“I just feel restless” she said.
“Is there anything you do to lessen that feeling or help it go away?” I asked.
“Yes, I move and stretch my legs but it’s temporary” she replied.
Feeling restless at night can be attributed to a number of things. Many people complain of ruminating thoughts and a restless mind. But the body can feel restless too.
Several patients have reported when relaying complaints of evening extremity discomfort with the urge to move, their providers have not been much help. So I dove into the research on Restless Leg Syndrome, to find out more and if there is a role for physical therapists or other movement practitioners.
Restless Leg Syndrome, also known as Willis-Ekbom disease is a sensorimotor disorder also classified as a sleep-related movement disorder.
Hallmark symptoms are described as uncomfortable sensations in the limbs that occur at rest. These sensations create an irresistible urge to move the body in order to find relief. Patients describe these feelings in a number of ways including: tingling, tightness, pain, discomfort and restlessness. They typically occur bilaterally and are much more common in the legs, hence the name.
The circadian pattern to RLS is not well understood but patients consistently complain of symptoms that occur at night with resolution in the morning. Secondary to this temporal feature, sleep initiation is the most common sequela. Depending on the severity of sleep loss, daytime sleepiness, reduced daytime function and psychological effects like depression are also frequently noted.
Periodic Limb Movement Syndrome (PMLS) is considered an associated feature that occurs with up to 90% of individuals with RLS. The involuntary movements experienced with PMLS are differerent than the voluntary movements a patient initiates to relieve their RLS symptoms. PLMS can occur while individuals are awake and asleep and are diagnosed with polysomnography (a sleep study).
The pathogenesis of RLS is not clear but there are several associated contributors and systems.
The two main proposed mechanisms for the pathophysiology of RLS are iron deficiency and altered dopamine metabolism. For more on the details of these proposed mechanisms read this article (3).
Not surprising, conditions that affect iron status such as pregnancy and renal failure are common comorbid conditions. Other
Genetics appear to play a role with 63% of patients report having at least one first degree relative with RLS.
Epidemiological studies show us that RLS has higher prevalence in some populations but it occurs across the board with age, gender, regions and alongside certain comorbidities.
General population prevelance is 3.9 – 15% of the population
Age: RLS can occur at any age but the prevelance tends to increase with age. That being said one study cites 38-45% of adults recalling symptom onset before the age of 20.
Gender: Women are twice as likely to have RLS as adults but there is no difference in gender prevalence in pediatric RLS.
Regions: RLS is more common in Western countries (10-15%) but has also been documented in 1.4 - 7.5% of Asian country populations and 2.9% of Indian.
Comorbidities: Common comorbidities include iron deficiency, obesity, type 2 diabetes, cardiovascular disease, end-stage renal disease, ADHD and depression.
RLS patients are classified in a few ways including early vs. late onset, chronic persistent vs. intermittent and primary vs. secondary RLS
Age of onset:
Early onset occurs before 45 years old and late onset after 45 years old
Chronic persistent RLS: Untreated symptoms occur at least twice/week on average for the past year.
Intermittent RLS: Untreated symptoms occur less than least twice/week on average for the past year.
Primary RLS is also known as idiopathic where the exact cause is not known. A high percentage of individuals in this group have a familial link to the disorder indicating that genetics may play a role.
Secondary onset refers to onset of RLS that is associated with other comorbid conditions such as pregnancy, iron deficiency, various neurological disorders and renal failure.
There is no biomarker for Restless Leg Syndrome. Rather the hallmark of RLS is the urge to move the affected limbs in an attempt to relieve the symptoms one experiences at rest.
RLS is diagnosed by individuals meeting the following criteria:
Essential 5 Diagnostic Criteria
1. An urge to move the legs usually but not always accompanied by, or felt to be caused by, uncomfortable and unpleasant sensations in the legs
2. The urge to move the legs and any accompanying sensations begin or worsen during periods of rest or inactivity such as lying down or sitting.
3. The urge to move the legs and any accompanying sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.
4. The urge to move the legs and any accompanying sensations during rest or inactivity only occur or are worse in the evening or night than during the day.
5. The occurrence of the above features is not solely accounted for as symptoms primary to another medical or a behavioral condition. (eg., myalgia, venous stasis, leg edema, arthritis, leg cramps, positional discomfort and habitual foot tapping)
Children tend to describe symptoms as pain more then adults which has probably lead to the misdiagnosis of “growing pains.” To help avoid this communication with kids needs adjusting.
It is recommended that when speaking with kids who might have RLS one use alternative questions like “Do your legs bother you at night?’ Children unlikely have “urge” in their vocabularly sp phrases like “need to move, want to move and gotta kick” are best.
In addition to the Diagnostic Criteria listed above the International Restless Leg Syndrome Severity Scale is the most common measure used clinically and in research to quantify symptoms with RLS.
