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Particularly around bedtime, many people (about 15% of the population) experience "pins and needles feelings," an "internal itch," or a "creeping, crawling sensation" in their legs, with a subsequent irresistible urge to relieve this discomfort by vigorously moving their legs. This movement totally relieves the discomfort. These symptoms are classic for restless leg syndrome.RLS makes if difficult to fall asleep and may also awaken you out of sleep, forcing you to walk around to relieve the discomfort. Though not considered medically serious, symptoms of RLS can range from bothersome to having a severe impact on you and your bed partner's lives.

Effects of RLS

RLS can make it hard to fall asleep and stay asleep. People with RLS often don’t get enough sleep and may feel tired and sleepy during the day. This can make it difficult to:

Concentrate, making it harder to learn and remember things
Work
Carry out other usual daily activities
Take part in family and social activities

Not getting enough sleep can also make you feel depressed or have mood swings.

RLS can range from mild to severe, based on:

How much discomfort you have in your legs and arms
Whether you feel the need to move around
How much relief you get from moving around
How much sleep disturbance you have
How tired or sleepy you are during the day
How often you have symptoms
How severe your symptoms are on most days
How well you carry out daily activities
How angry, depressed, sad, anxious, or irritable you feel

Types of RLS

There are two types of RLS:

Primary RLS is the most common type of RLS. It is also called idiopathic RLS. “Primary” means the cause is not known. Primary RLS, once it starts, usually becomes a lifelong condition. Over time, symptoms tend to get worse and occur more often, especially if they began in childhood or early in adult life. In milder cases, there may be long periods of time with no symptoms, or symptoms may last only for a limited time.
Secondary RLS is RLS that is caused by another disease or condition or, sometimes, from taking certain medicines. Symptoms usually go away when the disease or condition improves, or if the medicine is stopped.

Periodic Limb Movement Disorder

Most people with RLS also have a condition called periodic limb movement disorder (PLMD). PLMD is a condition in which a person’s legs twitch or jerk uncontrollably about every 10 to 60 seconds. This usually happens during sleep. These movements cause repeated awakenings that disturb or reduce sleep. PLMD usually affects the legs but can also affect the arms.

People with RLS feel uncomfortable sensations in their legs, especially when sitting or lying down, accompanied by an irresistible urge to move about. These sensations usually occur deep inside the leg, between the knee and ankle; more rarely, they occur in the feet, thighs, arms, and hands. Although the sensations can occur on just one side of the body, they most often affect both sides.

Because moving the legs (or other affected parts of the body) 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.

Most people find the symptoms to be less noticeable during the day and more pronounced in the evening or at night, especially during the onset of sleep. For many people, the symptoms disappear by early morning, allowing for more refreshing sleep at that time. Other triggering situations are periods of inactivity such as long car trips, sitting in a movie theater, long-distance flights, immobilization in a cast, or relaxation exercises.

The symptoms of RLS vary in severity and duration from person to person. Mild RLS occurs episodically, with only mild disruption of sleep onset, and causes little distress. In moderately severe cases, symptoms occur only once or twice a week but result in significant delay of sleep onset, with some disruption of daytime function. In severe cases of RLS, the symptoms occur more than twice a week and result in burdensome interruption of sleep and impairment of daytime function.

Symptoms may begin at any stage of life, although the disorder is more common with increasing age. Sometimes people will experience spontaneous improvement over a period of weeks or months. Although rare, spontaneous improvement over a period of years also can occur. If these improvements occur, it is usually during the early stages of the disorder. In general, however, symptoms become more severe over time.

People who have both RLS and an associated condition tend to develop more severe symptoms rapidly. In contrast, those whose RLS is not related to any other medical condition and whose onset is at an early age show a very slow progression of the disorder and many years may pass before symptoms occur regularly.

What causes restless legs syndrome?

In most cases, the cause of RLS is unknown (referred to as idiopathic). A family history of the condition is seen in approximately 50 percent of such cases, suggesting a genetic form of the disorder. People with familial RLS tend to be younger when symptoms start and have a slower progression of the condition.

In other cases, RLS appears to be related to the following factors or conditions, although researchers do not yet know if these factors actually cause RLS.

