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  Restless Leg Syndrome (RLS) / Periodic Limb Movement Disorder (PLMD)  
 
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Signs, symptoms and indicators | Conditions that suggest it | Contributing risk factors | Other conditions that may be present | It can lead to... | Recommendations

 

Restless leg syndrome (RLS) is a metabolic sleep disorder that causes feelings in the legs that sufferers have described using words such as: tingling, numbness, pins and needles, tiredness, itching, uneasiness, pain, cramping, aching, burning, creeping, crawling, simply indescribable...

These feelings happen during rest or sleep, especially in the lower legs, and create an urge to move the legs about as a way of relieving or completely getting rid of these feelings. If a person with restless leg syndrome tries to hold the legs still and not move them, the feelings only seem to get worse.
Restless leg syndrome does not cause any damage to one's health, but it very often leaves the sufferer feeling drowsy during the daytime from not getting a good night's sleep. People who have severe restless leg syndrome may feel a kind of spastic flexing of their hips, knees and ankles when they lie down, as well as leg pains in the morning after they get out of bed. While restless leg syndrome can be a problem at any age, it seems to be most serious in people who are middle-aged and older.

The exact cause of restless leg syndrome is unknown. There may be many different causes, including important underlying nutritional issues which will need to be resolved before symptoms improve. RLS tends to run in families. Although most cases of restless leg syndrome happen in healthy people, there is an increased chance of the syndrome occurring in people who have diabetes or chronic alcoholism, or who are pregnant. Cases of restless leg syndrome caused by pregnancy usually clear up after delivery of the baby.

According to a study, about half the cases of restless legs syndrome are caused by defects in a single gene. Researchers at the Max Planck Institute of Psychiatry in Munich, Germany, found that when restless legs syndrome (RLS) appears before the age of 30, it is likely caused by a single, yet-unidentified gene. In cases in which the syndrome appears after the age of 30, a combination of various genes and environmental causes is probably to blame.

The best treatment can often be arrived at only by active experimentation by the patient or in cooperation with a doctor who may wish to perform laboratory testing.

Periodic limb movement disorder (PLMD) and restless leg syndrome (RLS) are distinct disorders, but often occur simultaneously. Both PLMD and RLS are also called (nocturnal) myoclonus, which describes frequent or involuntary muscle spasms. Periodic limb movement was formally described first in the 1950s, and, by the 1970s, it was listed as a potential cause of insomnia. In addition to producing similar symptoms, PLMD and RLS are treated similarly.

Periodic limb movement disorder (PLMD) affects people only during sleep. The condition is characterized by behavior ranging from shallow, continual movement of the ankle or toes, to wild and strenuous kicking and flailing of the legs and arms. Furthermore, abdominal, oral, and nasal movement sometimes accompanies PLMD. Movement of the legs is more typical than movement of the arms in cases of PLMD. Movements typically occur for 0.5 to 10 seconds, in intervals separated by five to 90 seconds.

In 1979, the Association of Sleep Disorder Centers (ASDC) set the parameters for determining the presence of PLMD: A formal diagnosis of nocturnal myoclonus requires three periods during the night, lasting from a few minutes to an hour or more, each containing at least 30 movements followed by partial arousal or awakening. Today, these parameters are a bit more relaxed, and PLMD usually includes any repetitive, involuntary movement during the night.

The incidence of PLMD increases with age. It is estimated to occur in 5% of people age 30 to 50 and in 44% of people over the age of 65. As many as 12.2% of patients suffering from insomnia and 3.5% of patients suffering from excessive daytime sleepiness may experience PLMD.
 

 
 

Signs, symptoms & indicators of Restless Leg Syndrome (RLS) / Periodic Limb Movement Disorder (PLMD):
 
 
Symptoms - SleepCounter-indicators:
  Not having restless legs at night
 
 

Conditions that suggest Restless Leg Syndrome (RLS) / Periodic Limb Movement Disorder (PLMD):
 
 
Metabolic  Insomnia
 These limb movements usually occur in deep stage two sleep, but often cause arousal. Thus, PLMD can cause poor sleep, which may lead to sleep maintenance insomnia and/or excessive daytime sleepiness.
 
 

Risk factors for Restless Leg Syndrome (RLS) / Periodic Limb Movement Disorder (PLMD):
 
 
Circulation  Anemia (Iron deficiency)
 Iron may also represent a primary factor in the development of RLS, as suggested by pathologic and brain imaging studies. However, the method by which dopamine and iron - and probably other compounds - interact to generate the circadian pattern in the occurrence of RLS symptoms remains unknown. Secondary causes of RLS are associated with dopamine receptor blockers, end-stage renal disease, fibromyalgia, iron deficiency, discontinuation of opiates, pregnancy, use of spinal anesthesia, and uremia.

