Restless Leg Syndrome : by Ray Sahelian, M.D., treatment for restless leg syndrome

Restless Legs Syndrome treatment by Ray Sahelian, M.D.

Restless legs syndrome (RLS) is defined by four essential criteria needed for clinical diagnosis which were established by the International Restless legs syndrome Study Group.

These criteria are - Sign and Symptom - Restless Legs Syndrome RLS
1. The urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs
2. Symptoms of restless legs syndrome are worse during rest or inactivity
3. Symptoms are partially or totally relieved by movement
4. Restless legs syndrome is worse at night.

Restless legs syndrome is mostly thought of as a condition that affects adults, but it is also fairly common in children and teenagers.

Natural Treatment of Restless legs syndrome
Reduce or eliminate coffee, tea, cola beverages, cocoa from all sources including chocolate. Stop or reduce smoking and drinking alcohol. Reduce or eliminate any type of stimulant, including herbal teas, supplements of a stimulating nature, and over the counter cold medicines. Exercise helps a lot. Daily long, daily walks for at least an hour, especially in the morning. Perhaps massage, warm or cold baths, and acupuncture could benefit. Some people claim treatment with Vitamin B may slightly reduce the frequency, intensity, and duration of nocturnal leg cramps but more research is needed to determine whether B vitamins really work or make it worst in some people. B vitamin supplements are best taken in the early part of the day in a low dose. I suspect high doses of B vitamins could cause insomnia. I am not sure if kava is helpful but it is worth a try. Another option is Good Night Rx, we have not tested it for restless legs syndrome, but it could help one sleep deeper. Take Good Night Rx one to three hours before bed on an empty stomach. Another product to try is valerian root, see the email at bottom of page.

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Subscribe to a FREE Supplement Research Update newsletter at Physician Formulas. Twice a month we email a brief abstract of several studies on various supplements and natural medicine topics, and their practical interpretation by Ray Sahelian, M.D. If come across any studies regarding the natural treatment of restless legs syndrome, we'll make sure to mention them.

Causes of Restless Legs Syndrome
Restless legs syndrome is an intolerable internal feeling of itching or creeping sensations in the legs that forces the affected person to move his or her legs to get relief. It usually occurs at the end of the day in bed or when seated. Primary restless leg syndrome probably has some genetic basis. Secondary causes include iron deficiency, neurologic lesions, pregnancy (folate deficiency?) diabetes, and uremia. Other possible causes of restless legs syndrome include fibromyalgia, thyroid disease, B12 deficiency, varicose veins. Restless leg syndrome symptoms may be induced or exacerbated by medications such as antidepressants, lithium, and dopamine antagonists (neuroliptics, metoclopramide), H2 blockers. Caffeine also has been implicated in the worsening of restless leg syndrome symptoms.
People who suffer from restless leg syndrome often have debilitating psychiatric disorders, including depression and anxiety, which may cause the restless legs syndrome or be a result of the lack of sleep. Other risk factors are heavy smoking, unemployment status, hypertension, gastroesophageal reflux disease (gerd), arthritis, and diabetes. Sleep apnea and insomnia appear to be other risk factors for restless leg syndrome, along with difficulty falling asleep (taking more than 30 minutes), driving while drowsy and excessive daytime fatigue. Subjects with self-reported restless leg syndrome also have a higher incidence of being late for work, missing work, making errors at work and missing social events because of fatigue more often than those without restless leg syndrome.

Evaluation of the patient with Restless Legs Syndrome
The physical examination is usually normal and is performed to identify secondary causes and to rule out other disorders. A neurologic examination with emphasis on spinal cord and peripheral nerve function. A vascular examination to rule out vascular disorders. Do SMA, CBC, ferritin, and TSH. Patients with newly diagnosed restless legs syndrome or recent exacerbation of symptoms should have serum ferritin levels measured.

Pregnancy and restless legs syndrome
Predisposing factors of restless legs syndrome in pregnancy.
Mov Disord. 2007 Feb 6; Department of Neurology, Ankara Research and Training Hospital, Ministry of Health, Ankara, Turkey.
The occurrence of restless legs syndrome in pregnancy is well known. However, the mechanism of this association is unclear. In this study, we aimed to identify the factors that predispose women to have restless legs syndrome during pregnancy. In this study, lower hemoglobin levels and supplementation deficits of iron and vitamins were found be the risk factors for restless legs syndrome in pregnancy.

Medication for Restless Legs Syndrome
Pharmacologic treatment of restless legs syndrome includes dopaminergic agents, opioids, benzodiazepines and anticonvulsants. FDA has approved the dopamine agonist ropinirole (Requip) as first-line therapy for restless leg syndrome.

