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Restless leg syndrome (RLS) is a chronic neurologic disorder characterized by an irresistible and uncomfortable need for movement. (1,2) The condition carries debilitating potential from lack of sleep and the subsequent negative impact on quality of life. (2-4) Although the problem can be responsive to conservative treatment, RLS is often underdiagnosed and inadequately managed. (3,4) 

RLS affects up to 15% of the population.  Patients often turn to evidence-based chiropractors for help. Your ChiroUp clinical advisory team recently did a deep dive into this topic, and we’re sharing what we learned, including a valuable new downloadable patient infographic to help relay the current best-practice advice.

This blog reviews seven essential concepts, including:

  • What causes RLS?
  • What are the five diagnostic criteria?
  • What can be done to help?
  • Six things RLS patients need to avoid (#6 will surprise you)

1. What Causes RLS?

Short answer- inadequate oxygenation and some nervous system disorders.

While the pathogenesis of restless leg syndrome is uncertain, many experts believe that CNS dopaminergic dysfunction is a central mechanism. (9) Other authors suggest an autoimmune origin for RLS. (10) A genetic contribution is likely as more than half of RLS patients share a family history of the disorder. (11,72) 

RLS commonly presents secondary to various chronic medical disorders, including (10,14-16,19): 

  • Cardiovascular disease
  • Diabetes
  • Peripheral neuropathy
  • Renal disease
  • Sleep apnea
  • Disorders of dopamine dysfunction, i.e., Parkinson’s disease, Huntington’s disease, and Tourette’s syndrome.

The chronic inflammation and hypoxia associated with hypertension, heart disease, and stroke are thought to be contributory mechanisms. (10) RLS may also occur as a secondary side effect to various drugs, including antidepressants, anti-psychotics, and anti-epileptics. (15) 

Restless leg syndrome is more common during pregnancy. (12-14) More than half of pregnant females experience RLS symptoms. (13) Patients with an iron deficiency disorder are at higher risk for developing RLS. (15,16) Researchers have identified an association between vitamin D deficiency and RLS. (17) 

2. What Are the Symptoms?

Short answer- an unpleasant need for movement that keeps me awake, so I feel bad.

Sensations are often described as (14,21):

  • Nervous energy
  • Jittery
  • Creeping
  • Itching
  • Insects crawling
  • Worms moving
  • Water moving
  • Soda bubbling in the veins
  • Tingling
  • Pulling
  • Burning
  • Throbbing
  • Grabbing
  • Electric currents
  • Pain 
  • Nervous energy
  • Jittery
  • Creeping
  • Itching
  • Insects crawling
  • Worms moving
  • Water moving
  • Soda bubbling in the veins
  • Tingling
  • Pulling
  • Burning
  • Throbbing
  • Grabbing
  • Electric currents
  • Pain 

Up to 85% of RLS patients report insomnia, which is also an aggravating factor for the condition. (3,25) Not surprisingly, RLS symptoms are more common in patients with sleep apnea. (25,26) RLS patients frequently complain of exhaustion, inability to focus, impaired memory, lack of performance, and poor mood. (26) RLS patients report a higher incidence of anxiety and depression. (3) RLS symptoms typically become more frequent and last longer with age. (26) 

3. What Aggravates RLS?

Short answer- stressors, especially chemicals.

In addition to sleep deprivation and physical inactivity, other provocative factors include (25,26): 

  • Alcohol, nicotine, and caffeine
  • Stress
  • Obesity
  • Various medications, including anti-depressants, anti-nauseants, anti-psychotics, and some cold or allergy medicines that contain antihistamines. 
Symptom Augmentation via Medication?

Numerous prescription medications are used to manage RLS, including sleep medications, muscle relaxants, anti-convulsant drugs (Gabapentin, Neurontin®, Gralise®, Horizant®, Pregabalin, Lyrica®), and dopamine agonists (Requip®, Neupro®, Mirapex®). (20,26) 

Unfortunately, many RLS medications carry undesirable side effects, including the possibility of symptom augmentation, wherein symptom severity increases and spreads from the legs into the arms and other parts of the body as an ironic secondary reaction to long-term medical management. (9,29,66-69,73) 

4. How is RLS Diagnosed?

Short answer- 5 of 5 IRLSSG criteria.

The classic symptoms of RLS also serve as the formal diagnostic criteria as defined by the International Restless Legs Syndrome Study Group (IRLSSG). (1,22,23)

  1. An urge to move the legs, not always accompanied by unpleasant sensations.
  2. Beginning or worsening during periods of rest or inactivity.
  3. Partial or total relief following movements such as walking or stretching.
  4. Symptoms occur or are worse during the night or evening.
  5. Symptoms are not accounted for by another medical or behavioral condition.

