What is Restless Legs Syndrome (RLS)?

Restless Legs Syndrome (RLS), also known as Willis-Ekbom Disease, is a neurological disorder characterized by an uncontrollable urge to move the legs, often accompanied by uncomfortable sensations. Symptoms typically worsen at night, leading to sleep disturbances and reduced quality of life.

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Symptoms of Restless Legs Syndrome

The primary symptoms of RLS include:

1. Uncomfortable Sensations – A creeping, crawling, tingling, or burning feeling deep inside the legs.
2. Urge to Move Legs – An overwhelming need to move the legs to relieve discomfort.
3. Worsening at Rest – Symptoms flare up during inactivity (sitting or lying down).
4. Nighttime Aggravation – Most severe in the evening or at night, disrupting sleep.
5. Temporary Relief with Movement – Walking, stretching, or massaging the legs eases symptoms temporarily.

Note: Some people also experience periodic limb movements during sleep (PLMS), where legs jerk involuntarily every 15-40 seconds.

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Causes of Restless Legs Syndrome

The exact cause of RLS is unknown, but several factors contribute:

1. Genetic Factors

• About 50% of RLS cases have a family history.
• Linked to gene variants affecting dopamine and iron regulation.

2. Dopamine Dysfunction

• RLS is associated with low dopamine levels, a neurotransmitter controlling muscle movement.

3. Iron Deficiency

• Low ferritin levels (iron stores) in the brain disrupt dopamine production.
• Common in pregnant women, kidney disease patients, and frequent blood donors.

4. Chronic Diseases

• Diabetes, kidney failure, and peripheral neuropathy worsen RLS.
• Parkinson’s disease patients often have RLS due to dopamine issues.

5. Medications & Substances

• Antidepressants (SSRIs), antihistamines, and antipsychotics can trigger RLS.
• Caffeine, alcohol, and nicotine may aggravate symptoms.

6. Pregnancy (Secondary RLS)

• Up to 30% of pregnant women develop RLS, especially in the third trimester (likely due to iron deficiency and hormonal changes).

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When to See a Doctor

Consult a neurologist or sleep specialist if:
✔ Symptoms occur 3+ times per week and disrupt sleep.
✔ You develop daytime fatigue, mood swings, or depression.
✔ Over-the-counter remedies (iron, magnesium) don’t help.

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Next Steps: Diagnosis & Treatment

RLS is diagnosed through medical history, blood tests (iron levels), and sleep studies. Treatment includes:

• Iron supplements (if deficient)
• Dopamine agonists (ropinirole, pramipexole)
• Lifestyle changes (exercise, warm baths, massage)

Restless Legs Syndrome (RLS) – Comprehensive Treatment Guide

Medical Treatments for RLS

1. Dopamine Agonists (First-Line Treatment)

• Ropinirole (Requip): Start with 0.25 mg 1-2 hours before bedtime
• Pramipexole (Mirapex): Initial dose 0.125 mg in evening
• Rotigotine (Neupro): Transdermal patch (1-3 mg/24 hours)
• Side Effects: Nausea, dizziness, impulse control disorders (gambling, shopping)

2. Alpha-2-Delta Ligands (For Refractory Cases)

• Gabapentin Enacarbil (Horizant): 300-600 mg at 5 PM
• Pregabalin (Lyrica): 50-300 mg at bedtime
• Particularly effective for RLS with neuropathic pain

3. Iron Supplementation

• Oral Iron (Ferrous Sulfate): 65 mg elemental iron + 100 mg vitamin C on empty stomach
• IV Iron (If Ferritin <75 μg/L):
  • Ferric Carboxymaltose (Injectafer)
  • Iron Sucrose (Venofer)

4. Opioids (Severe, Treatment-Resistant RLS)

• Low-dose Oxycodone (5-10 mg)
• Buprenorphine/Naloxone (Belbuca)
• Risk: Tolerance, dependence (use as last resort)

Non-Pharmacological Treatments

1. Lifestyle Modifications

• Caffeine/Alcohol Elimination: Complete avoidance after 12 PM
• Smoking Cessation: Nicotine worsens symptoms
• Evening Exercise: Moderate cycling/elliptical 4-6 PM

2. Sensory Counterstimulation

• Compression Devices: Pneumatic leg massagers
• Temperature Therapy:
  • Hot bath (104°F) 1 hour before bed
  • Cold packs during flares

3. Sleep Optimization

• Delayed Sleep Phase Protocol: Gradually shift bedtime later
• Weighted Blankets: 15-20% body weight
• Vibration Pads: Bed-mounted vibration therapy

Emerging Therapies (Clinical Trials)

• Peripheral Nerve Stimulation
• Cannabinoids (Nabiximols)
• Ketamine Infusions

Treatment Algorithm

1. First Line: Dopamine agonist + iron (if ferritin <75)
2. Second Line: Switch to alpha-2-delta ligand
3. Third Line: Low-dose opioid + continued iron
4. Refractory Cases: Neuromodulation therapies

Note: Augmentation (worsening symptoms) occurs in 50-70% of long-term dopamine agonist users – requires careful monitoring.

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