Restless leg is mystery
Life can be mysterious. This could be said of many things, but certainly holds true in medicine. Many important questions about health and disease remain unanswered. Some mysteries might surprise you, like how does Tylenol actually work? We don’t really know.
Many medical conditions have an unknown origin or no definitive treatment. Examples are plentiful, such as many auto-immune conditions. Neurologic diseases commonly are unexplainable, at least at our current level of understanding. Just as important as the ‘why’ of some disease is the treatment, how do we make it better? For numerous medical problems, we are stumbling blindly in the dark, searching for answers. Ask anyone with Restless Leg Syndrome, generally referred to as RLS.
RLS is a common condition, some estimates claiming 1 out of 10 adults suffer from it. Restless Leg Syndrome is believed to be a neurologic problem (of nerves), and causes uncontrollable leg movements. It’s more common with age, although a third had these sensations by 18 years of age. People often have difficulty describing the strange sensations that can be part of RLS. These odd feelings typically occur when at rest and usually interfere with sleep.
As with many diseases, the diagnosis is one of exclusion. In other words, we can determine someone has RLS only after every other possibility has been eliminated. There is no blood test, no special MRI study, allowing a physician to make the diagnosis of RLS. The “clinical picture” of the condition is what is used. A reliable characteristic is the sleep disturbances, often accompanied by uncomfortable but difficult to describe sensations. Symptoms get worse when sitting or lying down but are relieved by activity. It is considered characteristic that these findings are worse at night.
Sadly, there is a strong association with anxiety and depression. And about a third of those with Restless Leg Syndrome have symptoms severe enough to require medical attention. To the uneducated, this might sound like a trivial inconvenience, but to those suffering from this chronic malady, RLS is not conducive to a good quality of life.
Likely there is a simple explanation for these spontaneous movements but we don’t know it. Studies have proven there to be a genetic component but we don’t know what genes are involved. These individuals tend to have imbalances in dopamine, an important neurotransmitter in the central nervous system, although we are uncertain why. Iron function is also off, but the relationship and how it all works has, to date, escaped our grasp.
Modern medicine generally has difficulty providing solutions to problems that it doesn’t understand. Naturally, various pharmacologic therapies have been tried over the years, with agents improving dopamine levels one of the most popular options. These drugs were first used for RLS in 1987 and have dominated the market ever since. But, like every drug, they have side effects.
The term “augmentation” has been coined for the progressive, symptomatic worsening of RLS in response to these pharmacologic agents, the meds most often used to treat. This is the number one reason these drugs fail, a fact recognized for the last 20 years. Unfortunately, many other medications aggravate RLS. The lengthy list includes some common drugs, like various antihistamines (e.g. Benadryl), antinausea medications like Meclizine and Compazine, even many antidepressants like Elavil and Prozac.
Pregabalin (commercial name “Lyrica”) has been used for years as an off-label treatment by many of those who regularly treat RLS patients. Recent studies have shown it to be just as effective as the number one dopamine-raising drug with less of the negative consequences. Opiates still provide an alternative treatment option in RLS. And yet, because large, high-quality clinical trials evaluating the use of opiates for RLS have not been performed, the dopamine drugs remain as the published “Best Practice” for RLS.
Some lifestyle changes can be helpful, a problem for which there is no cure. Warm water soaks, along with massage, can relax the affected muscles. The application of warm or cool packs also is helpful. This use of heat or cold in general appears to be beneficial and lessen the strange limb sensations.
Establishing good “sleep hygiene”, the term for your sleep routine, is important since fatigue tends to worsen RLS. Recommended is a cool, quiet, sleeping environment, rising and retiring at the same time each day. Finally, get at least seven hours of sleep every night. As with most things, moderate, regular exercise can relieve symptoms, though overdoing it can worsen them. Sometimes cutting back on caffeine can be helpful. Avoid products containing caffeine, like chocolate, tea, and soft drinks, at least for some specific period, as a test.
A new development in the search for relief of RLS symptoms is a specialized foot wrap, specially designed to pressure specific muscles of the foot. In theory, the pressure sends messages to your brain which responds by telling the muscles affected by RLS to relax. The result seems to be a reduction in symptoms. Studies performed to date reveal a 90 percent improvement in RLS symptoms as compared to 60 percent for the most popular dopamine-sparing drug.
Although it remains very much a mystery, Restless Leg Syndrome research continues. For some of those afflicted with RLS, the symptoms are mild and little more than an inconvenience. But sleep is essential for mental health and well-being. A hallmark of RLS is the disturbance of this nightly healing process. Anxiety and depression are frequent companions to this condition. Until a better explanation for RLS is provided, all we can hope to do is lessen the symptoms. Another medical mystery in need of solutions.
Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments at firstname.lastname@example.org.