Sunday, January 7, 2007

Conquering Restless Legs: Victory over Defeat

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 features:

1. There is a desire to move the legs in association with unusual or uncomfortable sensations deep within the legs.
2. There are overt restless movements in a response to or in an effort to relieve the unusual sensations or discomfort.
3. Symptoms are worse or exclusively present at rest (inactivity or relaxation) and might be temporarily improved by voluntary movements of the affected limbs.
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 unrelated.

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 just dulling symptoms. However, because treatment is generally needed over a long period of time, painkillers are not the usual treatments of first choice.

1 comments:

Kathy Joyce said...

Restless legs can be made worse by drinking caffeine, alcohol or smoking. Try cutting back on these, especially in the evening and if possible stop smoking altogether.