Restless Leg Syndrome may indicate other problems

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Do you go to bed at night and experience the sensation that you need to constantly be moving your legs? You could be suffering from Restless Leg Syndrome

Restless Leg Syndrome is a neurological movement disorder. The individual experiences the urge to move their legs, most notable at night, approximately 15-30 minutes after retiring to bed. They experience a crawling, itching, creeping sensation of the lower extremities, usually below the knees and usually bilaterally. The sensations tend to decrease with activity.

What causes RLS?

Some studies indicate there is a problem with the brain in regards to the metabolism of dopamine.

There appears to be a dysfunction of the Hypothalamic dopaminergic cells called Hypocretins. These are a source of spinal cord dopamine. Hypocretins are hypothalamic transmitters that control the sleep-wake cycle, and arousal.

Individuals with RLS have been found to have an increase in Hypocretins in the Cerebral spinal fluid. This would explain why individuals with RLS tend to be in a constant state of movement with their legs. Individuals with Narcolepsy — the sleeping disorder — have been found to have low levels of Hypocretins.

There is evidence to show that there is a problem with metabolism of Iron in the brain of some individuals with RLS. These people appear to have Ferritin Levels below 50 ng/ml.

RLS can be secondary due to pregnancy, Diabetes, venous insufficiency, and Uremia/kidney failure.

Pregnancy reported symptoms may be due to Iron Deficiency, folate deficiency, and/or hormone changes.

Individuals in Dialysis have shown a 6-60 percent reported diagnosis of RLS.

Patients with Venous insufficiency complain of symptoms as well. Studies show that the individuals that receive sclerotherapy experience 98 percent initial relief from RLS and 72 percent continue to be symptom free 2 years. After sclerotherapy.

Certain medication may exacerbate RLS. These include antihistamines, SSRI’s (medication for treatment of mood disorders), certain meds used for vomiting cessation, Lithium, and Tricyclic antidepressants.

Obesity, excess caffeine intake, hypothyroidism, and hypoglycemia have been noted to be a contributing factor as well.

There may be an association with MS as well as Parkinson’s Syndrome.

RLS affects children and adults. Most individuals first experience the symptoms of RLS between the ages of 11-20. However, these symptoms are often “written of” as growing pains or other issues. It is not until the 40’s that a person is often diagnosed with Restless Leg Syndrome.

How is RLS diagnosed?

1. Reported signs and symptoms including the urge to move legs-occurring mostly at night. There is a creeping, crawling, itching sensation in the lower extremities. The symptoms are worse with rest and inactivity and improve with stretching.

2. Individuals may participate in a sleep study where there is noted periodic limb movement.

3. Individuals notice improvement with treatment of Dopamine medication.

4. Blood work may be done to evaluate Serum Ferritin levels and a CBC.

How is RLS treated?

There are several levels in RLS. The diagnosis of Intermittent RLS is identified as irritating symptoms enough to require treatment when present but daily medication is not needed.

This level is treated by :

1. Encouraging activity and stretching on a regular basis

2. Limit the use of Caffeine, alcohol, and tobacco

3. If overweight, lose weight

4. Mental Stimulating activities such as cross word puzzles have been shown to decrease RLS symptoms

5. Look at medication that may be causing or exacerbating the symptoms.

6. Medication: If Ferritin levels are below 50 ng/ml, your provider may consider Iron replacement. One study showed that individuals low levels of Ferritin were treated with Ferrous Sulfate for 2 months and they showed remarkable improvement after that time. Current recommended dose is 325 mg. of Ferrous Sulfate every 8 hours with Vitamin C 100-200 mg also. Your provider will re-check your Ferritin levels after 3-4 months and will continue Iron replacement until Ferritin levels are above 50 ng/ml. Other medication options include:

Carbidopa/levodopa, opioids, or Neurontin. Neurontin appears to be very effective if the individual is experiencing neuropathic pain as well.

Daily RLS: This level is treated with non- pharmacological methods as noted above. The first line medication for daily RLS is a Dopamine Agonist such as Mirapex or Requip. Neurontin or a low potency opioid is another option for this level as well.

Some individuals experience Refractory RLS. This level causes people to experience symptoms earlier in the day and also possibly some extension into the arms and trunk.

While Carbidopa/levodopa is effective in some instances, it has been shown to cause augmentation with patients who require daily medication for treatment of RLS. To treat Refractory Restless Leg Syndrome, Neurontin, an opioid, or benzodiazapam may be added to a dopamine agonist medicine.

This is a disorder where the signs and symptoms can e effectively controlled for the majority of the patients. There may be some “trial and error” to determine which method of treatment is most effective for each patient.

If you have any of these symptoms, seek medical evaluation and treatment so that you can once again experience a quiet and restful sleep.

Tami Griffith, CFNP-BC
Granby Medical Center
Granby, CO

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