Restless legs

The symptoms of restless legs had been noted by Dr Thomas Willis as far back as 1685 Restless legs is also known as Ekbom’s syndrome, because Dr Ekbom, a Swedish neurologist, wrote about it in the 1940s

‘Restless legs’ is a very unpleasant feeling in the legs that is difficult to describe. You feel you must move them to get rid of the sensation. It is not pins-and-needles, but is more like a crawling, prickling and tingling irritation just under the skin (Sleep Medicine2004;4:101–9).

Restless legs usually comes on when you have been sitting or lying still for a while, especially in bed just as you are getting off to sleep or when you wake in the night. It may also come on when you have to sit in a confined space, such as a cinema or plane.

It is very unusual to have it in one leg – usually both legs are affected, mainly the calves, but sometimes the thighs or feet. Some people also have it in their arms.

The only way to get rid of the feeling is to move your legs or get up and walk, which can be awkward if you are sitting at a public function, and annoying for your partner when you are in bed. If you try to keep still, the feeling becomes stronger and stronger, and more like a painful ache until you simply have to move.

Causes of restless legs
No one knows what causes restless legs, but researchers think it is probably due to a lack of availability of dopamine (a chemical transmitter) in a small area of the brain or spinal cord, rather than a problem in the legs themselves.

• In three-quarters of sufferers, the tendency to restless legs is inherited.
• In a few people (usually elderly), it is due to a shortage of iron.
• Some people have restless legs only when they are pregnant or find that pregnancy worsens it.
• Sometimes a similar feeling occurs in people who have illnesses that affect small nerves in the skin (such as diabetes or rheumatoid arthritis).
• Stress, fatigue, smoking, caffeine and alcohol can all make it worse.
• Some medications (for example, antidepressants and calcium channel blocker drugs for blood pressure) can cause or worsen restless legs.

What you can do
Stop smoking. Restless legs is another good reason for stopping smoking.

Consider reducing coffee, tea, alcohol. You may have to do some detective work to decide if these causes apply in your case. The caffeine in coffee and strong tea makes restless legs more likely, as well as interfering with sleep. Try cutting them out and see if the problem improves. Likewise, try to work out if alcohol might be a factor in your case.

Deal with stress. This is easier said than done but, if you have noticed that the problem is worse when you are tense, consult your public library for books or tapes on relaxation.

Do not nap during the day. This can make it more difficult to sleep at night.

Cool your legs. Some people find that cooling the legs helps to prevent attacks, or relieves the sensation. Make sure your bedroom is cool and airy. Try putting your feet in cold water for 5 minutes before going to bed, and avoid using a hot water bottle or electric blanket in the winter. During an attack, remove the bedclothes from your feet and legs to allow them to cool down.

Massaging the legs with a mint or herbal leg cream or gel gives some relief.

Try a painkiller. Some people find that a painkiller such as paracetamol (acetaminophen) or ibuprofen gets rid of the unpleasant feeling.

What your doctor can do

Check your iron stores. Your doctor can do a blood test to check your iron stores. If these are low, an iron supplement might help.

Check the medication you are taking. Your doctor can review any medication that you are taking, as some medications can worsen or cause restless legs.

Look for other causes. Your doctor can also decide whether you have ordinary restless legs, or whether it is due to some condition such as rheumatoid arthritis.

Discuss treatment. Some prescription drugs can help restless legs, but they all have some side effects. You will need to decide whether the discomfort in your legs and disturbance of your sleep is bad enough to warrant them.

If you are pregnant, or trying to become pregnant, you will just have to put up with the problem until after the pregnancy – you should not take any of the drugs used to treat restless legs. The problem will probably disappear within a few weeks after the birth of your baby.

Dopamine drugs are becoming very important treatments for restless legs. They compensate for the lack of availability of dopamine in specific areas of the brain.

• Ropinirole (Ardartrel) is a dopamine drug that seems to be very effective for restless legs with minimal side effects, though headache, nausea and dizziness occasionally occur. It is taken as a single dose in the evening.
• Pramipexole(Mirapexin) is another dopamine drug that is effective for restless legs. Like pergolide, it has been tested on only a small number of people, but seems to be an even more effective drug. It can cause drowsiness in the day and also nausea and insomnia.
• Pergolide is another dopamine drug. Researchers in America tested it in patients with restless legs and found that it was effective in relieving the problem. At present pergolide has been tried in only a small number of people with restless legs. Side effects include nausea, constipation and low blood pressure, so it is started at a low dose. There have been worries that, in rare cases, it could damage the valves of the heart.
• Levodopa with carbidopa (the drugs are combined in one tablet) is a dopamine drug for Parkinson’s disease that has been used for severe cases of restless legs. The major drawback is that the symptoms initially improve, but tend to come back after a few months and are even worse than before. This occurs in about 80% of people. For this reason it is not used much.

Tranquillizers. Clonazepam is a tranquillizer that has been used for many years for restless legs. It can help if the problem is not too severe, but you may find you are drowsy in the day. If you are elderly, it is not a good choice, because you might become confused or have a fall.

Anti-epilepsy drugs, such as carbamazepine or gabapentin, are sometimes used to treat restless legs.

Useful contacts
Restless Legs Syndrome Foundation is a US organization that provides information and support to sufferers. Their informative website tells you everything you could ever want to know about restless legs. Remember that some of the drugs mentioned might not be available in the UK, or might not be appropriate in your case. Write to: 819 Second Street SW, Rochester, MN 55902-2985, USA.
www.rls.org

Ekbom Support Group is a UK not-for-profit organization to help people with restless legs. The newsletter section has tips for members. Write to: 18 Rodbridge Drive, Thorpe Bay, Essex SS1 3DF, UK.
www.ekbom.org.uk

RLS:UK is a group of doctors and other specialists who are interested in RLS. Its website is clear and simple, and contains reliable information. Some of its funding comes from the pharmaceutical company GlaxoSmithKline.
www.restlesslegs.org.uk/

Southern California RLS Support Group has an interesting ‘Patient Letters’ section on its website, in which people explain how they cope with restless legs.
www.rlshelp.org

Bandolier RLS website. Bandolier is an organisation related to Oxford University, UK. It looks at the best scientific evidence for health care. It now has a special website about restless legs. The site is sponsored by the pharmaceutical company GlaxoSmithKline, but the information on the site is independent. This site is brilliant for anyone who wants detailed scientific information about treatment options.
www.jr2.ox.ac.uk/bandolier/booth/booths/RLS.html