Diet

  Caffeine Intoxication
 Excess caffeine levels cause restlessness. Caffeine has been shown to increase subjects’ proneness to develop RLS at lower levels of blood glucose. It is therefore no surprise that a xanthine-free diet (no coffee, tea, cola beverages, cocoa) has been reported to be another effective dietary measure RLS sometimes following a short period of caffeine withdrawal. [J Clin Psychiatry 39: pp.693-8, 1978; Ann Intern Med 119: pp.799-804, 1993]

Hormones

  Low Serotonin Level
 See the treatment link between RLS and tryptophan/5HPT.

Immunity

  Chronic Fatigue / Fibromyalgia Syndrome
 Secondary causes of RLS are associated with dopamine receptor blockers, end-stage renal disease, fibromyalgia, iron deficiency, discontinuation of opiates, pregnancy, use of spinal anesthesia, and uremia.

Lab Values - Chemistries

  Elevated BUN
 Iron may also represent a primary factor in the development of RLS, as suggested by pathologic and brain imaging studies. However, the method by which dopamine and iron - and probably other compounds - interact to generate the circadian pattern in the occurrence of RLS symptoms remains unknown. Secondary causes of RLS are associated with dopamine receptor blockers, end-stage renal disease, fibromyalgia, iron deficiency, discontinuation of opiates, pregnancy, use of spinal anesthesia, and uremia.

Metabolic

  Hypoglycemia
 Based on afternoon glucose tolerance testing, many patients with RLS - particularly if they also have spontaneous leg cramps - appear to have hyperinsulinism causing functional ‘hypoglycemia’ during testing. In fact, some patients may have an attack of muscle cramps at the same time as their lowest level of plasma glucose. In an open trial, a group of 350 patients with this type of glucose tolerance curve were placed on a sugar-free, high protein diet along with frequent nibbling and at least one night feeding. The vast majority experienced a prompt remission or, at least, a striking reduction in symptoms. [J Med Assoc 60(5): pp.29-31, 1973]

Nutrients

  Iron Requirement
 See the treatment link between RLS and iron.

  Magnesium Requirement
 See the treatment link between RLS and magnesium.

  Folic Acid Requirement
 See the treatment link between RLS and folic acid.

  Vitamin E Requirement

Organ Health

  Kidney Failure
 Secondary causes of RLS are associated with dopamine receptor blockers, end-stage renal disease, fibromyalgia, iron deficiency, discontinuation of opiates, pregnancy, use of spinal anesthesia, and uremia.

Uro-Genital

  Possible Pregnancy-Related Issues
 Secondary causes of RLS are associated with dopamine receptor blockers, end-stage renal disease, fibromyalgia, iron deficiency, discontinuation of opiates, pregnancy, use of spinal anesthesia, and uremia.
 
 

Restless Leg Syndrome (RLS) / Periodic Limb Movement Disorder (PLMD) suggests the following may be present:
 
 
Hormones  Histapenia (Histamine Low)
 
 

Restless Leg Syndrome (RLS) / Periodic Limb Movement Disorder (PLMD) can lead to:
 
 
Risks  Increased Risk of Coronary Disease / Heart Attack
 People with restless legs syndrome (RLS), especially the elderly, may be at an increased risk of developing cardiovascular disease, according to a study published in the April 10, 2007, issue of Neurology®, the scientific journal of the American Academy of Neurology.

For the study, conducted at the University of Montreal's Sacré-Coeur Hospital, ten people with untreated RLS spent the night in a sleep laboratory, where researchers monitored periodic leg movements and blood pressure changes. RLS is a neurological disorder in which people have a strong urge to move their legs. Symptoms such as periodic leg movements are typically most severe at night when the legs are resting and can occur every 20 to 40 seconds, increasing blood pressure.

The study found blood pressure rates during periodic leg movements rose by an average of 20 points for the systolic reading, which is the top or first number, and by an average of 11 points for the diastolic reading, which is the bottom or second number.

"This repetitive rise in blood pressure during periodic leg movements could be harmful to the cardiovascular system, especially in severe cases of RLS, the elderly, and those with a long history of the disease," said the study's lead author Paola Lanfranchi, MD, MSc, with the Université de Montréal in Quebec, Canada. "Past studies have shown that significant blood pressure changes, as shown in our study, are associated with the development of vascular and heart damage. Furthermore, drastic blood pressure surges at night have been associated with a higher rate of stroke in the elderly."

In addition, the study found blood pressure changes increased the most with age and those with a longer history of the disease.
 
