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Restless Leg Syndrome

 

Restless Leg Syndrome Introduction

Restless Legs Syndrome (RLS) is a relatively common neurological condition in which people suffer from unpleasant sensations in the legs and an overwhelming urge to move them in order to relieve these sensations. [1] This condition is characterized by the involuntary jerking of the legs during times of inactivity and become more intense in the evening and night, especially at the onset of sleep.

Symptoms usually abate by the early morning hours, allowing for more productive sleep patterns. In addition, symptoms may commonly occur during periods of inactivity such as sitting for long periods of time (car trips, plane rides, movie theaters). Because the sensations are relieved by movement of the legs, this needed movement results in a difficulty in falling and staying asleep. Symptoms actually increase during periods of inactivity and when lying down.

Left untreated, a person with Restless Leg Syndrome can become exhausted as a result of interrupted sleep cycles. Oftentimes, people with Restless Leg Syndrome do not seek medical attention because they feel that their doctor will not understand what they are experiencing, that symptoms are too mild, or that the condition is not treatable. To compound this problem, physicians may wrongly ascribe the symptoms of Restless Leg Syndrome to stress, insomnia, anxiety, muscle cramping, arthritis or [Aging|aging]]. Stress, caffeine or fatigue may exacerbate symptoms. [2, 3]

Restless Leg Syndrome Statistics

The unpleasant leg sensations of Restless Leg Syndrome are most often described as a crawling, drawing, pulling, tingling, boring, wormy, prickly, pins and needles sensation, or a sensation of pain. [4] Sensations are usually localized deep within the affected limb, primarily between the knee and ankle. At times, the symptoms may occur in the upper leg, feet, arms, or even hands. Although symptoms usually occur on both sides of the body during an episode, they may only affect one side in certain individuals. With these sensations, people have an overwhelming urge to move the legs in order to diminish these uncomfortable feelings. However, movement only provides temporary respite from the sensations and they usually recur within minutes.

A large majority (80%) of people with Restless Leg Syndrome have what is known as periodic limb movement disorder (PLMD). PLMD is marked by stereotypical, repetitive movements of the limbs (but mainly the legs) occurs during sleep. These movements usually occur roughly at 20 to 40 second intervals, and contribute to fragmented sleep and daytime exhaustion. Periodic limb movement disorder may also be referred to as periodic leg movements (PLMs), periodic movements in sleep (PMS), nocturnal myoclonus, and limb jerks.

The movements of PLMD are different from those of Restless Leg Syndrome. PLMD movements are involuntary unlike those of Restless Leg Syndrome in which the patient moves in order to relieve the sensations. Many people with Restless Leg Syndrome tend to develop PLMD, but most people with PLMD do not have Restless Leg Syndrome. The cause of both conditions is presently unknown.

Symptoms of Restless Leg Syndrome vary widely, and range from mild to severe.

  • Mild Restless Leg Syndrome occurs infrequently with little sleep disruption.
  • Moderate Restless Leg Syndrome may occur once or twice a week but lead to significant sleep disruption and resultant daytime sleepiness.
  • A person with severe Restless Leg Syndrome will experience symptoms more than twice a week with much sleep disruption and impaired daytime function.

Symptoms may improve spontaneously over a period of weeks or months, or sometimes years. If improvements do occur, it happens during the early stages of the condition. Improvement without treatment is fairly uncommon. Left untended, Restless Leg Syndrome seems to worsen with increasing age.

Restless Leg Syndrome Symptoms

  • By most estimates, Restless Leg Syndrome affects roughly 2 to 5 percent of the population; however, it is thought that many more people have Restless Leg Syndrome and have not been diagnosed, suffering from a mild form of the disorder. [5] Other research indicates that as many as 12 million Americans are affected by Restless Leg Syndrome. [6]
  • Lower prevalence rates of Restless Leg Syndrome have been noted in Japan, India, and Singapore, leading researchers to speculate that ethnic or racial factors may play a role in the development of Restless Leg Syndrome.
  • Restless Leg Syndrome is more common (and symptoms are more severe and last longer) in the elderly and is thought to affect 10 to 11 percent of this population.
  • Symptoms of Restless Leg Syndrome can occur at any age. Some may start in infancy while most people with Restless Leg Syndrome are affected in middle age or later.
  • Oftentimes, Restless Leg Syndrome occurs in a familial pattern, meaning that more than one person in a family is usually affected. Restless Leg Syndrome occurs in both males and females, but slightly more women are affected.
  • Investigators believe that one main cause of Restless Leg Syndrome is a type of defective signaling mechanism in the brain involving the neurotransmitter dopamine. Dopamine levels follow a particular pattern during a 24-hour cycle; they are lowest at night when Restless Leg Syndrome symptoms are most prevalent.

