Restless Legs Syndrome (RLS)

Topic Overview

What is restless legs syndrome?

Restless legs syndrome (RLS) is a disorder related to sensation and movement. People with restless legs syndrome have an unpleasant feeling or sensation in their legs when they lie down to sleep. Most people also have a very strong urge to move their legs, and moving the legs sometimes makes them feel better. But all this movement makes it hard or impossible to get enough sleep.

When you don't get enough sleep, you may start to have problems getting things done during the day because you're so tired. You may also be sleepy or have trouble concentrating. So it's important to see your doctor and get help to manage your symptoms.

What causes restless legs syndrome?

Usually there isn't a clear reason for restless legs. The problem often runs in families. Sometimes there is a clear cause, like not getting enough iron. If that's the case, treating the cause may solve the problem.

Women sometimes get restless legs while they are pregnant. The problem usually goes away after the baby is born.

Other problems that are sometimes linked to restless legs syndrome include kidney failure, rheumatoid arthritis, diabetes, nerve damage, anemia, and Parkinson's disease. But most people who seek treatment do not have any of these other problems.

What are the symptoms?

Restless legs syndrome makes you feel like you must move your legs. These feelings are often described as tingling, "pins and needles," prickling, pulling, or crawling.

Moving your legs will usually make your legs feel better, at least for a short time. This problem usually happens at night when you are trying to relax or go to sleep.

After you fall asleep, your legs may begin to jerk or move. These movements are called periodic limb movements. They can wake you from sleep, which adds to your being overtired. Although periodic limb movement is considered a separate condition, it often happens to people who have restless legs syndrome.

How is restless legs syndrome diagnosed?

One of the hardest parts of having restless legs syndrome is getting to the diagnosis. Often doctors don't ask about sleep or don't ask about the symptoms of restless legs. If you're not sleeping well, or if you think you may have restless legs syndrome, tell your doctor.

Your doctor will talk with you about your symptoms to make sure that the feelings in your legs you describe are typical of restless legs syndrome and not caused by some other problem.

You may have blood tests to rule out other problems that could be causing your symptoms. In some cases, the doctor may order tests of your nerves to be sure there is no nerve damage. Your doctor may also order a sleep study called a polysomnography. This test records how often your legs jerk or move while you sleep.

How is it treated?

If your symptoms are mild, a few lifestyle changes may be enough to control your symptoms. Some changes that may help:

• Avoid tobacco, alcohol, and caffeine.
• Keep your bedroom cool, quiet, and comfortable, and use it only for sleeping, not for watching TV.
• Get regular exercise.
• Massage the leg or the arm, or use heat or ice packs.

When symptoms are more severe, medicines may help control your leg movements and help you sleep. There are different types of medicine, and you may have to try a few to find the one that works best.

Frequently Asked Questions

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	RLS: Getting more sleep

Symptoms

The main symptom of restless legs syndrome (RLS) is an irresistible urge to move your legs because of uncomfortable and sometimes painful sensations deep within your legs. Some people describe the sensations as aching, creeping, crawling, or prickling. Symptoms usually begin about 15 minutes after you lie down to sleep or to relax, or when you have not moved for long periods, such as when traveling in a car or airplane. Symptoms that occur frequently can result in significant sleep loss, fatigue, and problems with daytime functioning.

After they are asleep, most people with RLS also have involuntary or jerking leg movements called periodic limb movements. These movements can interrupt your sleep, which adds to problems with fatigue. Periodic limb movements may also occur during the day, although most people move around after their legs begin to bother them. As a result, the periodic limb movements that people have when they are awake may not be noticed except under unusual circumstances.

Restless legs syndrome and periodic limb movements also often disturb the sleep of a bed partner. This can cause fatigue for both people and can strain the relationship.

Symptoms may start during infancy or any time during your life. At first, your symptoms may be mild and occur only once in awhile. Typically, symptoms get worse with age. After age 50, many people with this condition have daily symptoms and suffer from significant sleep loss. Severe insomnia, fatigue, anxiety, depression, and lack of social activity can become a problem and cause a decline in quality of life.

Restless legs syndrome may develop or become worse during pregnancy, especially after week 20. Symptoms usually disappear soon after the baby is born, unless the mother had this condition before she became pregnant.