Address other comorbidities
Patients should seek medical care from a provider who is able to screen for and treat the comorbid conditions as listed above like iron deficiency, type 2 diabetes, cardiovascular disease, renal function, etc with referrals to further specialists as needed.
Address other potential sleep issues
Before jumping into pharmacological treatment it important to address sleep hygiene as well as other potential sleep disorders like Obstructive Sleep Apnea as they can exist concomitantly.
Pharmacological interventions are the most common interventions for individuals seeking medical care for RLS. These include anticonvulsants, dopaminergic agents and benzodiazepines. Not only do many of these drugs have side effects they can also lead to augmentation.
Augmentation is a phenomena frequently seen in individuals taking medication for RLS. “Augmentation refers to a worsening of the symptoms that occurs very commonly among RLS patients after long-term treatment with certain medications.” (2)
Since there isn’t a known cure for individuals with RLS it is suggested that best care is seeking a combination of strategies to alleviate symptoms. Research shows there are several non-pharmacological interventions that are effective in this realm
RLS is underdiagnosed and while there is a lot we don’t know about this disorder health and fitness professional can assist individuals with RLS via education on lifestyle changes, suggesting potential treatments and ways to navigate the healthcare system.
At the bottom of this post I’ve provided a list of resources and references. Scroll down, educate yourself and share!
Several studies support the benefits of exercise in helping decrease the symptoms associated with RLS. The majority focus on aerobic training but there are also studies suggesting a combined aerobic and resistance training program also has merit. There are no clear cut recommendations as of yet for dosing or timing.
In addition to helping decrease the intensity of RLS symptoms, exercise is recommended for its positive impact on the risk for comorbid conditions like obesity, type 2 diabetes etc.
Pneumatic compression is a modality that has been shown to help individuals with RLS in limited studies. The hypothesis is that these devices can cause venous compression resulting in stimulation of endothelial mediators (like nitric oxide) as a result of vascular compression and that these mediators help reduce the symptoms of RLS.
NIR (Near infrared) Light Therapy, Massage and Accupuncture- These are all potential interventions for helping decrease the severity of symptoms with RLS but have not been thoroughly studied so their effectiveness is inconclusive.
While up to 15% of the population suffers from RLS, studies have shown that only a small minority seek medical care for their symptoms.
What’s the deal when a relatively common health condition is consistently underdiagnosed and left untreated?
-> An information gap <-
Movement practitioners are often the gate-keepers to health information. We can be part of the solution. The ease of access to a personal trainer or physical therapist who is versed in topics such as sleep and nutrition can help guide individuals with RLS in the right direction. My hope is this post allows you to help someone.
While we don’t have complete information there is reason to feel hopeful about the interventions explored.
To learn more check out the following websites and the articles in my references.
1. Koo BB. Restless leg syndrome across the globe: epidemiology of the restless legs Syndrome/Willis-Ekbom disease. Sleep Med Clin 2015;10:189–205.
2. Guo S. et al. Restless Legs Syndrome: From Pathophysiology to Clinical Diagnosis and Management. Front. Aging Neurosci. June 2017; 9 (177)
3. Didato G, Di Giacomo R, Rosa GJ, Dominese A, de Curtis M, Lanteri P. Restless Legs Syndrome across the Lifespan: Symptoms, Pathophysiology, Management and Daily Life Impact of the Different Patterns of Disease Presentation. Int J Environ Res Public Health. 2020;17(10):3658
4. Mitchell UH. Nondrug-related aspect of treating Ekbom disease, formerly known as restless legs syndrome. Neuropsychiatr Dis Treat. 2011;7:251-257.
5. Franco B, Daubian-Nosé P, De-Mello MT, Esteves AM. Exercise as a favorable non-pharmacologic treatment to Sleep-Related Movement Disorders: a review. Sleep Sci. 2019;12(2):116-121. doi:10.5935/1984-0063.20190064
6. Aukerman, M. M., Aukerman, D., Bayard, M., Tudiver, F., Thorp, L., & Bailey, B. (2006). Exercise and restless legs syndrome: a randomized controlled trial. Journal of the American Board of Family Medicine : JABFM, 19(5), 487–493.
7. Esteves AM, Mello MT, Benedito-Silva AA, Tufik S. Impact of aerobic physical exercise on Restless Legs Syndrome. Sleep Sci.2011;4(2):45-48
8. Lettieri CJ, Eliasson AH. Pneumatic compression devices are an effective therapy for restless legs syndrome: a prospective, randomized, double-blinded, sham-controlled trial. Chest. 2009 Jan;135(1):74-80
9. Xu XM, Liu Y, Jia SY, Dong MX, Cao D, Wei YD. Complementary and alternative therapies for restless legs syndrome: An evidence-based systematic review. Sleep Med Rev. 2018 Apr;38:158-167.
Photo credit: Danny G and Elizabeth Lies on Unsplash