Restless Legs Syndrome (RLS)

What Is Restless Legs Syndrome?

Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a neurological disorder that causes an irresistible urge to move your legs while resting. People with RLS often feel discomfort or tingling in their legs — sometimes in the arms — that improves briefly with movement. Because symptoms often worsen in the evening, RLS can severely disrupt sleep and daytime energy.

According to the American Academy of Sleep Medicine, 13% of Americans report that they have been diagnosed with RLS. Untreated RLS can lead to chronic sleep deprivation, fatigue, irritability and difficulty concentrating. Some people develop anxiety or depression related to poor sleep.

With consistent treatment and healthy routines, most people experience significant relief and maintain normal daily activities.

Causes

Restless legs syndrome is linked to how the brain uses dopamine, a chemical messenger involved in muscle movement. It can also occur with other medical conditions, such as peripheral neuropathy, diabetes, kidney disease or iron deficiency.

Low iron stores are a major factor — when serum ferritin levels fall symptoms often worsen. Addressing iron deficiency can reduce symptoms or prevent progression.

Signs and Symptoms

RLS symptoms usually occur at night or during rest. The uncomfortable feelings are often described as:

• Aching
• Creeping
• Crawling
• Pulling
• Tingling

Symptoms are temporarily relieved by moving or stretching the legs but return when movement stops. Some people also notice arm involvement or daytime tiredness from disrupted sleep.

Periodic limb movement disorder is a related disorder, in which people move their toes, feet, ankles or legs during sleep. They may be unaware of these movements during sleep, but a sleep partner may notice them. While most people with restless legs syndrome also have periodic limb movement disorder, the reverse is not true. The two disorders are not the same.

Risk Factors

About half of people with RLS have a family history of the condition. It is more common in older adults and during pregnancy. RLS may also appear in those with anemia, low iron, kidney problems, or certain medications (antidepressants, antihistamines, antipsychotics).

Diagnosis

A complete medical history is essential for diagnosis. In many cases, RLS symptoms will be detected by one’s sleeping partner first. If RLS is suspected, your doctor will conduct a complete physical exam and ask you questions about your lifestyle, including your family history, your job, your habits, your hobbies, your current medications and your symptoms. 

For RLS, doctors often use the URGE criteria:

• U: Urge to move the legs, usually with discomfort.
• R: Rest or inactivity triggers symptoms.
• G: Getting up or moving relieves symptoms.
• E: Evening or nighttime worsening.

Your doctor may also review medications and order tests to check for anemia, kidney disease or neuropathy.

Sleep Study

A noninvasive overnight test that monitors body functions during sleep, including leg movement, breathing and oxygen levels. While not always necessary for diagnosis, it can confirm periodic limb movement disorder. Most patients sleep comfortably while connected to sensors that record data for analysis.

A sleep study provides data essential in evaluating sleep and sleep-related complaints and problems. It can help in identifying sleep stages, brain waves, eye movement, muscle tone, body position, blood-oxygen levels, breathing events, snoring, heart rate and general sleep behavior.

Sleep studies are performed in a sleep laboratory that is specially equipped with computerized monitoring equipment. Most sleep studies take place at night. After you change into your nightclothes, the technician will connect you to a number of electrodes that will record your brain waves and muscle movements throughout the night. A microphone will record snoring, and two belt-like straps around the chest and lower abdomen will monitor chest and abdominal movements during breathing. Despite all of the equipment, most people say their sleep is not disrupted. After the technician is certain that electrodes are recording properly, the lights will be turned off and you can go to sleep. You will be able to talk to the technician, who will constantly monitor your test from an adjoining room. The technician will also help you if you need to use the restroom during the night.

You will be awakened in the morning, the electrodes will be removed, and you may shower and dress. Since the electrodes are applied with water-soluble glue or tape, removal is not painful. You will be asked to complete a questionnaire about your sleep the previous night, and then you can go home.

Your doctor will explain the results to you and talk with you about follow-up treatment, if required.

Lab Tests

Blood Tests

There’s no specific blood test for RLS, but serum ferritin levels below 75 µg/L can indicate the need for iron supplementation or intravenous (IV) iron. Your doctor may also test for kidney disease, thyroid disorders or vitamin deficiencies.

Treatment

RLS is often lifelong, but symptoms can be managed effectively with a combination of medications, iron therapy and lifestyle changes.

