Restless Leg Syndrome (RLS) Symptoms and Treatment (A Better Night’s Sleep Podcast)

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[Dr. Julie Kinn] Welcome back to “A Better Night’s Sleep”, a podcast about sleep, sleep
disorders, and evidence-based treatment from military health sleep experts. I’m Dr. Julie Kinn, with the Defense Health
Agency. [Dr. Jonathan Olin] And I’m Dr. Jonathan Olin,
Medical Director of the Evans Army Community Sleep Lab. [Kinn] Today, we’re going to be talking about
restless leg syndrome, R-L-S. And I’ve got to admit, right up front, most
of what I know about this topic is based on infomercials I’ve seen on TV. So, Jon, you’re going to be doing the heavy
lifting as always. So bearing that in mind, what is restless
leg syndrome? [Olin] Sure. It’s a subjective condition, meaning the patient
or individual report it. It’s generally described as a creepy-crawly
feeling or an urge to move that’s worse at night. It interferes with falling asleep and gets
better with movement. Some textbooks say it occurs in 10-ish percent
of the population. In my experience, that’s a little high, and
maybe I’m seeing a younger population than many of the textbook populations. So, it can range in severity too, but again,
it’s a subjective sensation of needing to move arms or legs, often legs, and diurnal
variation, meaning worse at night. Interferes with falling asleep, better if
you get up and move around. [Kinn] Is it more common in people who are
just generally fidgety, for example, the kind of folks who, during a meeting when they need
to sit still, will always be tapping a foot or shaking their leg? [Olin] Generally not. So that’s one of the…there are these four
diagnostic criteria that I mentioned just now, and there’s even a mnemonic, with URGE,
which is U-R-G-E, obviously. So URGE, the U is that sensation. It’s rest-induced, so it’s worse with inactivity. It gets better with movement, but it’s worse
in the evening, so there needs to be diurnal variation. So, someone who’s fidgeting all day, and it’s
not worse in the evening, that’s not restless leg syndrome. [Kinn] Is diagnosing restless leg syndrome
similar to diagnosing sleep apnea, where someone would have to do an overnight sleep study
in a lab setting? [Olin] That’s a good question, and the answer
is no. So again, this is a clinical or a subjective,
where a person presents history, and then the diagnosis is made off of that. Sometimes, in a sleep study, we’ll see people
move their legs when they’re asleep. In fact, that’s pretty common. About 80 percent of people with restless leg
syndrome, or RLS, will have leg movements in the study noted. But, they don’t need a sleep study to make
that diagnosis. [Kinn] So it sounds more like something that
can be diagnosed after just a conversation with your physician or sleep doc. [Olin] Correct. And, obviously, there’s a whole range of severity. So if someone says, “Yeah. I have that,” but it’s once a month and it’s
not a big issue then, obviously, it’s not going to be high on the priority list to treat. But if someone says, “Yes. I have insomnia,” I sometimes ask, “What percentage
of your insomnia is related to this leg sensation?” And if they say one or two percent or it barely
happens, then we need to move on. Maybe they’re having some other things that
we talked about in earlier podcasts — maybe they’re having nightmares, maybe they’re checking
their watch, looking at clock, maybe they’re drinking a little bit too much caffeine. But if they said, “Oh my goodness. If my legs were fixed, I’d be happy,” then
that’s front and center, and that needs to be addressed. [Kinn] Basic question here. Is it painful? Does it feel like a leg cramp? [Olin] Generally not. It’s a need to move, but some people will
discuss kind of a “bugs crawling on their skin”. It’s generally not pain, so that’s going to
be differentiated from nocturnal evening cramping, or it could be in the calves, and they’ll
get up and stretch, so that’s distinctly different. Those of our listeners who exercise regularly,
maybe they did a long bike ride or did a long run, and they’ll get a hamstring kind of spasm
at night. That’s not restless leg syndrome. [Kinn] And I would imagine there’s some confusion
during pregnancy, too, right? Don’t women more likely have leg cramps during
the night while pregnant? [Olin] That’s true. But, actually, there are several conditions
where restless leg syndrome IS more commonly seen, and pregnancy is one. [Kinn] Oh, really? [Olin] I’m not an OB-G, but if people can
have leg cramping at night during pregnancy, they also can have restless leg syndrome symptoms,
and those can and often do resolve, postpartum. [Kinn] Just one of those fun symptoms no one
warns you about until after you’re pregnant. [Olin] Exactly. So there are a couple, three other conditions
where restless leg symptoms are seen. Some may be relevant for our listeners. So one is treatment with an SSRI, selective
