Restless Legs Syndrome May Be Misdiagnosed
Rose Franco, MDMedical College of Wisconsin Pulmonologist and Critical Care Physician
Imagine a feeling of insects crawling inside your legs as you’re trying to fall sleep. People who have Restless Legs Syndrome (RLS) experience this or similar sensations on a regular basis. RLS, a cause of sleeplessness for millions of Americans, is often under-diagnosed or misdiagnosed. Rose Franco, MD, discusses the diagnosis of RLS and treatment options.
Q. What is Restless Legs Syndrome?Restless Legs Syndrome is a chronic neurological condition. It is characterized by unpleasant sensations in the legs and an irrepressible urge to move the legs that intensifies while resting and is especially bothersome when trying to sleep. These sensations usually occur in the lower legs. Symptoms are usually worse at the end of the day.
To relieve the discomfort, people keep their legs in motion by stretching them or getting up and walking. Unfortunately, this interrupts the sleep cycle, hindering a person’s ability to fall or stay asleep. RLS is a lifelong condition, and symptoms tend to worsen with age.
Q. What are the symptoms of RLS?The main symptoms include unpleasant sensations, sleeplessness and the fatigue that results. People have described the sensations as feeling like soda fizzling in their legs, ants crawling in their skin, tingling, itching, prickling, burning or a deep ache in their legs. The longer the legs are immobile, the more unpleasant the sensation tends to be.
Q. Who is affected by RLS?While men and women are affected equally by RLS, age plays a role. About 5 percent of people in their 20s have RLS, while up to 25 percent of people over age 65 have it. About 10 percent of the population experiences RLS at some time; 2.5 percent of people suffer from RLS on a daily basis.
Q. What causes RLS?There are two forms of RLS. One form is inherited and is linked to a particular chromosome. If one parent has the genetic form of RLS, a child has a 50 percent chance of having RLS as well.
If there is no family history of RLS, the condition may be related to low iron levels in the blood, certain medications, pregnancy, and certain chronic diseases, such as kidney failure and peripheral neuropathy (a problem with nerve function outside of the spinal cord). In all of these conditions, there is a hyper-excitability reflex in the spinal cord that causes RLS symptoms.
We also know that certain medications (especially antidepressants and antihistamines), alcohol, caffeine and certain foods can worsen RLS symptoms.
Q. How is RLS diagnosed?There is no RLS “test.” We make a clinical diagnosis based on a person’s history and symptoms. I ask patients to do a self-analysis of their sleeping problem by keeping a diary to record their daytime and nighttime symptoms. I also take a thorough history, looking at each person’s lifestyle, diet, medications and any underlying medical conditions. In 1995, the International Restless Legs Syndrome Study Group identified criteria for diagnosing RLS:
- A desire to move the limbs
- Symptoms that are worse or present only during rest and are partially or temporarily relieved by activity
- Motor restlessness (a buildup of discomfort and involuntary limb jerking if a person remains still, with an urge to move the legs)
- Nighttime worsening of symptoms These guidelines assist sleep medicine physicians in asking the right questions that will lead to a diagnosis of RLS.
Q. Why are so many cases undiagnosed?RLS develops gradually, and many people have lived with it for so long that they no longer recognize how much it disrupts their functioning. They don’t remember what it was like not to have the sensations and normal sleep. They think there’s no help, and they don’t discuss their symptoms with their doctor. When people discuss symptoms with their physician, their doctor may not be trained to ask the right questions. A lack of sleep may have many causes, and a physician must ask the right questions to diagnose RLS or another cause.
Q. What are the treatment options?While there is no cure for RLS, various therapies can minimize symptoms and increase periods of restful sleep. I first look for reversible causes. If there’s an associated medical condition, treating the condition may alleviate RLS symptoms. For example, if a person has anemia due to an iron deficiency, prescribing an iron supplement may relieve the RLS symptoms. If someone is taking medication that is known to increase the symptoms of RLS, I may recommend discontinuing the medication or trying to find a substitute medication. In some cases, this may not be possible.
I counsel patients on ways to eliminate various triggers from their diet that may worsen their RLS symptoms, such as nicotine, chocolate, caffeine, alcohol and complex starches like pasta, bread and ice cream.
Moderate exercise may also help. Gentle walking and stretching 30 minutes before bedtime can reduce the urge to move the limbs after going to bed. Using hot or cold packs, or running hot or cold water on the legs, may also relieve symptoms.
Maintaining a regular sleep pattern is also important. The more sleep-deprived a person is, the greater the symptoms of RLS. Medications also help many people. In 2005, the FDA approved ropinirole specifically for the treatment of moderate to severe RLS. This drug regulates the hyper-excitability of the nerves. People can also empower themselves with information. A good resource is the American Academy of Sleep Medicine’s Web site: sleepeducation.com.
Source: Every Day, Interview with Rose Franco, MD
Date: Aug - Dec 2006