Dear Dr. Sangani,

Please find out what you can about restless leg syndrome. I have been plagued with it since taking calcium-enhancing drugs which have been stopped. I keep tossing and turning in the bed due to pain in my legs. Are there any other long-term problems? – Woman with Restless Legs

Dear Restless,

I have been asked this question so many times I would not even be able to give you a count. It is much more common than you think. I’ve asked Dr. Krishna R. Nalluri, a board-certified neurologist, to help answer your questions.

Q: What is restless leg syndrome?
A: Restless leg syndrome is a common, poorly understood disorder characterized by unpleasant sensations of the limbs (deep within the legs and sometimes in the arms) that are precipitated by rest and relieved by activity.

These unpleasant sensations are sometimes described as a creeping, crawling, tingling, burning, aching, painful, pins-and-needles, or an indescribable type of feeling. Symptoms are usually worse in the evening or nighttime, and sleep disturbances are common. It can significantly interfere with both sleep quality, and quantity. Consequently, people can experience daytime drowsiness and fatigue.

Eight percent of people experiencing the restless leg syndrome also have periodic limb movements of sleep which are stereotyped movements of legs or arms occurring in long train every 20 to 40 seconds – which include bending of the big toe or foot and the knee or hip. It affects 2 to 15 percent of the people. Although restless leg is diagnosed most often in people in the middle years, many individuals with restless leg can experience symptoms as early as in their childhood. These may have been called growing pains. Other children may have been thought to be hyperactive, because they had difficulty sitting quietly.

Restless leg syndrome can be considered a primary condition from unknown cause or secondary or due to a known cause (example, due to uremia, polyneuropathy, iron deficiency, pregnancy, diabetes mellitus, rheumatoid arthritis, etc.). During pregnancy, particularly the last few months, up to 15% of the women develop the restless leg syndrome.

After delivery, the symptoms often vanish. The use of some medications seems to worsen the symptoms of restless leg. These drugs include calcium-channel blockers (used to treat high blood pressure and heart conditions), most nausea medications, some cold and allergy medications, major tranquilizers, phenytoin, and most medications that are used to treat depression.

Q: What are the symptoms of this disease and how does it get diagnosed?
A: Adults with restless leg usually complain of bothersome sensations deep in the legs or arms that produce an irresistible urge to move. Symptoms are worse or present exclusively when the individual is at rest, and the sensations are typically lessened by voluntary movements of the affected extremity. The symptoms are also worsen in the evening and at night, especially when the individual lies down. Movements of the toes, feet, or legs known as restlessness are typically seen when the affected individual is sitting or lying down in the evening, and the restlessness may be seen as fidgetiness or nervousness.

Associated features include difficulty falling and staying asleep, being abnormally tired or even experiencing sleepiness during the waking hours, and chronic sleep deprivation with resultant daytime sleepiness. It can affect the ability to work or to participate in social activities, and also can affect interpersonal relationships. With its classical symptoms, restless leg is diagnosed by reviewing the medical history. After ruling out other medical conditions, the health care provider can make the diagnosis of restless leg.

There are no laboratory tests that currently exist to confirm the diagnosis of restless leg. However, a thorough physical examination including necessary lab tests can reveal temporary disorders such as iron deficiency or uremia that may be associated with restless leg. Some people, including those with ‘periodic limb’ movements of sleep, may require overnight sleep studies.

Q:  How is this condition treated?
A: If an underlying iron or vitamin deficiency is found to be the cause of your restless legs, supplementing with iron, vitamin B12 or folate may be sufficient to relieve your symptoms. Current recommendations include checking if serum ferritin level and supplementing with iron if your ferritin level is less than 50 micrograms per liter. A physician can review the patient’s medical history and the medications and modifications can be made if necessary.

A healthy, balanced diet is important in reducing the severity of restless leg. It is better to avoid caffeine-containing products. The consumption of alcohol increases the intensity of symptoms for most individuals, and it may be better to avoid alcohol.

Implementing a program of sleep hygiene is important. Sleep hygiene involves having a cool, quiet, and comfortable sleeping environment, going to bed at the same time every night, arising at the same time every morning, and obtaining a sufficient number of hours of sleep to feel well rested. Typically, sleep experts recommend that exercise should take place at least five to six hours before bed-time. However, some people with restless leg find that using a stationary bike or treadmill before bedtime may be useful for them.

Self-directed activities that counteract the symptoms of restless leg appear to be effective although temporary. These include walking, stretching, taking a hot or cold bath, massaging the affected limb, applying hot or cold packs, using vibration, and practicing relaxation techniques such as biofeedback, meditation, or yoga – which may help reduce or relieve the symptoms.

The use of medications may be necessary. These drugs include dopaminergic agents, sedatives, pain relievers, and anti-convulsants. Although dopaminerigc agents are used to treat Parkinson’s disease, restless leg is not a form of Parkinson’s disease. Each drug or class of drugs has it own benefits, limitations, and side effect profile. The choice of medication is dependent upon the timing and severity of the symptoms and also other associated symptoms. Any of these medications should be started at a low dose and increased very slowly to decrease potential side effects.