Cara woke again this morning, exhausted from a sleepless night. Once again, she has been awake for hours during the night, reading, trying to go back to sleep only to find herself awake again in a short time. She is so tired all the time. At work she feels dull, grumpy and irritable. She is so miserable. Everyone at work must really be tired of her crankiness. She thinks that she is certainly tired of feeling like this. Today, she will call her doctor for an appointment.
Mary Hammock, M.D, internal medicine practitioner in Chattanooga, says that symptoms like Cara's often bring patients to the doctor. "They complain of 'heebie jeebies' when they get into bed at night, crawling or tingling sensations and sometimes pain that interrupts or keeps them from falling to sleep," she says. "There are several categories of RLS. It is called primary if it runs in families. Pregnancy, illness or problems such as iron deficiency or medications such as antidepressants or over-the-counter drugs can cause the secondary type. If there is an underlying cause, we try to correct that. Most cases are idiopathic which means that we don't know the cause and we try different things to treat the patient," she explains. "Lifestyle things like alcohol can sometimes make it worse. RLS seems to occur more frequently in smokers, so if they can discontinue that, restless legs get better."
Hammock says that people having these symptoms should contact their physician. "The first things the doctor would check are the patient's iron levels then the medications the patient is taking to determine whether the cause may be related," she notes. "Patients sometimes do not report for a long time because the symptoms seem odd, but now there are commercials about it and people are more aware. Periodic limb movement or jerking of limbs during sleep often goes along with RLS and can interrupt sleep for the patient's partner as well."
A Common Condition
A common condition that is often not diagnosed, Restless Legs Syndrome (RLS) is estimated to affect about two in ten adults in the United States. Prevalence tends to increase with age, but it can occur in children. Over one-third of patients with severe cases had their first symptoms before they were age 20, though they were not diagnosed until later in life. Incidence may be slightly higher in women. Severity of symptoms increases with age. It often occurs in families, indicating a genetic origin, but the exact mode of transmission is unknown.
RLS is a central nervous system disorder causing unpleasant leg sensations that lead to uncontrollable urges to move the legs, especially when lying down or inactive. Patients describe such sensations as burning, creeping or crawling like insects under the skin (called paresthesias or dysthesias) which makes it almost impossible to perform normal activities such as automobile or air travel or sitting through a movie in the theater. They report agitation and inability to rest that may cause negative impact on the quality of life because of chronic sleep deprivation and stress. Resulting fatigue affects daily functioning with social, occupational and family activities, leading to job loss, problems with relationships and enjoyment of leisure. Patients may complain of impaired memory, inability to concentrate and complete tasks. RLS is not caused by psychiatric problems or stress, but these factors can exacerbate the condition.
What Causes RLS?
Studies indicate that RLS is frequently associated with deficient iron levels or anemia, which, once corrected may reduce symptoms. It may be associated with chronic diseases such as kidney failure, diabetes, peripheral neuropathy or Parkinson's disease. Persons with RLS plus a chronic disease tend to develop symptoms more rapidly. Some pregnant women experience RLS, but the condition usually abates within four weeks after delivery. Certain medications such as cold or allergy medications, antinausea or antipsychotic drugs may exacerbate symptoms. Caffeine, alcohol and tobacco may aggravate or initiate symptoms. Reducing or eliminating these substances may relieve symptoms.
The relationship between RLS and venous reflux has been documented since 1982. In a recently published study (International Angiology 2005:24:99) 97 percent of patients presenting for study for RLS had venous reflux. Normally, veins return blood from the extremities to the heart and lungs to be re-oxygenated. A system of valves and muscle contractions in the calves enable blood to flow upward against gravity. When the system is compromised, bloods falls backward, becomes pooled and stagnate in the veins, leading to fatigue, swollen ankles, aching and cramps in the legs. The body's efforts to send the stagnate blood back to heart and lungs lead to constant urges to move the legs.
About 80 percent of persons with RLS also experience periodic limb movement disorder (PLMD), which is involuntary (patient cannot control it) leg twitching and jerking movements during sleep. The movements occur about every 10 to 60 seconds during the night disrupting sleep. The cause is unknown.
