Can we do anything about restless leg syndrome?

A sailboat in New York City. (Dr. Noorali Bharwani)
A sailboat in New York City. (Dr. Noorali Bharwani)

Restless legs syndrome (RLS) is a common condition that is frequently unrecognized, misdiagnosed and poorly managed.
Restless leg syndrome: is it a real problem?
Paul E Cotter and Shaun T O’Keeffe
Ther Clin Risk Manag. 2006 Dec; 2(4): 465–475.

Restless Leg Syndrome (RLS) is a neurologic disorder and is the most common movement disorder, characterized by an irresistible urge to move the legs when at rest. This affects sleep, daytime productivity and mood. It can affect your personal health and can cause harm to others. It is usually a long-term disorder.

RLS is also known as Willis-Ekbom Disease. In 1672, Sir Thomas Willis first described RLS. It was not until almost three centuries after Willis, in 1945, that Karl-Axel Ekbom provided a detailed and comprehensive report of this condition.

Ekbom described the essential diagnostic symptoms, differential diagnosis from other conditions, prevalence, relation to anemia, and common occurrence during pregnancy.

RLS affects about 10 per cent of the population, most commonly in women older than 35 years of age. I know some men suffer from this as well. The prevalence increases with age. There may be a family history of the condition.

There are no tests to confirm the diagnosis. Symptoms of RLS are classical. Mostly the symptoms start in the evenings when a person is trying to relax. There is urge to move the legs. This is associated with a burning and prickling sensation. Symptoms ease up if the person gets up and starts moving.

Some people may not have any cause for RLS, some have the condition secondary to medical conditions like iron deficiency or kidney disease. Symptoms of RLS may be associated with many other medical conditions.

Dopamine deficiency may be implicated in RLS. Dopamine is a neurotransmitter made in our brain. It plays a role as a “reward center” and in many body functions, including memory, movement, motivation, mood, attention and more. Imbalances in dopamine can lead to a variety of disorders, including Parkinson’s disease, ADHD, addiction, and schizophrenia.

Since there is no cure for RLS, treatment may be required for life. None of the treatment is going to relieve symptoms all the time. But it may provide some relief.  Treatment requires lifestyle changes and medication to improve quality of life, improve sleep, and correct underlying conditions or habits that trigger or worsen RLS symptoms.

If your symptoms are mild, a few lifestyle changes may be enough to control your symptoms. Avoid tobacco, alcohol, and caffeine. Regular exercise, massage to the legs, heat or ice packs can help. Taking calcium and magnesium before bed may help. Patients whose serum iron level is low may benefit with iron therapy.

If your symptoms are more severe, specific medication may help control the urge to move and help you sleep. There are different types of medications and you may have to try a few to find the one that works best.

The best evidence exists for use of dopaminergic agonists such as Ropinirole (Reequip) and Pramipexole (Mirapex) and anticonvulsant such as Gabapentin (Neurontin) agents in treating primary RLS with dopamine agonists favoured. In some cases, opioid (tramadol, codeine, oxycodone) pain medication may be required.

If the medications do not help or you are having side effects, you may have to try other treatments, such as a pneumatic compression device. This device pumps air in and out of sleeves to make them tight and loose around your legs while you are resting.

In conclusion, I will take a quote from John Hopkins (Neurology and Neurosurgery) website, “Unfortunately, there is no known cure for restless legs syndrome. At present, there is no one drug which works for everybody, but most individuals with restless legs syndrome will find some benefit and relief with the currently available medications for treating this disorder…”

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Quinine Not a Safe Drug for Treating Nocturnal Leg Cramps

A young tourist in Los Angeles, 2007. (Dr. Noorali Bharwani)
A young tourist in Los Angeles, 2007. (Dr. Noorali Bharwani)

Nocturnal leg cramps, that are cramps occurring at night, also known as rest cramps, are a painful involuntary muscle contraction that typically occur in the legs or feet during prolonged periods of rest and often interrupt sleep, says an article in the Canadian Medical Association Journal (CMAJ March 3, 2015).

Leg cramps are seasonal and roughly double between the winter lows and summer highs. It is not clear why there is such a seasonal occurrence. There is a midsummer peak and a midwinter dip.

Quinine sulfate at a dose of 200-300 mg at night has been used for many years to treat nocturnal leg cramps, says the article. Quinine is modestly effective. Other drugs were found to be either possibly effective (vitamin B complex, naftidrofuryl, calcium-channel blockers) or likely not effective (gabapentin, magnesium).

There is a long list of possible side effects that can occur with the usual dose of quinine. Some of the side effects are tinnitus (ringing in the ears), high-tone hearing loss, photophobia (visual intolerance to light) and other visual disturbances, just to mention a few.

Rarely, it can cause serous blood disorders (immune thrombocytopenic purpura and drug-mediated thrombotic microangiopathy). Overdose of quinine sulphate can cause serious and even fatal arrhythmias (irregular heart rhythm).