 

Recommendations for Restless Leg Syndrome (RLS) / Periodic Limb Movement Disorder (PLMD):
 
 
Amino Acid / Protein  Tryptophan / 5 HTP
 Tryptophan, a serotonin precursor, has been shown to help a small percentage of RLS sufferers. [Am J Psychiatry 143(4): pp.554-5, 1986]

Drug

  Conventional Drugs / Information
 Apart from the use of drugs to treat RLS, components used in the manufacture of drugs or supplements may be causing or aggravating the problem. If you can remember having started taking a new medication or supplement shortly before the onset of symptoms, consider stopping it for a time to see if symptoms improve. You may also wish to consider stopping all 'unnecessary' supplements to see if any of those may be causing the problem.

Gabapentin was effective for restless leg syndrome (RLS), according to the results of a double-blind crossover study published in the Nov. 26, 2002 issue of Neurology. Longer studies will be needed to confirm long-term tolerability of this drug.

"Gabapentin may be a potent agent for treatment of even severe RLS, without the disadvantages of long-term complications of previously favored treatments," study author Diego Garcia-Borreguero, MD, from the Fundacion Jimenez Díaz in Madrid, Spain, says in a news release.

Generally, there are three classes of drugs that are used to treat PLMD and RLS. These are benzodiazepines, Parkinson drugs, and narcotics. Medical treatment of PLMD and RLS often significantly reduces or eliminates the symptoms of these disorders, though not always. There is no cure for PLMD or RLS, and medical treatment must be continued to provide potential relief.

Clonazepam is the most commonly employed benzodiazepine treatment. It is effective in many cases, but not all, and it usually causes drowsiness or sedation. Sometimes, clonazepam allows the patient a better, more restful night's sleep without affecting the occurrence of limb movement. Patients with PLMD may have other sleep disorders, such as obstructive sleep apnea, which the use of clonazepam could worsen.

The drugs used to treat Parkinson's disease are also very effective against PLMD and RLS. These include, L-dopa/carbidopa, bromocriptine (which suppresses the excretion of prolactin), pergolide, and selegiline. If either benzodiazepines or Parkinson's medications do not relieve symptoms, then narcotics, such as codeine, oxycodone, methadone, and propoxyphene are sometimes employed.

In May of 2005, ropinirole HCl (Requip®), which also is used to treat Parkinson's disease, was approved by the Food and Drug Administration (FDA) to treat moderate-to-severe (i.e., 15 or more episodes per month) restless legs syndrome. This medication may result in extreme drowsiness and may cause patients to fall asleep during daily activities (e.g., driving). Other side effects include dizziness, nausea and vomitting, sweating upon standing

Environmental

  Chemical Avoidance
 I know of one husband and wife who had this problem develop and then resolve for both of them at the same time - twice. It was related to a brand of supplements they were using. What it was in particular that caused this was never discovered, but removal of the products by this one company did resolve it completely.

Mineral

  Iron
 RLS has been associated with an iron deficiency as measured by low ferritin levels. The anemia that results from an iron deficiency may or may not have appeared yet; patients whose serum ferritins were lowest initially improved the most.

  Magnesium
 Magnesium deficiency, which is known to increase neuromuscular excitability, can also cause this syndrome. [Rom J Neural Psychiatry 31(1): pp.55-6, 1993]

Vitamins

  Vitamin Folic Acid
 Folic acid at 5-50mg per day (a very large dose) may be helpful when the condition runs in the family; otherwise, it may only help the occasional person. RLS may be an early neurologic manifestation of folate deficiency, the most common of all the vitamin deficiencies. Often the deficiency is not due to a poor diet, but to a genetic factor causing a folate dependency. While not all RLS patients complain of uncomfortable sensations, folate-deficient patients always suffer from them. [Folic Acid in Neurology, Psychiatry and Internal Medicine, New York, Raven Press, 1979]

  Vitamin E
 400 to 800 IU per day of vitamin E has helped in cases of RLS. In one trial involving 9 patients, 7 had complete relief following supplementation, one had almost 75% relief and one had 50% relief. It may take up to three months for the full benefit to become apparent. [Calif Med 111: pp.87-91, 1969]
 
 


KEY
Weak or unproven link
Strong or generally accepted link
Very strongly or absolutely counter-indicative
May do some good
Likely to help







GLOSSARY

Anesthesia:  Loss of sensation caused by neurological dysfunction or a pharmacological depression of nerve function.

Cardiovascular:  Pertaining to the heart and blood vessels.

Chronic:  Usually Chronic illness: Illness extending over a long period of time.