Dopamine precursor combinations such as carbidopa-levodopa can be used on a "one-time" basis or as circumstances may require. Useful for persons with intermittent restless legs syndrome because dopamine agonists take longer to have an effect. Therapeutic effect may be reduced if taken with high-protein food. Can cause insomnia, sleepiness and gastrointestinal problems.

Dopamine agonists such as pergolide 0.05 mg, bromocriptine 1.25 mg, pramipexole 0.125 mg, ropinirole 0.25 mg are useful in moderate to severe restless legs syndrome. Recent reports indicate high efficacy of dopamine agonists, but the role of their long-term use is unknown. Can cause severe sleepiness, which may limit its use during daytime. Use of the dopamine agonists pergolide and cabergoline is associated with an increased risk of cardiac valve regurgitation.

Opioids such as codeine, hydrocodone, oxycodone 5 mg, propoxyphene 65 mg, tramadol 50 mg can be used on an intermittent basis to help the discomfort of restless legs syndrome. However, they can cause constipation, urinary retention, sleepiness or cognitive changes. Tolerance and dependence possible with higher doses of stronger agents. Only use opioids in severe cases.

Benzodiazepines such as clonazepam 0.25 mg, temazepam 15 mg, are helpful in some patients with restless legs syndrome when other medications are not tolerated and may help improve sleep. Can cause daytime sleepiness and cognitive impairment, particularly in the elderly.

Iron (ferrous sulfate) 325 mg in patients with serum ferritin levels <50 痢 per dL. Ideal means of administration has not been established. Oral treatment may take several months to be effective and may be poorly tolerated.

Requip for Restless Legs Syndrome
A large study confirms that restless leg syndrome markedly reduces quality of life and interferes with sleep and that the drug Requip provides significant improvement in symptoms of restless legs syndrome.
Requip, also known as ropinirole, was approved in May 2005 by the US Food and Drug Administration for the treatment of restless leg syndrome. SOURCE: Mayo Clinic Proceedings January 2006.

Restless Legs Syndrome Research Update
Regulators have approved the first U.S. treatment for restless legs syndrome, a condition that can disrupt sleep and daily activities. The neurological condition, which involves a compelling urge to move the legs, affects one in 20 adults in the United States and is a cause of insomnia. Although its exact cause is unknown, researchers believe it may be related to dopamine, a chemical that carries the signals between nerve cells that control body movement. Glaxo, Europe's biggest drug maker, said the drug Requip (ropinirole) works by stimulating dopamine receptors in the brain. The U.S. Food and Drug Administration approved the drug for use in moderate to severe cases of restless legs syndrome. Requip is already a treatment for Parkinson's disease. In clinical trials for restless legs syndrome, the most common side effects of Requip were nausea, extreme drowsiness, vomiting, dizziness and fatigue. In December 2004, a European Union panel of experts initiated a probe of the drug after concerns surfaced about the product's effectiveness and long-term safety. Called Adartrel in Europe, the drug is sold in a few countries but has not yet received full European approval.

Role of dopamine receptor agonists in the treatment of restless legs syndrome.
CNS Drugs. 2004;18(1):27-36.
Treatment of restless legs syndrome with levodopa leads to symptom relief, but augmentation (occurrence of symptoms before levodopa administration in the evening) may occur, limiting the long-term use of this drug. This article gives an overview of the treatment in general and the role of dopamine receptor agonists in the therapy of Restless legs syndrome and periodic limb movements (PLMs). Dopamine receptor agonists are widely used as an effective treatment for Restless legs syndrome and PLMs, presumably because of their longer half-lives, lower likelihood of augmentation and good tolerability compared with levodopa. It was shown that, for example, pergolide, ropinirole, pramipexole and cabergoline alleviated Restless legs syndrome symptoms in 70-90% of patients. A new non-oral (transdermal) formulation of one dopamine receptor agonist, rotigotine, has recently been developed and shown to be efficacious in Restless legs syndrome. Further research should focus on long-term observations and comparisons of different dopamine receptor agonists in Restless legs syndrome.

More information about RLS
Restless Legs Syndrome is a common, yet often undiagnosed, neurological sensorimotor disorder. About 5 percent of the U.S. adult population is affected by restless legs syndrome. Patients with restless legs syndrome often experience an urge to move their legs at night due to uncomfortable leg sensations that worsen during periods of rest or inactivity, often interfere with the ability to sleep, and are partially or totally relieved with movement, such as walking or stretching. While symptoms can vary from person to person, they are generally described as an urge to move the legs accompanied by burning, creeping, crawling, aching, tingling, or tugging sensations in the legs. Additionally, people with restless legs syndrome will often have disruptions in sleeping, which may be caused by periodic limb movements. As a direct result of restless legs syndrome, patients may experience daytime tiredness, mood disturbance, and inability to perform daily activities, which can have a substantial negative impact on patients' quality of life.