Other conditions-such as leg cramps, certain nerve disorders, or arthritis-can produce symptoms that are similar to those of restless legs syndrome. However, most of those other conditions do not occur primarily at night and when a person is at rest. Leg cramps that are not caused by restless legs syndrome often do occur at night, but they usually involve intense pain in certain muscles, unlike leg cramps caused by restless legs syndrome.

The kind of "nervous leg" seen in some people during the day is not restless legs syndrome, in most cases. People who have "nervous legs" are not moving their legs because they feel the need to. In fact, they are often unaware that they are moving their legs.

Exams and Tests

A doctor diagnoses restless legs syndrome by asking questions about your symptoms. A physical exam may be done to look for other possible problems that could be causing your symptoms.

Restless legs syndrome is diagnosed by your doctor based on the following four criteria:

• You have an urge to move your legs, usually because of uncomfortable sensations such as tingling, "pins and needles," prickling, crawling, or pain. In some cases, you may not feel any unpleasant sensations but still feel the urge to move your legs or your arms.
• The sensations and the urge to move your legs begin or get worse during periods of rest or inactivity, such as when you are sitting or lying down.
• The sensations and the urge to move your legs are partially or totally relieved by movement. But relief may be temporary and only last while you are walking, stretching, or moving your legs.
• The urge to move your legs and the sensations are worse in the evening or at night. But some people may have severe sensations and urges to move their legs throughout the day and night.

Other factors that may support a diagnosis include:

• Having a family history (in a parent or sibling) of restless legs syndrome.
• Having periodic limb movements-involuntary jerking or movement of your legs-while you are awake or asleep.
• Showing improvement when the medicine dopamine is used.

A sleep study called a polysomnography may be done to help your doctor diagnose restless legs syndrome or rule out other sleep disorders. This test records the electrical activity of your brain, eye movements, muscle activity, heart rate, breathing, air flow through your nose and mouth, and blood oxygen levels.

Although this test is not essential, it provides details of limb movement symptoms. These details may help evaluate the severity of your symptoms. The severity ranges from people who have restless legs syndrome occasionally, with only mild difficulty falling asleep, to those who have it frequently, with repeated interruptions of sleep. Serious sleep problems can greatly affect your ability to function during the day.

Common problems with diagnosing restless legs syndrome

Many cases go undiagnosed because:

• Many people do not seek a doctor's help when they have symptoms.
• Most people visit a doctor during the day, when symptoms are not present or are only mild.
• Some doctors do not recognize the condition and may believe that the symptoms are caused by other conditions, such as insomnia, stress, muscle cramps, or arthritis.

Restless legs syndrome does occur in children but it is difficult to diagnose for the same reasons. Children often are not able to describe their symptoms. A parent's observations of the child's behavior and sleep may be helpful. Knowing that a parent or other close relative has restless legs syndrome can also help the doctor make a diagnosis of restless legs syndrome in the child.

Other conditions to consider

Polysomnography and related sleep study tests may also be done to help identify problems that can interfere with sleep. You may be evaluated for other conditions with symptoms similar to restless legs syndrome. These conditions include varicose veins, arthritis, or intermittent claudication (a tight, aching, or squeezing pain in the calf, foot, thigh, or buttock that occurs during exercise).

You also may be asked about behaviors, habits, and physical traits that may be related, such as:

• Smoking.
• Lack of regular, moderate exercise.
• Being overweight and having a high body mass index.

You may also have tests to check for other diseases or health conditions-such as diabetes, peripheral neuropathy, pregnancy, kidney problems, or iron deficiency anemia-that can cause your symptoms. Tests will vary depending on what your doctor identifies as likely problems.

Treatment Overview

Treatment for restless legs syndrome is based on the type of symptoms you have and how bad your symptoms are. Getting regular exercise and enough sleep may relieve mild symptoms. Medicines may be tried when symptoms are severe and interfere with sleep and daily functioning. If your symptoms are being caused by another medical condition (such as iron deficiency anemia), that condition can be treated first.

Initial treatment

Changing your daily routine is sometimes enough to control your symptoms. Stretching, walking, exercising regularly, taking a hot or cold bath, using massage, and avoiding smoking and caffeine may reduce or control your symptoms.

If your symptoms are caused by another medical condition such as diabetes or iron deficiency anemia, you will be treated for that condition first. For example, if iron deficiency is causing restless legs syndrome, you will be prescribed iron supplements.

Restless legs syndrome that starts during pregnancy usually goes away soon after the baby is born, most often within days. Your doctor may recommend conservative treatment, such as regular exercise and stretching, to relieve symptoms. Your condition may be reevaluated if it doesn't go away after you have given birth.