Restless Leg Syndrome Treatment

If Restless Leg Syndrome is due to an underlying disorder, finding and treating the cause is the most appropriate goal. Symptomatic treatment consists of using benzodiazepines (e.g. clonazepam) if symptoms are mild; levadopa or opiods (e.g. codeine) if symptoms are more severe, or anticonvulsants (e.g. carbamazepine), which are helpful for some patients. [7, 8] It should be noted that all these medications have side effects and are only palliative at best. In fact, the medical treatment of Restless Leg Syndrome using these medications does not address the underlying cause of the condition, nor do they work to support the body to perform in a more healthful way. Restless Leg Syndrome as a condition does not result from suboptimal levels of the above drugs; it is a condition warranting deeper investigation.

Supplements helpful for Restless Leg Syndrome

Folic Acid

Folate is a term that refers to different forms of folic acid. Some foods, such as dark leafy green vegetables, are a great source of folic acid, while other foods are fortified with folic acid. In order for appropriate absorption, folic acid needs to go through a metabolic process which occurs at a pH of about 6-7. [9] In addition, folate has a very synergistic relationship with vitamin B12, as many metabolic reactions and processes in the body are dependent on these cofactors. For example, proper function of nerves and nerve conduction are directly related to these two nutrients. In fact, a primary sign of B-12 and folate deficiency is impaired sensations in the limbs.

While not exclusively singled out as the cause of Restless Leg Syndrome, inadequate intake of these nutrients may predispose one to this condition. In a study concerning 6 women aged 31- 70 with various neurological disorders including restless leg syndrome, improvement in their symptoms could be attributed to folic acid supplementation. This study suggests restless leg syndrome could be one of the main clinical presentations of a folic acid deficiency. [10] Researching examining folic and iron deficiency in pregnant women also provides evidence that low levels of each of these nutrients may be a contributing factor in Restless Leg Syndrome. [11]

Magnesium

Magnesium, an important and abundant mineral in the body, plays a positive role in Restless Leg Syndrome. Magnesium is shown to contribute to over 300 metabolic reactions in the body, including energy production and protein and carbohydrate metabolism. [12] Magnesium also plays a role in nerve conduction, especially those concerning muscle function. Magnesium acts as a mild muscle relaxant, and may serve to relax the muscles of the limbs, ensuring that proper levels of rest occurs during periods of sleep.

Although both low and high levels of magnesium have been reported in those with RSL, supplementation seems to help with symptoms. A study involving 10 subjects suffering from insomnia due to restless leg syndrome showed an improvement in sleep and Restless Leg Syndrome symptoms after supplementation with magnesium. [13, 14] Magnesium is necessary to maintain the electrical potentials of nerves and muscles, and for the transmission of these impulses across the neuromuscular junction.

Iron

Iron is the most important transitional metal in the body, since it is involved in several metabolic processes, such as DNA synthesis and energy production. This process is related to its ability as an electron donor/acceptor and oxygen transporter. [15] While a deficiency can cause anemia, an excess can cause hemochromatosis and thus tight regulation is important for proper function on many levels. Deficiency can have an effect on the central nervous system and there are implications that low levels of iron can contribute to Restless Leg Syndrome. [16]

Restless Leg Syndrome is children may have a direct connection to iron deficiency. A study completed by the Mayo Clinic involving 538 children with sleep disorders (23 with diagnosed Restless Leg Syndrome), showed a commonality of low blood iron levels. In addition, research done with pregnant women shows that low iron levels may be a contributing factor to the Restless Leg Syndrome that is commonly experienced. [17]

Kava Kava (Piper methysticum)

Kava has been traditionally used as a ceremonial herb as early as the late 1600’s. Today it is known for its uses in anxiety disorders, stress, insomnia, and restlessness, musculoskeletal pain and more. The herb’s pharmacological activity has mainly been attributed to components called kava-lactones.