Restless legs syndrome emails
Q. At 43 years old, I am a long-term sufferer of restless legs syndrome, which is worsening with age. I am getting to the point where I am ready to take prescription medication for it. Before I do, however, I am trying to explore all other avenues. I tried taking a combination of vitamins (the B's, Vit. C, folic acid) , including tyrosine, prescribed by a naturopath...to no avail. I am a partial vegetarian. I eat no red meat (I eat fowl and fish/seafood). I have one cup of coffee in the morning. I drink minimal alcohol. I have a healthy lifestyle..am a serious cyclist but lack of sleep prevents me from training to my full potential. My routine blood tests shows my iron level as normal.
A. As we have more information on restless legs syndrome, we will post it on our site.

Q. I found a quote on the muira puama page, "Indigenous peoples use muira puama for the therapy of ...neuromuscular problems..." Is it worth trying this herb for restless legs? I have not restless legs but leg jerking that prevents all sleep unless I take pharmaceuticals. Currently I'm on gabapentin which does work and seems harmless, but I'm always looking for other options. My leg jerking, BTW, is definitely a "brain thing" and not a leg muscle thing. Tiring the leg muscles has zero effect.
A. Muira puama may cause insomnia in high doses, we don't think it would be helpful.

Q. My husband started having symptoms with restless legs syndrome RLS in his early 20's. After a surgery he had on his elbow he realized that the Hydrocodone helped tremendously with the restless legs syndrome symptoms and found ways to get his hands on more of them (Opiates) for a couple years before I realized that he had a problem. After I realized what was going on I was shocked!! This was not the man I married ( a drug addict). He had a sleep study done and the restless legs syndrome was then confirmed, but the medicines they tried him on still didn't help get rid of the restless legs syndrome. So, he went back to the hydrocodone. Someone mentioned to him about a Methadone clinic. They told him it would help him come off the pain meds. HUGE MISTAKE!!! Little did we know what a huge mistake we had just made!! Not long after that he inrolled himself in a rehab center, but within 3 months after discharge he started back on the pain meds. because of the restless legs syndrome. Now, don't get me wrong he does have a family hx of addictions. His uncle and his grandfather were both alcoholics. So, this is not all to blame on the restless legs syndrome, but he says it has a lot to do with it. It has been approx. 3-4 years since the rehab and needless to say one thing has led to another and he has now tried hard drugs. He says he hates this and he wants help. He says he wants to go to rehad and end this, but he's affraid of the restless legs syndrome coming back. He says "you have no idea what it's like". I can't tell if this is more of a drug abuse thing or underlying restless legs syndrome thing.

Q. I am 38 and have suffered with Restless Legs Syndrome for many years. I wanted to let your readers know that I have found that taking coral calcium before going to bed helps my legs to relax and I sleep great. Also, mangosteen seems to have helped keep the twitches and creepy crawly sensations to a minimum.
A. Thanks for letting us know. We will wait to see if others with restless legs syndrome give us feedback with similar benefits in regards to coral calcium or mangosteen.

Q. I had suffered with restless leg syndrome for many years, not knowing it had a name, or that other people experienced this very uncomfortable disorder. I have been able to track episodes of restless leg syndrome directly to the eating of high sugar foods in the afternoon, or later in the day/evening. Elimination of the sweets has eliminated restless leg syndrome.
A. Thanks for letting us know.

Q. Do you have a product for restless leg syndrome? I'm taking marapex at this time and would like to stop taking it.
A. We don't have a product for restless legs syndrome at this time, but ask your doctor if Good Night Rx may be something to try, we have not tested it for this but if your doctor approves, and you don't combine it with other drugs in the evening, it may be worth to try occasionally.

Q. Could 5-HTP or the amino acid tryptophan help with RLS?
A. We're not sure, we have not tested these nutrients for this condition.

Q. I am a very active 72 year old woman who has had restless legs since I was in my early 40's. I have tried about everything and have been to a number of different doctors. One doctor put me on Valium and that has been a
wonderful thing for me. I am also on Mirapex and Neurontin for the same restless legs syndrome problem. I only take a half of a 5mg Valium table every night. Without it, I do not know what I would do. I have a severe case, and I hate to increase the Valium, but I have so many nights where I end up sleeping on the floor, because I have to move so much. I am considering increasing the Valium to at least a whole 5mg tab at night. I know Valium is addictive, but to prove to myself that I could go off of it, I did it completely without any effects in less than 3 months. Of course, I am back
on it. I loved your web site on restless legs syndrome and will subscribe to your newsletter. Thank you for your interest in a very severe health problem.
A. Hopefully someday we can find a natural cure for restless legs syndrome.

