A sleep disorder is a physical and psychological condition or disturbance of sleep and wakefulness caused by abnormalities that occur during sleep or by abnormalities of specific sleep mechanisms. Although the sleep disorder exists during sleep, recognizable symptoms manifest themselves during the day. Accurate diagnosis requires a polysomnogram, widely known as a "sleep test."
It is estimated that some 40 million Americans suffer from chronic, long-term sleep disorders. Another 20 to 30 million Americans suffer from some kind of sleep disorder on an irregular basis. The annual costs in productivity, health care, and safety have been estimated in the billions of dollars.
Restless Legs Syndrome (RLS) is a neurological disorder in which patients experience irrepressible sensations in the legs or arms while sitting or lying still. Terms used to describe RLS may include creepy, crawly, pulling, tingling, itching, or gnawing. Often the person with RLS has difficulty being specific about the sensations in their legs. The sensations are rarely described as painful. RLS differs from the "pins and needles" feeling when the blood supply is cut off from a limb ("My foot fell asleep!"). These uncomfortable feelings usually begin in the evening and upon arrival to bed, unless severe, RLS is absent during the morning and early afternoon.
Symptoms are worse or only present when the affected individual is at rest. The sensations usually disappear or diminish when the limb is moved. The person with RLS may experience movements of the toes, feet or legs in the evening when he/she sits or lies down. For this reason, RLS individuals are often labeled "nervous" or "fidgety." Because those with RLS have a constant need to stretch or move their limbs to get rid of the uncomfortable feelings, sleep is often disturbed. Those who suffer from RLS can have very severe insomnia.
Excessive Daytime Sleepiness during the day due to sleep deprivation can be one result of RLS. Severe RLS also limits certain activities because of the confinement of traveling in a car or airplane, sitting through a meeting, or watching a movie. These individuals find it nearly impossible to sit without moving for any length of time. Anxiety and depression are often associated with RLS. Approximately 80 percent of people with RLS also suffer from Periodic Limb Movement Disorder (PLMD).
Five to 15 percent of the population will experience RLS at some time in their life. RLS is more commonly seen in the elderly, and it may be more prevalent in women, although it can occur at any age and in any sex.
It is difficult to determine a general age of symptom onset. Most RLS sufferers are diagnosed between the ages of 30 and 60. Often, a healthcare provider was unable to identify or treat the disorder. However, many people with RLS report having had symptoms most of their lives. Children as young as 3 years old have been diagnosed with RLS. Many adults diagnosed with RLS were called "hyperactive," or "fidgety" as children because of their constant movement and an inability to sit still.
One-third to one-half of RLS cases are considered to be due to heredity. A child, regardless of gender, whose parent suffers from RLS has a significantly increased risk of inheriting RLS. The genetic form of RLS is often more severe and more difficult to treat.
There are some secondary causes of RLS that may intensify the underlying symptoms of RLS. Pregnancy and nutrient deficiency (iron) can cause RLS. Occasionally the ingestion of more caffeine than usual may worsen the symptoms of RLS. Symptoms may decrease or disappear altogether when caffeine is eliminated from the diet. In a study by Goodman et al., nearly 20% of women complain of RLS during a singular pregnancy. In some cases, poor circulation seems to be the cause of RLS, especially when associated with pregnancy. Nutrient deficiencies, such as iron deficiency anemia, have also been linked to Restless Legs Syndrome.
Disorders that seem to have a connection with or provoke RLS include rheumatoid arthritis, anemia, muscle or nerve disorders, kidney diseases, and alcoholism.
If a person has not presented with a family history or secondary factors of RLS, the cause often remains a mystery.
If an individual suspects he or she has RLS, self-help measures may alleviate the tingling sensations. These include avoiding stimulants (coffee, tea, soda, chocolate, certain medications), becoming overly tired, and exposure to very warm or very cold environments before going to bed.
A regular exercise program in the late afternoon, especially involving the legs, has shown to be effective in treating very mild cases of RLS. However, it is interesting to note that symptoms often get worse at the onset of regular exercise, but decrease after a week or two. Extension stretching of the calves, thighs, and hips at bedtime may help relieve symptoms. Home remedies such as a hot bath, leg massage, heating pad and aspirin may also help. Vitamin or mineral supplements can also be investigated, although to make an objective evaluation about whether or not they are effective, keeping a sleep log is recommended.
