing daytime fatigue, and is associated with depression and anxiety. It affects both sleep and daytime functioning.
Prevalence
RLS affects approximately 5-10% of adults in Western populations, with moderate to severe symptoms occurring in 2-3%. It is more common in women (about 2:1 ratio) and prevalence increases with age. RLS can begin at any age, including childhood, and tends to worsen over time. There is a strong genetic component, with about 50% of patients having an affected first-degree relative.
Causes
The exact cause of RLS is not fully understood, but it involves dysfunction in the brain's dopamine system and iron metabolism. Primary RLS appears to be genetic, with several risk genes identified. Secondary RLS can be caused by: iron deficiency (the most important modifiable factor), kidney failure/dialysis, pregnancy (temporary), neuropathy, certain medications (antihistamines, antidepressants, antipsychotics, anti-nausea drugs), caffeine and alcohol, and other medical conditions. The brain may have difficulty using iron even when blood levels appear normal.
Symptoms
Urge to move the legs
An uncomfortable, sometimes irresistible need to move the legs. The urge is typically accompanied by or caused by unpleasant sensations in the legs.
Unusual sensations
Described variously as creeping, crawling, pulling, itching, tingling, burning, or 'pins and needles' feelings deep inside the legs. Some patients struggle to describe the sensation.
Symptoms worse at rest
Symptoms begin or worsen during periods of inactivity such as sitting or lying down.
Symptoms worse in evening/night
There is a distinct circadian pattern with symptoms being most severe in the late evening and night, often peaking around midnight.
Relief with movement
Walking, stretching, or moving the legs provides temporary relief, but symptoms return when movement stops.
Sleep disruption
Difficulty falling asleep due to symptoms, and sometimes awakening during the night with recurrent symptoms.
Arm involvement
While legs are most commonly affected, some patients also experience symptoms in the arms.
Diagnosis
Self-Assessment Questions
If you answer yes to any of these questions, consider consulting a sleep specialist:
- 1Do you have an uncomfortable urge to move your legs, especially when sitting or lying down?
- 2Are the sensations associated with your urge to move uncomfortable (creeping, crawling, pulling)?
- 3Are your symptoms worse in the evening or at night?
- 4Do your symptoms improve when you walk or move your legs?
- 5Do your symptoms make it difficult to fall asleep or stay asleep?
- 6Do you have family members with similar symptoms?
RLS is diagnosed clinically based on the presence of four essential criteria. Blood tests are important to check iron levels and rule out secondary causes. Sleep studies may be done to assess for periodic limb movements.
Clinical Criteria
Diagnosis requires all four criteria: urge to move legs with uncomfortable sensations, symptoms worse at rest, relief with movement, and symptoms worse in evening/night.
Iron Studies
Serum ferritin and iron saturation should be checked. Low ferritin (below 50-75 ng/mL) is associated with RLS even if not frankly deficient.
Blood Tests
Complete blood count, kidney function, thyroid function, and other tests may identify secondary causes.
Polysomnography
Sleep study can document periodic limb movements in sleep (PLMS), which occur in about 80% of RLS patients. Not required for diagnosis.
IRLS Rating Scale
The International RLS Study Group Rating Scale quantifies symptom severity and can track treatment response.
Treatment
Treatment begins with addressing any underlying causes (especially iron deficiency) and triggers. Medications are used for more severe symptoms, but must be carefully managed to avoid 'augmentation' (worsening of symptoms over time).
Iron Supplementation
If ferritin is below 50-75 ng/mL, iron supplementation (oral or IV) is first-line treatment. IV iron may be more effective and faster-acting.
Alpha-2-Delta Ligands
Gabapentin enacarbil (Horizant), gabapentin, and pregabalin are first-line medications. They improve sensory symptoms and sleep without causing augmentation.
Dopamine Agonists
Pramipexole (Mirapex), ropinirole (Requip), and rotigotine patch are effective but carry significant risk of augmentation with long-term use. Used at low doses when needed.
Low-Dose Opioids
For severe, refractory RLS, low-dose opioids (oxycodone, methadone) may be used carefully. Effective but require monitoring for dependence.
Avoid Triggering Medications
Discontinue or substitute medications that worsen RLS: antihistamines, most antidepressants (except bupropion), anti-nausea drugs, antipsychotics.
Treat Underlying Conditions
Managing kidney disease, neuropathy, and other conditions contributing to RLS.
Lifestyle Adjustments
- •Check and optimize iron levels (ferritin should be above 50-75 ng/mL)
- •Avoid caffeine, especially in the afternoon and evening
- •Limit alcohol consumption
- •Avoid medications that worsen RLS (antihistamines, many antidepressants)
- •Maintain regular moderate exercise (not too close to bedtime)
- •Apply heat or cold to the legs as needed
- •Try leg massage or stretching before bed
- •Keep a consistent sleep schedule
- •Distract yourself during symptoms with mental activities
- •Consider compression devices or vibrating pads designed for RLS
Patient Support Resources
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