As of September 30, 2010, Health Canada had received 71 reports of serious adverse reactions suspected of being associated with quinine use (41 were either life threatening or required hospital admission), says the article. In 2009, the US Food and Drug Administration (FDA) explicitly noted an unfavourable risk-benefit ratio for quinine when used for leg cramps.

Although quinine is modestly effective, concerns regarding potential adverse effects have tempered enthusiasm about its use for nocturnal leg cramps, says the article. In fact practice guidelines for American neurologists on the symptomatic management of muscle cramps concluded that, although likely effective, quinine should be avoided for routine use because of the potential for toxic effects.

The author of the article says that quinine does not have Health Canada approval for the treatment of nocturnal leg cramps, yet it is widely used for this indication.

What else can be done for nocturnal leg cramps? Nightly calf and leg muscle stretching showed significant decrease in both the frequency and severity of leg cramps. The author does not suggest that quinine should be completely banned. It can be tried for short period. During the trial, patients should be closely monitored and the quinine stopped after four weeks if there is no benefit, says the article.

Patients continuing to take quinine after four weeks should be followed and advised periodically to try stopping it, says the author of the article.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Restless Legs can Disturb Your Sleep

A beautiful place in Kananaskis to dream, relax, listen to music, dance and sleep. (Dr. Noorali Bharwani)
A beautiful place in Kananaskis to dream, relax, listen to music, dance and sleep. (Dr. Noorali Bharwani)

Before we talk about your legs and how they are connected to your sleep, let me tell you what others have to say about sleep. If you are a person who believes in meditation then you would agree with Dalai Lama, who said, “Sleep is the best meditation.” I believe in that.

If you are a George Bernard Shaw fan then you will agree with him, “Marriage is an alliance entered into by a man who cannot sleep with the window shut, and a woman who cannot sleep with the window open.” I won’t tell you where I stand on that.

If you tell your doctor you are constantly tired, have day time sleepiness, have difficulty falling asleep at night, have to move your legs at bedtime to find comfort then you probably have restless legs syndrome.

A syndrome is a group of symptoms that collectively indicate or characterize a disease, psychological disorder, or other abnormal condition.

According to an article in the Canadian Medical Association Journal (CMAJ November 19, 2013), restless legs syndrome is a neurologic movement disorder that may adversely affect sleep, and thereby result in daytime fatigue, somnolence and a reduced quality of life.

The article goes on to say, “This condition has also been associated with hypertension and cardiovascular disease. The pathophysiology of restless legs syndrome is incompletely understood.”

Restless legs syndrome is common, affecting five to 15 per cent of the population. Making a diagnosis is not easy. The National Institutes of Health state that four criteria are essential for diagnosis:

  • An urge to move the legs usually accompanied by, or caused by, uncomfortable and unpleasant sensations in the legs;
  • Unpleasant sensations that begin or worsen during periods of rest or inactivity;
  • Unpleasant sensations that are partially or totally relieved by movement;
  • And unpleasant sensations that are worse in the evening or at night compared with during the day or that only occur in the evening or at night.

There is no specific laboratory test or treatment to conclusively confirm the diagnosis or treat it. Management by a sleep specialist is required. Avoiding alcohol, caffeine and cigarette smoke may help.

According to the article, the American Academy of Sleep Medicine has recently published detailed management guidelines – available online.

If I remember correctly, Marilyn Monroe was said to have trouble sleeping. I wonder why. She said, “The nicest thing for me is sleep, then at least I can dream.”

That’s it for today. Think big, laugh a lot, sleep well and have sweet dreams.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Restless Leg Syndrome Leads to Restless Sleep

After a night of restless sleep. (iStockphoto)
After a night of restless sleep. (iStockphoto)

Recently, one of my friends was diagnosed with restless leg syndrome (RLS). It is also known as Ekbom’s syndrome. It is a movement disorder. Important thing to remember is that it is not a psychological or emotional condition. It is thought to be a neurological disorder and it is believed that a brain chemical known as dopamine is involved.

About three to 15 per cent of the population is affected by RLS. It is more common in women than men. The prevalence increases with age. There may be a family history of the condition. Some medications can trigger RLS.

Individuals suffering from this disorder have a distressing need or urge to move the legs, usually accompanied by an uncomfortable, deep-seated sensation in the legs that is brought on by rest (sitting or lying down), relieved with moving or walking, or worse at night or in the evening.

RLS can be associated with involuntary limb movements while patient is awake and/or periodic limb movements (PLM) while patient is asleep. Studies show that more than 80 per cent of people with RLS also have PLMs. But the majority of people with PLMs do not have RLS.

The diagnosis of RLS is based on the clinical history. RLS may be a symptom of iron deficiency therefore the iron status should be assessed. Overnight sleep study may be helpful. There is no good medication to control the symptoms.

If you have unexplained leg pain then discuss your symptoms with your doctor and get proper investigations done at a sleep clinic.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!