|Conquering Restless Legs:
Victory over Defeat
Gary E Cordingley, MD, PhD
RLS and PLMS might look like alphabet soup, but to millions of people with restless
legs syndrome and periodic leg movements of sleep, they spell misery.
Do your legs have the heebie-jeebies and creepy-crawlies, especially at night? Do you just have to move
them? Do these symptoms play heck with your sleep? Then you just might have restless legs syndrome
(RLS), a condition for which treatment is available.
While I was still in training to become a neurologist, I got excited when I made a diagnosis of Ekbom's
syndrome, as RLS was then known. In those days, the condition seemed rare and exotic, something a doctor
almost never encountered.
Nowadays, in my community practice of neurology, I see cases of RLS almost every day. So where were all
these people 25 years ago? Unless the disease has suddenly started propagating like mad, one has to
conclude that previously the patients weren't talking, the doctors weren't listening--or both.
Estimates of the prevalence of this condition vary widely, but in a large study conducted in five European
countries, 5.5% of the population over the age of 14 had this condition. RLS occurs in both genders, but is
slightly more frequent in women. RLS occurs at any age—including in childhood—but becomes more common
with advancing years.
Although there is now much more awareness of restless legs syndrome among doctors and patients alike, it is
still often underdiagnosed or misdiagnosed. For example, a child's symptoms might get misdiagnosed as due
to growing pains or attention deficit disorder, and an adult's symptoms might get interpreted as due to nerve
damage or poor circulation.
What are the usual symptoms? In 1995 an international conference of experts agreed upon the following four
#1. There is a desire to move the legs in association with unusual or uncomfortable sensations deep within the
#2. There are overt restless movements in a response to or in an effort to relieve the unusual sensations or
#3. Symptoms are worse or exclusively present at rest (inactivity or relaxation) and might be temporarily
improved by voluntary movements of the affected limbs; and
#4. Symptoms occur most frequently during the evening or early part of the night.
In addition, most people who have restless legs syndrome also have "periodic leg movements of sleep" or
PLMS, previously abbreviated as PMS, but this was, uh, confusing. PLMS refers to abrupt, brief leg
movements, generally affecting both legs, and which occur repeatedly during the first several hours of sleep.
The person with PLMS might know only that their bedclothes are a mess the next morning. However, the
spouse or other sleeping partner might experience disruption of their own sleep by the movements. Sometimes
they relocate to another bed because of them.
The usual course of RLS is that the condition is present for life, and can worsen over time. RLS and PLMS are
among those conditions described as due to a "chemical imbalance" in the brain. The abnormality does not
show up on MRI scans, CT scans, electroencephalograms (EEGs), spinal taps or blood tests.
Although no cure yet exists, treatment can reduce symptoms and improve function. While medications are the
mainstay of treatment, many patients find that physical maneuvers improve their symptoms, like rubbing their
legs or periodically getting up and walking around.
Choice of medication depends on what else is going on with the patient. In some cases the RLS is due to
another condition in need of its own treatment, like iron deficiency, anemia, diabetes, nerve damage or
advanced kidney disease. Pregnancy can also induce RLS, though in this situation the symptoms usually
resolve after the woman delivers.
The most common form of RLS occurs without evidence of a second, underlying condition, except for a
possible genetic link to relatives with RLS. In these patients drugs that boost dopamine--one of the brain's
chemical transmitters--are the first choice. These are the same drugs used in Parkinson's disease, another
condition in which dopamine is in short supply. However, for the most part, the two diseases are otherwise
Dopamine-blocking drugs--comprising most of the anti-nausea and anti-psychotic medications-- can have the
unintended consequence of worsening symptoms. For example, in the author's practice, a young woman with
RLS went to an emergency room because of a migraine attack. She received an intravenous dose of the
dopamine-blocker promethazine (brand name Phenergan) and this made her legs acutely restless and
uncomfortable. In another case, an elderly woman with memory loss and agitation received risperidone
(Risperdal) and this caused RLS symptoms that had not been present previously.
Certain drugs that also serve as anticonvulsants, like gabapentin (Neurontin) and clonazepam (Klonopin), can
help. Painkillers also work, and probably do so by interacting with a specific set of painkiller receptors in the
brain, rather than by just dulling symptoms. However, because treatment is generally needed over a long
period of time, painkillers are not the usual treatments of first choice.
This essay only brushes the surface of this fascinating condition. To learn more, visit the website of the aptly
named We Move organization.
(C) 2005 by Gary Cordingley