Due to its sedative effects, it has been shown to improve sleep quality, making it a good option for those that suffer from restless leg syndrome as an obstacle to sleep. Some research suggests that the sedative effects may be due to an increase in GABA binding sites, and that it can produce local muscle paralysis by mechanisms similar to cocaine. [18, 19] Furthermore, the produced muscle sedation does not effect respiration. [20]

References

[1] Collado-Seidel V.; Winkelmann J.; Trenkwalder C. Aetiology and Treatment of Restless Legs Syndrome CNS Drugs, July 1999, vol. 12, no. 1, pp. 9-20(12)

[2] Jermain DM. Sleep Disorders. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy, A Pathophysiologic Approach, 4th ed. Stamford, CT; 1999:1215.

[3] Krueger BR. Restless legs syndrome and periodic movements of sleep. Mayo Clin Proc. 1990;65:999-1006.

[4] Ambrogetti A, Olson LG, Saunders NA. Disorders of movement and behavior during sleep. Med J Aust. 1991;155:336-340.

[5] “Restless Legs Syndrome Fact Sheet”, NINDS. April 2001. National Institute of Neurological Disorders and Stroke, National Institutes of Health. Bethesda, MD 20892 NIH Publication No. 01-4847

[6] Cuellar N. Restless legs syndrome: a case study. J Neurosci Nurs. 2003 Aug;35(4):193-201.

[7] Montplaisir J, Lapierre O, Warnes H, Pelletier G, The treatment of the restless leg syndrome with or without periodic leg movements in sleep. Sleep. 1992 Oct;15(5):391-5.

[8] “Restless Legs Syndrome Fact Sheet”, NINDS. April 2001. National Institute of Neurological Disorders and Stroke, National Institutes of Health. Bethesda, MD 20892 NIH Publication No. 01-4847

[9] Gregory JF 3rd, Case study: folate bioavailability. J Nutr. 2001 Apr;131(4 Suppl):1376S-82S.

[10] Botez MI, Cadotte M, Beaulieu R, Pichette LP, Pison C Neurologic disorders responsive to folic acid therapy. Can Med Assoc J. 1976 Aug 7;115(3):217-23

[11] Lee KA, Zaffke ME, Baratte-Beebe K, Restless legs syndrome and sleep disturbance during pregnancy: the role of folate and iron. J Womens Health Gend Based Med. 2001 May;10(4):335-41.

[12] Murray, Michael T Encyclopedia of Nutritional Supplements, Minerals: Magnesium, Pg 162 ┬ęPrima Publishing 1996

[13] Frankel BL, Patten BM, Gillin JC. Restless legs syndrome. Sleep-electroencephalographic and neurologic findings. JAMA. 1974 Dec 2;230(9):1302-3.

[14] Hornyak M, Voderholzer U, Hohagen F, Berger M, Riemann D. Magnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study.

[15] Murray, Michael T Encyclopedia of Nutritional Supplements, Minerals: Iron, Pg 208 ┬ęPrima Publishing 1996

[16] Krieger J, Schroeder C. Iron, brain and restless legs syndrome. Sleep Med Rev. 2001 Aug;5(4):277-286.

[17] Lee KA, Zaffke ME, Baratte-Beebe K, Restless legs syndrome and sleep disturbance during pregnancy: the role of folate and iron. J Womens Health Gend Based Med. 2001 May;10(4):335-41.

[18] Jussofie A, Schmiz A, Hiemke C. Kavapyrone enriched extract from Piper methysticum as modulator of the GABA binding site in different regions of rat brain. Psychopharmacology 1994;116:469-74.

[19] Singh YN. Effects of kava on neuromuscular transmission and muscle contractility. J Ethnopharmacol 1983;7:267-76.

[20] Lehmann E, Kinzler E, Friedemann J. Efficacy of a special Kava extract (Piper methysticum) in patients with states of anxiety, tension and excitedness of non-mental origin- a double-blind placebo-controlled study of four weeks treatment. Phytomedicine 1996;3:113-9.