Restless

By Peter Galvin, MD

Restless legs syndrome (RLS) is a neurological disorder that causes an overwhelming urge to move the limbs, especially the legs, and can adversely affect sleep and quality of life. The urge to move the legs is often accompanied by uncomfortable feelings in them such as achiness or tingling during the evening or night. Symptoms usually develop or worsen during periods of rest (lying down or sitting) and are temporarily relieved by movement. Patients with RLS may have difficulty falling asleep, staying asleep, and/or returning to sleep.

About 8% of US adults experience symptoms of RLS each year, and 3% have moderately or severely distressing symptoms at least twice a week. RLS affects 10% of people aged 65 years or older and is about twice as common in women than men. Conditions associated with RLS include multiple sclerosis (27.5% of patients), end-stage kidney disease (24%), iron deficiency anemia (24%), peripheral nerve damage (21.5%), Parkinson disease (20%), and pregnancy, especially during the third trimester (22%). Other risk factors include a family history of RLS and northern European ancestry.

Patients are diagnosed with RLS based on their symptoms; a sleep study is not recommended for diagnosis of this disorder. There are medications that can trigger or worsen RLS including antihistamines, serotonergic antidepressants (SSRIs, e.g. Zoloft), and dopamine antagonists (antipsychotic drugs, some anti-nausea medications, and melatonin). IF RLS develops, these drugs should be stopped if possible. All patients should undergo testing for iron-deficiency anemia, and those who test positive should be treated with iron supplements (ferrous sulfate or gluconate by mouth or intravenous iron).

Those with infrequent RLS symptoms can be treated on an as-needed basis with dopamine agonists (i.e. levodopa, used to treat Parkinson disease). For those with frequent and bothersome symptoms, first-line treatment is gabapentinoid medications (gabapentin and pregabalin), which improve symptoms in about 70% of patients. If symptoms continue despite first-line treatment, patients may be given another gabapentinoid medications, low-dose opioids (such as oxycodone or methadone), or dopamine agonists (such as pramipexole or ropinirole). However, treatment with dopamine agonists requires close monitoring because these drugs can also worsen symptoms.

For patients whose symptoms persist despite pharmacologic treatment, a peroneal nerve stimulator may provide some benefit. This is a device that is worn on the lower leg for 30 to 60 minutes a day, typically in the evening. It provides electrical impulses to the peroneal nerve in the lower leg and can relieve symptoms by mimicking voluntary movement.

For more information go to the website of the National Institute of Neurological Diseases and Stroke at www.ninds.nih.gov

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