For those people, or for others whose symptoms do not affect their quality of life, no treatment may be necessary. For people with more severe symptoms, medicines are available. Lifestyle changes can also make a significant difference. 

Medications

Several medications may be used to treat RLS. Some medications can make restless legs worse. These include some antihypertensive medications (taken for high blood pressure) and antidepressants. Your doctor may recommend stopping these medications, finding alternatives that do not worsen your symptoms or adding medications to treat RLS.

Over-the-counter medications such as acetaminophen or ibuprofen can be helpful in some people with RLS. The medications most commonly prescribed for restless legs syndrome are dopaminergic agents and gabapentin. Dopaminergic drugs alter the activity of dopamine, a chemical that carries messages in the central nervous system.

Medications prescribed for RLS may include the following: 

Alpha-2-Delta Ligands: These nerve-calming drugs (gabapentin, pregabalin) are often first-line treatments, especially when pain, insomnia or anxiety are present.

Dopamine Agonists: Medications such as ropinirole (Requip®), pramipexole (Mirapex®) and rotigotine (Neupro®) help regulate dopamine and reduce leg discomfort.

Iron Therapy (Oral or IV): If tests show iron deficiency or low-normal ferritin levels, iron supplements may help. When iron levels remain low despite oral therapy, IV iron infusions may be considered.

RLS Medications and Pregnancy

Although RLS can often worsen — or appear for the first time — during pregnancy, doctors usually don't recommend taking drugs for RLS while pregnant, although sometimes supplemental iron may be helpful if bloodwork is suggestive. If the symptoms of restless legs syndrome are being caused by another disease, such as peripheral neuropathy or diabetes, treating the underlying disease may reduce the symptoms. Similarly, because low blood levels of iron can also cause these disorders, treating anemia or low iron levels may relieve the symptoms.

Lifestyle Management

The first step in managing restless legs syndrome is to improve sleep habits — what specialists usually call sleep hygiene. Sleep hygiene related to RLS may include the following: 

• Diet: Caffeine, nicotine and alcohol can all make RLS worse and should be avoided or limited, including caffeine-containing foods such as chocolate.
• Exercise: Moderate exercise may help relieve the symptoms. However, heavy exercise can make the symptoms worse. Massaging the legs may help the feeling go away.
• Environment: The bedroom environment may be overlooked as a cause of sleep disturbance. Although many people feel they fall asleep quickly while watching television, the bright lights may disrupt sleep. Other sources of light such as hallway fixtures or street lamps may have a similar effect. The level of acceptable bedroom light is different for each individual. While many people prefer the bedroom to be kept very dark, others, especially those fearful of the dark, may find comfort in a dim light. The bedroom should be kept quiet. If bright light or noise cannot be avoided, earplugs and eye masks may be helpful. The temperature in the bedroom should be comfortable.
• Communication: Explaining RLS to your family and coworkers may help them understand why you feel the need to pace or stand.
• Movement: An essential part of restless legs syndrome is the urge to move the limbs. Fighting this urge only makes it worse; when you want to move, move. If standing is more comfortable during the day, a higher desk can be used to allow you to stand while working. Some desks can be adjusted to different heights.
• Sleep Schedule: Maintain a regular bedtime and waking time. This includes weekends and vacations. Avoid taking naps during the day. Napping in the late afternoon or early evening can disturb nighttime sleep.
• Relaxation: Stress may make restless legs syndrome worse; techniques such as deep breathing or progressive muscle relaxation, in which each muscle group is tensed and relaxed in turn, may improve symptoms. "Clock watchers" who become alarmed as the seconds and minutes tick away while they remain awake should remove the clock from the bedroom.
• Temperature: Taking a hot bath or putting a heating pad on the uncomfortable limbs may help with RLS.

Clinical Trials

Clinical trials help determine new treatment options for diseases and conditions. Patients with RLS have access to clinical trials and should speak with their physician to determine what trials might work best for them.

See a Specialist

It’s important to be evaluated by a sleep specialist if you or a loved one: 

• Has symptoms of RLS
• Would like to improve your current treatment of RLS

At National Jewish Health in Denver, Colorado, we help hundreds of patients every year with sleep issues. Learn more about our Sleep Center, or use the button below to make an appointment.