Diabetes Mellitus:  A disease with increased blood glucose levels due to lack or ineffectiveness of insulin. Diabetes is found in two forms; insulin-dependent diabetes (juvenile-onset) and non-insulin-dependent (adult-onset). Symptoms include increased thirst; increased urination; weight loss in spite of increased appetite; fatigue; nausea; vomiting; frequent infections including bladder, vaginal, and skin; blurred vision; impotence in men; bad breath; cessation of menses; diminished skin fullness. Other symptoms include bleeding gums; ear noise/buzzing; diarrhea; depression; confusion.

Diastolic:  Pertaining to the relaxation phase of the heartbeat, or period when the heart muscle is resting and filling with blood. When used in blood pressure readings (for example 120/80), it refers to the second/lower number.

Dopamine:  A neurohormone; precursor to norepinephrine which acts as a stimulant to the nervous system.

Fibromyalgia:  (FMS): Originally named fibrositis, it is a mysteriously debilitating syndrome that attacks women more often than men. It is not physically damaging to the body in any way, but is characterized by the constant presence of widespread pain that often moves about the body. Fibromyalgia can be so severe that it is often incapacitating.

Folic Acid:  A B-complex vitamin that functions along with vitamin B-12 and vitamin C in the utilization of proteins. It has an essential role in the formation of heme (the iron containing protein in hemoglobin necessary for the formation of red blood cells) and DNA. Folic acid is essential during pregnancy to prevent neural tubular defects in the developing fetus.

Glucose:  A sugar that is the simplest form of carbohydrate. It is commonly referred to as blood sugar. The body breaks down carbohydrates in foods into glucose, which serves as the primary fuel for the muscles and the brain.

Hypoglycemia:  A condition characterized by an abnormally low blood glucose level. Severe hypoglycemia is rare and dangerous. It can be caused by medications such as insulin (diabetics are prone to hypoglycemia), severe physical exhaustion, and some illnesses.

Iron:  An essential mineral. Prevents anemia: as a constituent of hemoglobin, transports oxygen throughout the body. Virtually all of the oxygen used by cells in the life process are brought to the cells by the hemoglobin of red blood cells. Iron is a small but most vital, component of the hemoglobin in 20,000 billion red blood cells, of which 115 million are formed every minute. Heme iron (from meat) is absorbed 10 times more readily than the ferrous or ferric form.

Magnesium:  An essential mineral. The chief function of magnesium is to activate certain enzymes, especially those related to carbohydrate metabolism. Another role is to maintain the electrical potential across nerve and muscle membranes. It is essential for proper heartbeat and nerve transmission. Magnesium controls many cellular functions. It is involved in protein formation, DNA production and function and in the storage and release of energy in ATP. Magnesium is closely related to calcium and phosphorus in body function. The average adult body contains approximately one ounce of magnesium. It is the fifth mineral in abundance within the body--behind calcium, phosphorus, potassium and sodium. Although about 70 percent of the body's magnesium is contained in the teeth and bones, its most important functions are carried out by the remainder which is present in the cells of the soft tissues and in the fluid surrounding those cells.

Metabolism:  The chemical processes of living cells in which energy is produced in order to replace and repair tissues and maintain a healthy body. Responsible for the production of energy, biosynthesis of important substances, and degradation of various compounds.

Protein:  Compounds composed of hydrogen, oxygen, and nitrogen present in the body and in foods that form complex combinations of amino acids. Protein is essential for life and is used for growth and repair. Foods that supply the body with protein include animal products, grains, legumes, and vegetables. Proteins from animal sources contain the essential amino acids. Proteins are changed to amino acids in the body.

Restless Legs Syndrome:  This condition involves "creepy-crawly" sensations, mainly in the legs but occasionally in the arms and trunk. The sensations have the following features: - Occur during periods of inactivity - Become more severe at night - Are tied to an overwhelming urge to move the limb - Are sometimes relieved by movement of the limb - Often cause difficulty staying or falling asleep, leading to fatigue.

Stroke:  A sudden loss of brain function caused by a blockage or rupture of a blood vessel that supplies the brain, characterized by loss of muscular control, complete or partial loss of sensation or consciousness, dizziness, slurred speech, or other symptoms that vary with the extent and severity of the damage to the brain. The most common manifestation is some degree of paralysis, but small strokes may occur without symptoms. Usually caused by arteriosclerosis, it often results in brain damage.

Systolic:  Pertaining to the contraction phase of the heartbeat, or the pressure in the arterial system caused by the heart as blood is being pumped out. When used in blood pressure readings (for example 120/80), it refers to the first/upper number.

Tryptophan:  Essential amino acid. Natural relaxant and sleep aid due to its precursor role in serotonin (a neurotransmitter) synthesis. Along with tyrosine, it is used in the treatment of addictions.

Uremia:  Condition characterized by excessive urea and other nitrogen compounds in the blood due to renal insufficiency.