Q. This is not a study on valerian, just me and 2 other people that have RLS, Restless Leg Syndrome. I have been troubled with it for 15 years. When I sit down to relax is when it becomes a problem. Valerian is the only natural thing I have found that works. I take no other medications. I know of no research on the effectiveness of valerian on restless legs syndrome. I thought this might be of some interest to you.
A. Thanks for letting us know, it is very interesting, what is the valerian dosage, which product, and how many hours before bed you take it, and how many days did it take to work?
Q. In talking with the few people that use Valerian as I do for restless legs syndrome I found we were using it the same way. If the problem started we could take 2 to 3 capsules, 150 mgs each and the problem would go away in about 30 to 45 minutes. If I felt the problem before bedtime I would take 2 to 3 capsules 45 minutes to 1 hour before bed. valerian is not used as a daily thing, only if the restless legs syndrome was problematic. When at work and I was sitting it would cause problems also. I did the same, 2 to 3 capsules and it went away in about 30 to 45 minutes. I would try other things to make it go away also so I didn㦙 have the use the Valerian, getting up and walking it off worked but was not useful if you were trying to go to sleep, but at work it was ok. Then if the RLS returned I would use the Valerian. I would take hot shower and take the Valerian if it woke me up from sleep. I am a light sleeper so it was easy for the symptoms from restless legs syndrome to wake me. Hope this is helpful. Any more questions just let know and I will try to answer.

Q. When ever I sit down to rest, one or the other lower leg, starts to twitch every 45 seconds or so. My Doctor without doing any testing said I have restless leg syndrome and Rx Requip to supposedly replace the dopamine levels that he believes I am deficient in. The Requip usually, but not always, stops the twitching within an hours or so and then I can sleep. My question; have there been any studies to show that taking tyrosine boosts your bodies ability to produce dopamine, thereby eliminating the deficiency and potentially the twitch?
A. We have not seen such studies. The use of tyrosine is likely to increase alertness and interfere with proper sleep.

Q. I was reading other questions in your column that had to do with SAM-e acting similarly to Wellbutrin. I can't take Wellbutrin because of it works on the dopamine neurotransmitters. Is there a likelihood that SAM-e will exacerbate restless legs syndrome?
A. Wellbutrin focuses on the dopamine system and SAM-e influences many types of neurotransmitters. I have not prescribed SAM-e to patients with restless legs syndrome, however I prefer not to use medicines or supplements that have a stimulatory effect and causes insomnia to patients with RLS. SAM-e, even at 100 mg, may, in some people, cause insomnia.

Q. I recently read on your website that you avoid giving your patients with restless legs syndrome any type of supplement that is a stimulant in nature. You suggested not using Sam-e since that is a type of stimulant. I was wondering what you feel about NADH and since that is used to combat fatigue, if that is considered a stimulant.
A. The effects of low dose NADH, such as 2.5 mg, when used in the morning, should not interfere with sleep. Perhaps higher dosages such as 10 mg may interfere with sleep. We don't have any first hand experience with NADH regarding the treatment of restless leg syndrome. Please let us know how it works for you.

Q. I am trying to find out if L-tryptophan helps with stages 3 and 4 sleep. Also wondering if it is safe to take along with Wellbutrin XL. I know it's risky with the SSRI's. I had a sleep study done which confirmed a previous study's results -- restless leg syndrome, periodic leg movement disorder, positive EMG activity during REM sleep, and almost no stage 3/4 sleep. The sleep neurologist had nothing to offer except Mirapex, which I do not wish to take (Am on Clonazepam for the RLS, Gabapentin helps as well...). In retrospect, I have had PLMD since at least high school! I had taken L-tryptophan in the 80's before I went to medical school, and remember it helping something, but cannot remember what. I have read a fair amount of anecdotal things about valerian, but would like to give the tryptophan another shot.
I need good, restorative sleep!
A. I am not exactly sure which stages of sleep tryptophan helps, but many people who take a tryptophan supplement do notice deeper sleep. It is difficult to predict the interaction of trytpophan with Wellbutrin, Clonazepam and gabapentin, much depends on the dosages used and the timing of the drugs and the supplement. You could try tryptophan several hours before or one or two hours before bed on en empty stomach to see which works better. Let us know if any natural supplement works for your restless legs syndrome condition.