Restless Legs Syndrome & Periodic Leg Movements

Click on the links to be directed to sections below.
  1. Do you have restless legs syndrome?
  2. What are RLS/PLM?
  3. Can RLS/PLM affect my sleep?
  4. Who gets RLS/PLM?
  5. What tests are needed?
  6. Can RLS/PLM cause sleep apnoea?
  7. Who needs treatment?
    1. Mild or infrequent symptoms
    2. Severe and/or frequent symptoms

Do you have restless legs syndrome?

If you frequently experience the following symptoms, you may have a condition called restless legs syndrome (RLS) with or without accompanying periodic limb movements (PLM) in sleep.
  1. An irresistible urge to move the legs, usually accompanied or caused by unpleasant sensations in the legs such as tingling, crawling, creeping, cramping, burning or even pain.
  2. Beginning or worsening of these symptoms when resting or inactive such as when sitting down to watch television, travelling in a car or aeroplane, or lying down to sleep at night.
  3. A partial or total relief with movement (such as stretching or getting out of bed to walk), rubbing of legs or having baths.
  4. Worsening of the symptoms in the evening or at night.
  5. Involuntarily kicking or twitching of the legs in sleep.
If you do have RLS, you are not alone as approximately 12 million people in the USA suffer from this condition.

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What are RLS/PLM?

Restless Legs Syndrome affects approximately 5-15% of the population. This chronic movement disorder may begin at any age but the symptoms typically become more pronounced in the above 40 age group. In fact, symptoms tend to become worse and more frequent as the sufferer grows older. More females are affected than males, and females tend to report more symptoms as well. Although the name suggests a leg movement disorder, the restlessness and discomfort may spread to involve the arms in about 20-30% of more severely affected patients. One in five patients may report the abnormal sensations to be painful.

About 80% of patients with RLS also experience PLM in sleep. PLM is a term used to describe a series of complex, involuntary, repetitive and stereotypic upward movements involving upward motion of the big toe, downward and fanning motion of the other toes and accompanied by bending of the ankle, knees and thighs. In the sleep laboratory PLM are measured using electrodes placed on the skin on the front of the legs (anterior tibialis muscles). Leg movements are scored as PLM if occurring in a sequence of four or more movements lasting ½ to 5 seconds each episode and recurring every 20-40 seconds.

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Can RLS/PLM affect my sleep?

Patients with RLS may complain of varying degree of leg discomfort during the daytime. Some patients may even experience problems with memory and concentration. However, many patients are affected most significantly at bedtime as the symptoms are worse with inactivity and at night. Consequently many patients find it difficult to fall asleep. It is not uncommon for them to get up several times to walk about until symptoms are partially relieved.

PLM on the other hand occurs in sleep, and can range in intensity from mild twitches to violent kicks. Although the peak of PLM activity typically occurs in the early part of sleep, leg movements may be present for the entire night in more affected individuals. In the laboratory, PLM are considered severe if occurring 50 times or more per hour, especially if causing frequent brief awakenings (arousals) at least 25 times per hour. Patients are not consciously aware of these awakenings but if they occur very frequently sleep may be severely disrupted resulting in excessive daytime sleepiness. PLM may also result in the bed partner being kicked, sometimes violently, and wearing out of bedsheets on some occasions.

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Who gets RLS/PLM?

No one knows the exact cause of these disorders as yet. However, research has indicated that patients with RLS have problems with a brain chemical called dopamine and a decrease in the level of iron in an area of the brain controlling movements (substantia nigra). Dopamine regulates messages to the brain cells and iron is an important cofactor for the formation of L-dopa, the precursor of dopamine.

RLS may be classified as ‘primary’ when no specific causes are found and ‘secondary’ when certain conditions or medications that may cause or worsen RLS are present.

 

Primary RLS

RLS may run in families. In fact, more than 40% of patients have a family history of the disorder. There is ongoing research looking for genes that may be responsible for RLS.

 

Secondary RLS

Some of the more common factors are:

  • Low body iron stores: most commonly from bleeding or dietary deficiency, and can result in anaemia.
  • End-stage kidney failure: often those on dialysis, partly related to iron deficiency.
  • Pregnancy: particularly in the third trimester, also possibly from iron deficiency; up to 25% of women may develop RLS during pregnancy, most resolve after giving birth but may persist later in life.
  • Nerve damage from diabetes, alcohol, kidney failure or other conditions.
  • Arthritis of the lower back causing ‘pinched’ nerve.
  • Antidepressants such as the ‘selective serotonin reuptake inhibitor (SSRI)’ group and venlafaxine.
  • Anti-nausea medications such as metoclopramide (Maxolon) and prochlorperazine (Stemetil) as they block the action of dopamine in the brain.
In most cases, RLS symptoms may decrease or disappear when the associated factors are treated or removed.