People with low iron levels or anemia may be prone to developing RLS. Once iron levels or anemia is corrected, patients may see a reduction in symptoms.
Chronic diseases such as kidney failure, diabetes, Parkinson's disease, and peripheral neuropathy are associated with RLS. Treating the underlying condition often provides relief from RLS symptoms.
Some pregnant women experience RLS, especially in their last trimester. For most of these women, symptoms usually disappear within 4 weeks after delivery.
Certain medications-such as antinausea drugs (prochlorperazine or metoclopramide), antiseizure drugs (phenytoin or droperidol), antipsychotic drugs (haloperidol or phenothiazine derivatives), and some cold and allergy medications-may aggravate symptoms. Patients can talk with their physicians about the possibility of changing medications.

Researchers also have found that caffeine, alcohol, and tobacco may aggravate or trigger symptoms in patients who are predisposed to develop RLS. Some studies have shown that a reduction or complete elimination of such substances may relieve symptoms, although it remains unclear whether elimination of such substances can prevent RLS symptoms from occurring at all.

How is restless legs syndrome treated?

Although movement brings relief to those with RLS, it is generally only temporary. However, RLS can be controlled by finding any possible underlying disorder. Often, treating the associated medical condition, such as peripheral neuropathy or diabetes, will alleviate many symptoms. For patients with idiopathic RLS, treatment is directed toward relieving symptoms.

For those with mild to moderate symptoms, prevention is key, and many physicians suggest certain lifestyle changes and activities to reduce or eliminate symptoms. Decreased use of caffeine, alcohol, and tobacco may provide some relief. Physicians may suggest that certain individuals take supplements to correct deficiencies in iron, folate, and magnesium. Studies also have shown that maintaining a regular sleep pattern can reduce symptoms. Some individuals, finding that RLS symptoms are minimized in the early morning, change their sleep patterns. Others have found that a program of regular moderate exercise helps them sleep better; on the other hand, excessive exercise has been reported by some patients to aggravate RLS symptoms. Taking a hot bath, massaging the legs, or using a heating pad or ice pack can help relieve symptoms in some patients. Although many patients find some relief with such measures, rarely do these efforts completely eliminate symptoms

Physicians also may suggest a variety of medications to treat RLS. Generally, physicians choose from dopaminergics, benzodiazepines (central nervous system depressants), opioids, and anticonvulsants. Dopaminergic agents, largely used to treat Parkinson's disease, have been shown to reduce RLS symptoms and PLMD and are considered the initial treatment of choice. Good short-term results of treatment with levodopa plus carbidopa have been reported, although most patients eventually will develop augmentation, meaning that symptoms are reduced at night but begin to develop earlier in the day than usual. Dopamine agonists such as pergolide mesylate, pramipexole, and ropinirole hydrochloride may be effective in some patients and are less likely to cause augmentation.

In 2005, ropinirole became the only drug approved by the U.S. Food and Drug Administration specifically for the treatment of moderate to severe RLS. The drug was first approved in 1997 for patients with Parkinson’s disease.

Benzodiazepines (such as clonazepam and diazepam) may be prescribed for patients who have mild or intermittent symptoms. These drugs help patients obtain a more restful sleep but they do not fully alleviate RLS symptoms and can cause daytime sleepiness. Because these depressants also may induce or aggravate sleep apnea in some cases, they should not be used in people with this condition.

For more severe symptoms, opioids such as codeine, propoxyphene, or oxycodone may be prescribed for their ability to induce relaxation and diminish pain. Side effects include dizziness, nausea, vomiting, and the risk of addiction.

Anticonvulsants such as carbamazepine and gabapentin are also useful for some patients, as they decrease the sensory disturbances (creeping and crawling sensations). Dizziness, fatigue, and sleepiness are among the possible side effects.

Unfortunately, no one drug is effective for everyone with RLS. What may be helpful to one individual may actually worsen symptoms for another. In addition, medications taken regularly may lose their effect, making it necessary to change medications periodically.

What is the prognosis of people with restless legs?

RLS is generally a lifelong condition for which there is no cure. Symptoms may gradually worsen with age, though more slowly for those with the idiopathic form of RLS than for patients who also suffer from an associated medical condition. Nevertheless, current therapies can control the disorder, minimizing symptoms and increasing periods of restful sleep. In addition, some patients have remissions, periods in which symptoms decrease or disappear for days, weeks, or months, although symptoms usually eventually reappear. A diagnosis of RLS does not indicate the onset of another neurological disease.

Outlook

RLS can be unpleasant and uncomfortable. However, there are some simple self-care approaches and lifestyle changes that can help in mild cases. RLS symptoms often improve with medical treatment. Research is ongoing to better understand the causes of RLS and to develop better treatments.