Restless Legs Syndrome

Restless Legs Syndrome(RLS)

Restless legs syndrome is a common, often unrecognised, but treatable condition.
It was first accurately described in the 1940's by a Swedish Neurologist Dr Ekbom and has been called 'The Ekbom Syndrome'. It is a neurological rather than psychological condition in which the parts of the brain which control sensations and movements in the limbs, particularly the legs, are affected.

Read the Case Study

How do I know if I have restless legs syndrome?

People with restless legs syndrome become aware of some or all of the following:
  1. My legs feel different in the evenings and when I go to bed to when I wake up in the morning. The feeling is hard to describe but maybe in the thighs or calves and appears to be moving inside the muscles. The words that I might use are shown in table 1.
  2. The sensations that I have are worst when I feel tired in the evenings and may improve when I go to bed or may only start once I have gone to bed.
  3. These feelings are relieved by moving the legs and sometimes by massaging them.
  4. If I do not move my legs I develop an irresistible urge to move them or they may jerk involuntarily.
  5. These feelings in my legs are relieved by keeping them cool.
  6. The feelings in my legs may stop me from falling asleep when I go to bed. When I wake up during the night I may be aware that they are present.
  7. My partner says I am restless, twitchy or fidgety in bed.
  8. My partner has noticed that I kick my legs at predictable intervals.
  9. I frequently feel physically fatigued or sleepy during the day.
  10. Other members of my family have experienced similar symptoms.

Table 1: Description of limb sensations

  • Pins and Needles
  • Electric
  • Burning
  • Tired
  • Pulling
  • Uncomfortable
  • Alive
  • Painful
  • Itching
  • Stretching
  • Tingling
  • Creeping
  • Crawling
  • Irritating
  • Heavy
  • Like insects or worms inside the legs
  • Aching
 

Who gets restless legs syndrome?

RLS is equally common in men and women, except for the additional incidence in women during pregnancy. It occurs in a mild form in up to 10% of the adult population but in around 2% causes troublesome symptoms on most nights of the week. It may worsen slightly with age but if it runs in the family it usually starts at a younger age than when it is due to a medical condition.

What causes restless legs syndrome?

RLS is not a psychological or psychiatric disorder but is due to an abnormality of the control of sensation of movements in specific areas of the brain. It is thought that it is the result of a lack of dopamine in these parts of the brain. It is usually an isolated complaint with no other underlying illness but in a few patients RLS is related to:

  1. Iron deficiency. RLS may be the first sign of iron deficiency, even before anaemia appears.
  2. Kidney failure. RLS occurs in up to 70% of those with kidney failure.
  3. Neurological disorders. RLS can develop in several conditions which can affect the nervous system, particularly when the nerves from the spinal cord to the muscles are involved. This can occur for instance as a complication of diabetes. It is also common in people with Parkinsonism.
  4. Drugs. RLS May be triggered by a variety of drugs (table 2) but particularly caffeine which is present in tea, coffee, cola and 'high energy' drinks.

Table 2: Drugs that worsen restless legs syndrome

  • Glucocorticoids, e.g. Prednisolone
  • Tricyclic and selective serotonin reuptake inhibitor antidepressants
  • Lithium
  • Antipsychotics, e.g. phenothiazines
  • Antihistamines
  • Calcium channel blockers
  • Dopamine antagonists, e.g. metoclopramide
  • Withdrawal from anticonvulsants and hypnotics

How can RLS be diagnosed?

RLS is often mistaken for other conditions partly because the symptoms are difficult to describe and also because there is usually nothing abnormal to find during a physical examination. Some important questions to be asked to confirm the diagnosis are shown in table 3.

Table 3: Questions to ask in restless legs syndrome

  • Are there any unusual sensations inside the legs, which are worse in the evenings and least troublesome in the mornings?
  • Are these sensations worse at rest?
  • Is there an urge to move the legs in order to relieve the sensations?
  • Is there a need to keep moving the legs when you get into bed?

There are no specific tests for RLS but movement monitoring (actigraphy) can be useful and occasionally admission to hospital for sleep studies (polysomnography) may be needed. Polysomnography may show repetitive movements of the limbs (periodic limb movement disorder) even when you do not have symptoms of the restless legs syndrome during the day. These periodic limb movements may break up your sleep sufficiently to cause either insomnia or excessive sleepiness during the day. They often require the same treatment as the restless legs syndrome.

What can be done for RLS?

  1. Lifestyle changes. RLS is worse if you are tired. It is important to obtain sufficient sleep but of course RLS can make it difficult to both initiate sleep and stay asleep. Keeping your feet out of the bedclothes or having a fan in the bedroom at night may help you stay asleep. See the Sleep Hygiene page for day-to-day things you can do which may make you sleep better or worse.
  2. Avoid caffeine. It is important to avoid taking any caffeinated drinks after around 6 p.m., and not to take too many early in the day.
  3. Change drugs. Medication given for another condition may induce RLS and an alternative may need to be found.
  4. Treat the cause. If RLS is due to another medical condition such as iron deficiency or kidney failure these should be treated wherever possible.
  5. Drug treatment. This is often effective but it is best to only have a low dose and to take care with the timing of the medication so that the RLS symptoms can be suppressed as much as possible. The most effective drugs are the dopaminergic agents which compensate for any lack of availability of dopamine within the brain. Several of these are available and each has its advantages and disadvantages. Alternatives are conventional sleeping tablets (hypnotics) although these may cause hangover sleepiness on the next morning, and drugs like codeine may help. Some of the anticonvulsants, particularly gabapentin, are also useful.

Case Study

TGQ aged 37
TGQ went to see his General Practitioner because he had not been meeting his targets at work. His line manager had noticed that he had been making more mistakes than usual and had been working more slowly than his colleagues. He found it difficult to stay awake in meetings and felt that he had less energy generally than previously. He told his G.P. that he tried to get more sleep at night but found it difficult to fall asleep. After about 3 a.m. he would sleep soundly but woke feeling unrefreshed in the mornings. He denied feeling stressed by his problems at work but mentioned that he found it difficult to relax his legs both while he was in bed and also in the evenings before he went to bed. He did not have any pains in his legs and found it difficult to explain why he could not lie still for long in bed.

TGQ had not had any other medical problems except for heartburn. He had started drinking more coffee during he day in order to try to keep himself awake but this did not seem to work.

His G.P. recognised his description of his sensations in his legs as being due to the restless legs syndrome and checked his body's iron stores in view of his heartburn, which can lead to bleeding into the oesophagus. He was found to be iron deficient and was given iron tablets and advised to stop drinking coffee. Within 6 weeks he was aware that he was able to fall asleep more easily, his legs no longer felt restless and he was able to meet his targets at work.

How do I get referred?

Find out more