Alaska Institute of Oriental Medicine, Acupuncture & Massage Therapy

Restless Legs Syndrome (RLS)

                                          By: Jessica McInnis

Restless legs syndrome (RLS), also called Willis-Ekbom Disease, causes unpleasant or uncomfortable sensations in the legs and an irresistible urge to move them.  Symptoms commonly occur in the late afternoon or evening hours, and are often most severe at night when a person is resting.  They also occur when someone is inactive and sitting for extended periods. Moving the legs or walking typically relieves the discomfort but the sensations often recur once the movement stops.  RLS is classified as a sleep disorder since the symptoms are triggered by resting and attempting to sleep, and as a movement disorder, since people are forced to move their legs in order to relieve symptoms. It's best characterized as a neurological sensory disorder with symptoms that are produced from within the brain itself.

RLS occurs in both men and women, although women are more likely to have it than men. It may begin at any age; however, many individuals who are severely affected are middle-aged or older, and the symptoms typically become more frequent and last longer with age.  People with RLS feel the irresistible urge to move, which is accompanied by uncomfortable sensations in their lower limbs. The sensations in their legs are often difficult to define but may be described as aching throbbing, pulling, itching, crawling, or creeping.  The sensations can occur on just one side of the body, but they most commonly affect both sides.  They can also alternate between sides.  The sensations range in severity from uncomfortable to irritating to painful. Because moving the legs relieves the discomfort, people with RLS often keep their legs in motion to minimize or prevent the sensations. They may pace the floor, constantly move their legs while sitting, and toss and turn in bed.  RLS symptoms may vary from day to day, in severity and frequency, and from person to person.  In moderately severe cases, symptoms occur only once or twice a week but often result in significant delay of sleep onset, with some disruption of daytime function.  In severe cases, the symptoms occur more than twice a week and result in burdensome interruption of sleep and impairment of daytime function. People with RLS can sometimes experience remissions-spontaneous improvement over a period of weeks or months before symptoms reappear-usually during the early stages of the disorder. In general, symptoms become more severe over time.  

The cause of RLS is unknown (called primary RLS).  It does have a genetic component, however, and can be found in families where the onset of symptoms is before age 40. Evidence indicates that low levels of iron in the brain also may be responsible for RLS. Numerous studies suggests that RLS is related to a dysfunction in one of the sections of the brain that control movement (called the basal ganglia) that use the brain chemical dopamine.  Other factors or underlying conditions include certain medications, neuropathy, pregnancy (especially in the last trimester), use of alcohol, nicotine and caffeine, end-stage renal disease and hemodialysis, and iron deficiency. 

RLS is generally a lifelong condition for which there is no cure. However, current therapies can control the disorder, minimize symptoms, and increase periods of restful sleep.  In western medicine, RLS can be treated, with care directed toward relieving symptoms.  Moving the affected limb(s) may provide temporary relief.  Sometimes RLS symptoms can be controlled by finding and treating an associated medical condition, such as peripheral neuropathy, diabetes, or iron deficiency anemia. Iron supplementation or medications are usually helpful but no single medication effectively manages RLS for all individuals. Trail of different drugs may be necessary.  Treatment options for RLS include:

1. Lifestyle changes and activities may provide some relief in persons with mild to moderate symptoms of RLS. These steps include avoiding or decreasing the use of alcohol and tobacco, changing or maintaining a regular sleep pattern, a program of moderate exercise and massaging the legs, taking a warm bath, or using a heating pad or ice pack. Use of medical devices such as a foot wrap that puts pressure underneath the foot and another that is a pad that delivers vibration to the back of the legs.  Aerobic and leg-stretching exercises of moderate intensity also may provide some relief from mild symptoms.
2. A trail of iron supplements is recommended as the first treatment for individuals with low or low-normal blood tests called ferritin and transferrin saturation. 
3. Anti-seizure drugs, specifically gabapentin enacarbil, is becoming the first-line prescription drug for those with moderate to severe RLS. This drug can decrease such sensory disturbances as creeping and crawling as well as nerve pain.  Other dopamine-related medications are effective in managing RLS symptoms also, however, long-term use can lead to worsening of the symptoms in many individuals. 
4. Opioids are sometimes prescribed to treat individuals with more severe symptoms of RLS who did not respond well to other medications. 
5. Benzodiazepines can help individuals obtain a more restful sleep. These are the last-line drugs due to their side effects. 

In Traditional Chinese Medicine (TCM), RLS is usually diagnosed as a Qi depletion or internal wind resulting from both internal weakness, and excess pathogenic disturbances.   The internal weakness includes dysfunction of the liver and kidney, and insufficiency of blood and Qi. The excess pathogens can be wind, coldness, dampness, and blood stasis. Depending on the accompanying signs and symptoms, one might be diagnosed as not having enough Qi to hold the legs still (Qi depletion) or lack of yin or blood (internal wind). In both diagnosis, the underlying imbalance comes from some kind of depletion, so the strategy would be to build the body back up. Since RLS symptoms can vary from person to person, treatment based on disharmony patterns can be an effective option for the individuals. This is likely to include acupuncture, moxibustion, the use of an herbal formula, and food therapy, as rebuilding usually takes a many-faceted approach. 

Massage is highly beneficial for people with RLS.  Very little research has been conducted in an effort to understand how or why massage for RLS is effective, but most experts strongly recommend considering massage both for relieving and preventing RLS. Still, research is in agreement that both tactile and temperature stimulation appear to relieve the symptoms, and in some cases may prevent them from disrupting sleep.  This is one of the proposed uses of massage - as a way of stimulating the legs in order to reduce RLS. 

References

1. http://acupunctureinthepark.com/health-conditions/how-to-calm-restless-leg-syndrome/
2. http://www.shen-nong.com/eng/exam/restless_leg_syndrome_treating.html
3. http://www.progressivehealth.com/rls-massage.htm
4. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Restless-Legs-Syndrome-Fact-Sheet