serotonin reuptake inhibitor. [Kinn] An antidepressant? [Olin] Correct. Antidepressant/anti-anxiety med that’s often
used, for example, to treat PTSD — Lexapro, Celexa, Prozac, Zoloft, Paxil. Those meds can aggravate or cause restless
leg. If someone has, say, for example, severe PTSD
and reports significant improvement on a med and very mild intermittent restless leg, then
maybe that’s something they want to live with, meaning the restless leg, and they see, overall,
the benefits of the med outweigh the risk. If, on the other hand, someone started, I
don’t know, an antidepressant a few years ago, reported resolution of their symptoms
and now, for whatever reason, has restless leg, then maybe that could be looked at and
stopped, meaning the med, or at least reduced or looked at. There is an antidepressant, Wellbutrin, or
bupropion, that’s not associated with aggravating or increased restless leg symptoms. So med, pregnancy, as we discussed, and renal
failure, obviously, that’s going to be relatively uncommon in our active-duty population, end-stage
renal failure and people on dialysis — many of them will report significant restless leg. Iron deficiency can be seen — people with
iron deficiency can be seen to have restless leg. I’m not an OBG, I’m not an endocrinologist,
but in my lay version of thinking about it, that may be a factor with why some women have
it during pregnancy. [Kinn] Yeah, that would make sense. [Olin] So that’s just what I thought, but
I haven’t seen that in the literature. [Kinn] So, John, how do you treat restless
leg syndrome? [Olin] So I check an iron level, and specifically,
I’m looking for an iron level, a lab value of something called ferritin, that is a measure
of a person’s long-term iron storage, and I generally like to see that above 75. Now, labs sometimes call 10 or 15 or less
abnormal, but there can be people with significant restless leg symptoms that will have, say,
a ferritin of 25 or 30 or 35, so it’s above what the lab calls too low, but when you replace
their iron with iron tablets, generally with vitamin C, they’ll then get better. So it’s not low enough to cause them to be
anemic, they’re still making red blood cells, but it’s low enough so that they’re developing
restless leg symptoms. Iron is used as a cofactor in the production
of a compound called dopamine. It’s a neurotransmitter involved with movement,
Parkinson’s disease. Michael J. Fox, for example, many people know
of him and know that he has Parkinson’s. Dopamine’s an important neurotransmitter for
movement, so if you’re not making enough dopamine over the course of the day, by the time the
evening rolls around and your iron levels are a little bit low and you’re not making
enough, then maybe that’s why you develop some restless leg symptoms at night. There can be some non-med treatments that
are useful…stretching…some people like warm baths, some people like cold baths. I had one person who got weighted blankets. I think it was, frankly, over the internet,
where he got this sort of lead, heavy buckshot kind of blankets, put those on his legs and
just felt better with kind of the pressure. Some people, as I said, will do stretching. Caffeine can aggravate restless leg, so there
are some people that reduce or stop their afternoon caffeine; alcohol aggravates, exacerbates
restless leg, so reducing/stopping evening alcohol. And then there’s some meds that are useful,
they can be extremely effective…I had one person I saw in the last week or two, and
she had very severe restless leg symptoms, and lived with them for years, and was very
reluctant to take a med. Didn’t do well on one med, and then started
another med and had basically resolution of her restless leg. [Kinn] Sounds like the good news is that it’s
treatable and it’s manageable. [Olin] Yes. In my experience, there are a few different
treatment options, and I can’t think of anyone that have had moderate or severe restless
leg that hasn’t gotten significant improvement. [Kinn] It sounds like one of those conditions
that if someone notices these symptoms, they shouldn’t wait too long to go see a provider
because there really are quite a few treatment options, medication, non-medication options,
and a few simple lifestyle changes that can make a big difference. [Olin] I agree. [Kinn] Well, thank you, John, for the excellent
information as always, and thank you to our listeners for joining us on “A Better Night’s
Sleep” podcast. “A Better Night’s Sleep” is produced by
the Defense Health Agency. You can join us on social media @MilitaryHealth
on Facebook and Twitter. [music]
Please send us your questions. Our next episode will feature John’s responses
to a few that we’ve already received. Thank you so much to those of you who have
rated and subscribed to “A Better Night’s Sleep” on iTunes or wherever you get podcasts. Be sure to check out our other shows, including
the “Military Meditation Coach” and “Next Generation Behavioral Health.” [music]

 

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