How is RLS Discovered?
There is currently no single diagnostic test. RLS is diagnosed by evaluating the patient's history and description of symptoms. The International Restless Legs Syndrome Study Group (1995) identified four basic criteria for diagnosis:(1) desire to move the limbs associated with peculiar sensations described above, (2) symptoms that are present only or worsen when at rest, and are relieved by activity, (3) motor restlessness such as tossing and turning in bed, pacing the floor or rubbing the legs, (4) symptoms worsen in evening or night. Sensations occur most often between the knee and ankle but may also occur in feet, thighs, arms and hands. Both sides are usually affected. Symptoms are usually more noticeable at night, especially in the early hours of sleep. They may disappear near early morning, enabling the person to sleep. Though movement relieves symptoms, it is only temporary.
Because diagnosis is difficult, RLS often goes undiagnosed. It is especially difficult with children who have trouble describing their symptoms and can sometimes be misdiagnosed as "growing pains" or attention deficit disorder. If the person's history is suggestive of RLS, laboratory exams may be done to rule out other conditions. Electromyography and nerve conduction studies may be done to determine electrical activity in nerves and muscles. Doppler sonography may be used to evaluate muscle activity in the legs and document nerves or other movement-related problems.
How is RLS Treated?
For those persons with mild or moderate symptoms, prevention is important. Often lifestyle changes and changes in activity can relieve symptoms. If associated with other medical problems such as diabetes, treating the condition may relieve the symptoms. If not associated with other disease, treatment is symptomatic. Studies have shown that maintenance of normal sleep patterns can reduce symptoms. Moderate exercise, a hot bath, massage, application of heat or cold may reduce symptoms in some people, but rarely offer complete relief.
Physicians have used various medications in treatment of RLS. Selection of medications is determined by factors such as age, severity of symptoms and presence of pregnancy or pre-existing disease. Dopaminergic agents are the most used drugs for RLS. Central nervous system depressants, opioids and anticonvulsants relieve symptoms for some patients. Codeine, proposyphene or oxycodone can be prescribed to relieve pain, but add the problem of addiction. Good short-term results have been achieved with levodopa plus carbidopa, though most patients develop augmentation (symptoms begin to appear earlier in the day).
Ropinirole became the only drug approved by U.S. Food and Drug Administration specifically for moderate to severe RLS in 2005. Benzodiazepines (Clonazepam and Diazepam) help patients to get more restful sleep, but cause drowsiness in the daytime and do not completely relieve symptoms.
Treatment must be individualized for each patient since no single drug is effective for everyone with RLS. The drug that works for one person may worsen symptoms for another. Patients may develop tolerance for medications over time, making it necessary to change periodically. Regardless of medications used, it is very important for physicians or their staff to educate patients about drugs that are prescribed.
What is the Outlook for Persons with RLS?
RLS is a life-long condition with no cure and usually becomes more severe with age. The National Institutes of Neurological Disorders and Stroke and other major institutions across the country are conducting research to increase understanding of RLS and discover improved methods of prevention and treatment of the disease.
How Would I Know if I Have Restless Legs Syndrome?
- Do you have difficulty to describing sensations (creeping, crawling) in your legs or arms that are relieved by moving or rubbing them?
- Do they occur late in the day or during the night?
- Do they worsen when you are resting or inactive?
- Do these sensations keep you from falling asleep or wake you during the night?
- Does lack of sleep cause you problems during the day? (tired, sleepy, trouble paying attention, confusion)
- Does your bed partner report that your legs or arms jerk during sleep?
- Did your symptoms start when you started or stopped a medication?
- Are you pregnant, anemic, diabetic, or do you have kidney disease?
- Do you have a family member who has the same problems described above?
For more information, check out the following web sites:
Restless Legs Syndrome Foundation: www.rls.org/
Healthline: www.healthline.com
National Institute of Neurological Disorders and Stroke: www.ninds.nih.gov