Children with restless legs syndrome are not usually treated with drugs right away. Instead, regular, moderate exercise and regular sleep routines are tried first. If this treatment is not effective, the doctor may prescribe drugs-such as levodopa or dopamine agonists-that help increase a chemical in the brain called dopamine. These medicines can reduce symptoms as well as involuntary leg movements at night. Clonidine, a drug that is usually used to treat high blood pressure, has also been used to treat restless legs syndrome in children.

Ongoing treatment

If your symptoms are mild, you will probably be able to control the uncomfortable sensations and urges to move your legs through regular exercise, stretching, walking, losing weight if you are overweight, and by avoiding smoking and caffeine. Sometimes a hot or cold bath or massage can help. If your doctor determines that your restless legs syndrome is caused by another condition (such as diabetes or iron deficiency anemia), treating that condition will usually resolve your symptoms.

If your symptoms do not improve, drugs may be used to control involuntary leg movements and help you sleep, such as:¹

• Dopamine agonists, such as ropinirole (Requip), pramipexole (Mirapex), or the dopamine precursor, levodopa (Sinemet).
• Anticonvulsants, such as gabapentin (Neurontin).
• Opioids, such as oxycodone (Percocet), hydrocodone (Lortab), and tramadol (Ultram).

In addition, your doctor may prescribe sedative-hypnotics (including benzodiazepines and the newer non-benzodiazepine drugs like zolpidem [Ambien], zaleplon [Sonata], and eszopiclone [Lunesta]), alone or in combination with dopamine agonists, opioids, or anticonvulsants.

Medicines are started at the lowest effective dose. Sometimes doses are split, although both are usually taken in the evening. Sometimes drugs are combined to better control symptoms and manage side effects.

If your doctor recommends medicine, make sure that you discuss expectations and understand the potential benefits and risks of the drug. Let your doctor know about all of the other drugs you are taking. Drugs taken for other conditions sometimes contribute to restless legs syndrome. For example, antidepressants improve restless legs syndrome in some people, but make it worse in others.

Treatment if the condition gets worse

If you continue to have symptoms even though you are receiving treatment with drugs and are exercising regularly, eating right, and not smoking or using caffeine, your symptoms may need to be reevaluated. Many other conditions can cause the sensations found in restless legs syndrome, including several vitamin and mineral deficiencies.

Your doctor may recommend different drugs or a combination of drugs. Follow up with your doctor if your symptoms do not improve.

Home Treatment

There are ways to improve your symptoms of restless legs syndrome at home.

Try:

• Exercise. Regular, moderate exercise may reduce symptoms. Avoiding long periods between activity or sudden bursts of intense activity may also be helpful. Talk to your doctor before starting an exercise program.
• Heat or cold. Your symptoms may be relieved by bathing in very hot or very cold water. Applying a heating pad or ice bag to your legs may also help symptoms.
• Changing your sleep schedule. Fatigue can make your symptoms worse. Because symptoms typically improve around 4 a.m. to 6 a.m., try going to bed later than usual or allowing extra time for sleeping in to help you get the rest you need.

  RLS: Getting more sleep

• Stretching and massage. You may be able to control your symptoms by gently stretching and massaging your legs before bed or as discomfort begins.

Avoid:

• Caffeine and alcohol. These may make your symptoms worse.
• Certain drugs. It may help to avoid antidepressants, antihistamines, cold and sinus medicine, antipsychotic medicine, and certain antinausea drugs (metoclopramide or prochlorperazine). Taking products that contain these ingredients may make your symptoms worse. Your doctor needs to know what medicines you are taking in order to rule them out as a cause of your symptoms.
• Being confined for long periods. Try to plan for situations where you will need to remain seated for long stretches. For example, if you are traveling by car, plan to make occasional stops so you can get out and walk around.
• Excessive exercise. Although moderate exercise may help relieve symptoms, unusually intense workouts may make them worse. Try to identify at what level exercise helps and at what point it triggers restless legs syndrome.

See your doctor if your symptoms do not improve, if they become worse, or if they significantly interfere with your sleep and daily functioning.

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Related Information

• Insomnia
• Leg Problems, Noninjury
• Sleep Problems, Age 12 and Older

References

Citations

1. Earley CJ (2003). Restless legs syndrome. New England Journal of Medicine, 348(21): 2103-2109.

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