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What tests are needed?

RLS is diagnosed based on the symptoms described above. Your clinical evaluation should be as for any other medical conditions. Your physician will go through your medical history and medication list in detail, examine you physically, and order a blood test. The aim of all this is to:

  • Confirm the diagnosis of RLS.
  • Exclude other disorders that may mimic RLS e.g. anxiety, other neurological disorders.
  • Look for associated factors that may be reversible.
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Can RLS/PLM cause sleep apnoea?

The answer is no, although the two conditions may interact.

  • Obstructive sleep apnoea (OSA) is a condition where patients stop breathing very frequently during sleep, sometimes hundreds of times each night. Patients with OSA may sometimes have leg jerks during the night as a consequence of the upper airway repeatedly closing and opening. These leg jerks will disappear when the patient’s OSA is treated with continuous positive airway pressure (CPAP).
  • Conversely, PLM, particularly if severe, can disrupt sleep and worsen mild OSA. Successful treatment of PLM can result in an improvement in OSA in such a case.
A sleep study can therefore be of value in certain patients, if another cause of sleep disturbance such as OSA is suspected, and needs to be confirmed.

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Who needs treatment?

This depends on the severity and frequency of the symptoms. In all patients, associated factors (see secondary RLS) should be treated or removed where possible as this may decrease or abolish symptoms of RLS.

Mild or infrequent symptoms

Medications are generally not required in mild cases. Simple remedies such as the following may be adequate:
  • Decrease caffeine, avoid alcohol and nicotine.
  • Exercises focusing on stretching or bending, e.g. yoga.
  • Hot or cold packs to affected limbs.
  • Hot or cold baths.
  • Massage or rubbing of limbs.
  • Mental alerting activities e.g. crossword puzzles.
In those with reduced iron stores, iron supplementation may be considered after exclusion of potential causes (e.g. bleeding, dietary deficiency, kidney failure). Concurrent supplementation with vitamin C to aid iron absorption may be helpful.

Severe and/or frequent symptoms

In addition to the measures for mild symptoms, therapy with medications may be offered to patients with severe and daily symptoms in particular. There are quite a few medications that may be used, and the most common ones are:
Dopaminergic agents: increase the level of dopamine in the brain. These are the medications of choice for treatment of RLS and PLM and are taken an hour or two before bed.

  • Dopamine precursors were the earliest ones used. Examples of these are Sinemet and Madopar. These medications can be quite effective. However, because they are short-acting, a phenomenon called ‘augmentation’ may occur fairly commonly (65-80% of cases). ‘Augmentation’ has occurred if symptoms appear earlier and earlier in the day, and often intensifying in severity. Higher doses of these medications typically worsen rather than resolve ‘augmentation.’
  • Dopamine agonists are newer medications that do not commonly cause ‘augmentation.’ Earlier agents such as cabergoline contain a substance called ergot which may account for some reports of thickening of the heart valves and lining of the lungs. Patients on ergot-containing drugs need to be carefully monitored by their physicians. Newer medications such as ropinirole do not contain ergot and are now preferred. Doses are commenced low and increased gradually to reach a steady level, tailored to the individual patient’s response. Side effects such as nausea and headache are usually mild and transient. Pramipexole is another example of this class of medications and has been shown to be quite effective, but is not yet available in Australia.
Benzodiazepines: have a relaxing effect and slow down the central nervous system. They promote sleep and reduce RLS symptoms. Clonazepam is the most commonly used benzodiazepine for RLS. Its success in treating RLS is limited by its likelihood to cause side effects (next-day drowsiness) and reduced efficacy (tolerance) in long-term use.

Opioids: are pain-killing, relaxing medications. Similar to the benzodiazepines, the potential for abuse is low when used in patients with RLS. Codeine is the most common opioid used for RLS. Aperients may be needed for those that develop constipation with opioids.

Anticonvulsants: may be effective especially in patients who experience painful sensations with RLS. Gabapentin is most commonly used for these patients. Its potential side effects are next-day drowsiness and unsteadiness particularly in higher doses. As gabapentin may cause a rare but potentially serious blood reaction some blood tests are performed in the course of using this drug.

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