The formal diagnosis of RLS requires that all five diagnostic criteria are satisfied. (22,23 )

5. What’s in the RLS Differential Diagnosis?

Short answer- other vascular & neurologic issues (that the historical details can often rule out)

Differential diagnostic considerations include fibromyalgia, venous stasis, leg edema, orthostatic hypotension, vascular claudication, neurogenic claudication, osteoarthritis, leg cramps, neuropathy, radiculopathy, chronic regional pain syndrome, and positional leg discomfort. (14, 22) 

While most of the differential diagnostic possibilities share similar characteristics to RLS, there are several important contrasting clues. 

  • Venous disorders are generally related to ambulation and do not follow a circadian pattern. (31,32) 
  • Likewise, vascular and neurogenic claudication symptoms typically improve with rest and lack the urge for movement. (31,70) 
  • Nocturnal leg cramps are typically abrupt, unilateral painful involuntary spasms that may be relieved by foot dorsiflexion or stretching. (31,33-35) 
  • Positional leg discomfort typically involves a much more localized distribution, fades quickly with movement, and lacks a circadian pattern. (14, 31,35,36) 
  • Hypotensive akathisia from orthostatic hypotension occurs when sitting but not while lying down. (14)

6. How is RLS Treated?

Short answer- adjust your sleep habits & diet, then get moving.

Typically, RLS patients try multiple therapies with little relief. (37) The plethora of passive treatment options suggests that none are particularly effective. 

The NIH states that “RLS is generally a lifelong condition for which there is no cure.” However, current therapies can control the disorder, minimize symptoms, and increase periods of restful sleep.” (26) 

Conservative management has been shown to decrease RLS frequency and severity and improve quality of life. (4) Non-pharmacologic strategies are the first line of care. (38) Effective management of RLS can help mitigate the increased risk of future cardiovascular disease that is typically associated with the disorder. (39) The gold standard of management includes ADL counseling, emphasizing physical activity and sleep. (39) Considerations include:

Sleep

Providers should counsel patients on proper sleep hygiene including sleep schedules, optimal sleep environments, and limiting electronic use before bedtime. (38,40-42) 

Exercise

Prudently increasing physical activity is another essential strategy for RLS management. (38,26,43-49) While regular moderate exercise may relieve RLS symptoms, patients should avoid working out in the hours immediately before bedtime. (38) The benefits of exercise for RLS patients have been shown to dissipate within 48 hours, illustrating the importance of ongoing physical activity. (48) A 12-week yoga program has been shown to help decrease RLS symptom severity and stress while improving mood. (50,51) 

Relaxation

RLS patients may benefit from mind-body techniques, stress reduction, counseling, or cognitive behavioral therapy if needed. (43) Various physical relaxation techniques, including warm baths, hot packs, massage, and stretching have been advocated in the literature. (26,38,43,49) 

Physical Treatments

The application of hot or cold packs may provide palliative relief.  Vibration therapy may be helpful (52-54); however, the degree of benefit is questionable. (55) Acupuncture may provide benefit for RLS patients. (58,59)

Diet

Dietary counseling should include advice to limit caffeine, nicotine, and alcohol. (26,38,42,43) Patients should be screened for sleep apnea or other sleep-related breathing disorders that may impact outcomes. 

Supplements

Clinicians should screen for and manage deficiencies of vitamin D or iron. Iron supplementation is a well-established therapy for RLS. (9,60) Melatonin might be beneficial for some RLS patients. (61) Some sources recommend magnesium supplementation. (38)

7. Are There Any Awesome RLS Patient Education Tools to Save Me Time?

Short answer- We’re glad you asked 😏  ChiroUp has your back…and legs.

The ChiroUp graphic design team has summarized the essential RLS advice in the accompanying patient education infographic. Enjoy!

ChiroUp was created with chiropractors like you in mind. We understand the challenges that chiropractors like you and I face every day. Our software gives you all the tools to become more efficient and effective, which not only translates into more time to see more patients, but also to a better work/life balance. Let’s make it happen!

With ChiroUp, you’ll be able to prescribe an RLS condition report in seconds, review the entire RLP condition synopsis, and gain confidence that your advice is up-to-date. PLUS we’re about to get even more efficient and secure. This August, we’re releasing our latest version, ChiroUp 3.0. There’s never been a better time to be a part of the ChiroUp Pack. Click here for an exclusive look at our latest drop.

Get Started With ChiroUp

There’s never been a better time than now to get started with ChiroUp! Sign up for our FREE 14-day trial to try things out for yourself! 

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