If self-help remedies prove ineffective, a visit to a healthcare provider is recommended. In addition to a thorough physical examination, appropriate laboratory tests, and a medical history, patients are often diagnosed on the basis of three classic symptoms. These symptoms include an increase in the sensations in one or more limbs when at rest, an irrepressible urge to move or relieve the sensations in the affected limb, and the reduction of the symptoms after movement. The physician will need to verify if the symptoms are genetic or nutrient-related.
As mentioned before, the first step in treating any sleep disorder is to diagnose any underlying causes. Often treatment of these underlying problems can relieve the symptoms of RLS. As in all sleep disorder cases, good sleep habits are important to resolving the problem.
If the underlying cause of restless legs is a nutrient deficiency, a supplement of iron, B12, or folate along with a normal diet can be helpful. Some minerals or vitamins impair the body's ability to use other nutrients or may cause toxicity, so additional supplements should be maintained under the direction of a physician.
It is important to note that some medications worsen the symptoms of RLS. Over-the-counter drugs that appear to contribute to increased leg sensations include many cold, sinus, and allergy medications and most anti-nausea medications. Studies indicate that some prescription drugs including calcium-channel blockers used to treat high blood pressure or heart conditions, tranquilizers such as haloperidol and phenothiazines, phenytoin (an anticonvulsant used to treat seizures), and metoclopramide (Reglan, Octamide, Metoclopramide Intensol) worsen RLS symptoms. The use of antidepressants has also been shown to aggravate restless legs.
For persons with more serious cases of RLS and/or PLMD, consultation with a professional is recommended. In these cases, a doctor may resort to pharmacologic therapy. The U.S. Food and Drug Administration has not approved any drugs for the specific use of treating Restless Legs Syndrome; however, various drugs have been used in preliminary clinical trials. Regardless of efficacy and benefits, medications may have side effects and/or limitations.
Most RLS patients respond well to one of the four following classes of medications:
This class of drugs either raises dopamine, a chemical in the brain that facilitates smooth movement of voluntary muscles, or activates dopamine receptors, called dopamine-receptor agonists (D-RA). Dopaminergic agents are the choice for the treatment of Parkinson's disease, as well as the first-line of treatment for RLS.
A class of central nervous system depressants. These medications do not suppress the movements or sensations; they calm the central nervous system, allowing sleep and relaxation. For that reason, benzodiazepines are often used in combination with a dopaminergic agent.
Benzodiazepines have a history of causing stronger side effects in elderly patients. They have the potential for becoming habit-forming, producing psychological and physiological dependence. For this reason, patients are required to consult with their physician before increasing their dose or discontinuing their medication.
A class of potent, controlled narcotics reserved for severe cases that do not respond to other medications. Narcotics are typically used as painkillers. These drugs are codeine derivatives that include drugs such as Tylenol #3, Percocet (oxycodone), Darvon or Darvocet (propoxyphene), Talwin (pentazocine), Vicodin (hydrocodone), Dolophine (methadone), and others.
Some limitations of opioids include impairment in operating heavy machinery, the need to avoid alcohol, and the possibility of physical or psychological addiction. Dizziness, lightheadedness, nausea or vomiting, drowsiness, and constipation are some adverse reactions that can occur when taking opioids.
A class of drugs that work by suppressing sensory disturbances. In RLS patients, anticonvulsants are sometimes effective in treating the sensations and the urge to move. Neurotonin (gabapentin) has been shown to be the most effective.
Fatigue dizziness, sedation, clumsiness or unsteadiness, blurred or altered vision, nausea, vomiting, and tremors are all possible side effects. Because of this, it is not recommended that people taking anticonvulsants operate machinery, including a motor vehicle, until safety can be assured.
All of the medications mentioned above are available by prescription only and should be used under the supervision and care of a licensed physician.
As with most sleep disorders, finding the best treatment of the symptoms and dosage of the medication will take time. Each individual is different - what is effective for one person may worsen the restless legs for another. A unique combination of medication, lifestyle changes, and exercise is the key to alleviating the sensations of Restless Legs Syndrome.