Restless Legs Syndrome

An unpleasant feeling in the legs and a strong urge to move the legs are typical symptoms of Restless Legs Syndrome, or RLS. The symptoms only occur while resting, mainly in the evening and at night. They can seriously disrupt sleep.

At a glance

  • People with Restless Legs Syndrome (RLS) feel an unpleasant tingling or pulling feeling in their legs and the desperate urge to move their legs.
  • This sensation – known as paresthesia – only occurs while resting and stops when the person moves their legs. The symptoms are at their worst in the evening and at night.
  • RLS can occur with no identifiable cause but can also develop in association with pregnancy, an iron deficiency, or certain illnesses.
  • There are some measures that can alleviate symptoms. For example, regular exercise can help, as can cutting out caffeine and alcohol.

Note: The information in this article cannot and should not replace a medical consultation and must not be used for self-diagnosis or treatment.

An unclothed lower leg and foot on a bed

What is Restless Legs Syndrome?

People with Restless Legs Syndrome (RLS) feel an uncomfortable tingling or pulling in their legs. They also have a strong need to move their legs. This sensation – known as paresthesia – only occurs while resting and stops temporarily when the person moves their legs.

RLS is also usually associated with involuntary, jerky leg movements while sleeping.

A distinction is drawn between primary and secondary Restless Legs Syndrome. The cause of the primary form is not known. It often runs in a family. The secondary form occurs in association with certain circumstances or conditions, for example pregnancy or an iron deficiency.

Medical experts also refer to RLS as Wittmaack-Ekbom Syndrome.

What are the symptoms of Restless Legs Syndrome?

People with Restless Legs Syndrome (RLS) experience an unpleasant feeling in their legs and a strong urge to move them. They describe the feeling as a tingling, a feeling of tightness, or of pulling deep in their legs. There is usually no pain and the skin is not sensitive to touch.

People with Restless Legs Syndrome experience an unpleasant feeling in their legs and a strong urge to move them.

The symptoms only occur while resting. Walking or other leg movements temporarily improve them. Rubbing or massage also alleviates the symptoms. The paresthesia is worst in the evening and at night, typically starting shortly after going to bed.

In people with severe RLS, the symptoms occur earlier in the day, while sitting or lying down – for example, when reading a book or in the cinema. The paresthesia can be so severe at night that the person feels they have to stand up to find relief.

Interesting fact: Periodic leg movements while sleeping occur in 80 percent of people with RLS. These are jerky, last a few seconds, and are repeated in a certain cycle. Doctors also refer to these as “Periodic Limb Movements of Sleep” (PLMS).

What causes Restless Legs Syndrome?

The exact causes of Restless Legs Syndrome (RLS) are unknown. However, there is a genetic predisposition to “restless legs” – the syndrome runs in the family of 40 to 60 percent of people with RLS. It is likely that other factors combine with a genetic predisposition to trigger the Restless Legs Syndrome.

These factors include:  

Exactly what happens in the body to trigger Restless Legs Syndrome is not yet known. However, various changes in the nervous system that may be connected with the syndrome have been identified in people with RLS.

These include, for example, an iron deficiency and a dopamine balance disorder. Dopamine is a neurotransmitter – a messenger substance in the nervous system – known as the “happy hormone”. But dopamine regulates movements as well as feelings of happiness.

A blood circulation disorder in the legs could also play a part in the development of Restless Legs Syndrome.

Which factors favor Restless Legs Syndrome?

A key factor that increases the risk of Restless Legs Syndrome (RLS) is an iron deficiency. Low levels of iron in the blood can be an indicator of RLS.

Low iron levels in the blood can be an indicator of Restless Legs Syndrome.

Some medications also increase the risk of developing “restless legs”. These include:

  • antihistamines for allergy problems
  • certain anti-depressants that are used to combat depression, for example
  • betablockers: drugs that reduce blood pressure
  • dopamine antagonists: drugs that act on nerve metabolism

People with Restless Legs Syndrome should consult their doctor in connection with any medication they may be taking that could be contributing to the condition.

RLS can also occur in association with certain illnesses. 25 to 50 percent of people with chronic end-stage renal failure develop restless legs. It also occurs with nerve and bone marrow conditions, multiple sclerosis, and possibly Parkinson’s disease.

In children, Restless Legs Syndrome often occurs in association with attention deficit hyperactivity disorder (ADHD) and depression.

How common is Restless Legs Syndrome?

Restless Legs Syndrome (RLS) is common. It occurs in around 5 to 10 percent of adults and 2 to 4 percent of children and adolescents. However, it is estimated that only 2 to 3 percent of adults have moderate to severe symptoms.

RLS can occur at any age. However it is more common in people aged over 65. It occurs around twice as often in women as in men. In children, it is equally likely to occur in boys as in girls.

Some women also have restless legs when pregnant, particularly in their third trimester. The symptoms disappear again after the birth.

How does Restless Legs Syndrome progress?

Primary Restless Legs Syndrome (RLS), the cause of which is unknown, occurs before a person’s 30th birthday. There is often a prior history of RLS within the family. It typically develops slowly, being at its most severe between the ages of 40 and 60.

The symptoms get worse with age in around 70 percent of people with RLS. In severe cases, the person also often gets symptoms in their arms, often years after the problems have started in their legs.

Restless Legs Syndrome makes it difficult to fall asleep and causes wakefulness during the night. The sleep disorders or disrupted sleep that can be caused by RLS can have a severe impact on quality of life and cause daytime fatigue. People with restless legs are also prone to high blood pressure and headaches.

How is Restless Legs Syndrome diagnosed?

The doctor asks about symptoms and underlying conditions and can diagnose Restless Legs Syndrome (RLS) from the typical symptoms.

The physical examination is usually routine. A diagnosis does not require any further tests. However, the doctor takes a blood sample to determine iron level, as it is often too low in people with RLS. If there is any suspicion that another condition is causing the symptoms, other tests may be required.

How is Restless Legs Syndrome treated?

There are some measures that can alleviate the symptoms of Restless Legs Syndrome (RLS). In mild cases, massaging or rubbing the legs is enough to alleviate the symptoms. With severe RLS, there are some measures that can help people be less reliant on medication.

These measures include regular movement and mental stimulation during rest phases, for example, solving crossword puzzles. Cutting out caffeine, nicotine and alcohol also has positive effects.

It is a good idea to check whether any medication that is being taken may be making the symptoms worse. If so, the doctor can be consulted to see whether there are any suitable alternatives.

Getting enough sleep is also important because a lack of sleep can make the symptoms worse. When children, in particular, have Restless Legs Syndrome, parents should ensure that they have regular bedtimes and get enough sleep.

If the iron level in the blood is low, the doctor will prescribe iron tablets. However, iron shouldn’t be taken without consulting a doctor so as to avoid overdosing.

In severe cases, when these measures are not enough, medication can help.

When medicines are used to treat RLS, the following agents are the most common:

  • Dopamine antagonists such as pramipexole, ropinirole or rotigotine: these replicate the effect of dopamine on the brain.
  • Anticonvulsants such as gabapentin or pregabalin: these are drugs to relieve cramp and are also used with epilepsy.

Important: These drugs are effective but they have side effects. Dopamine antagonists can suddenly make the symptoms worse, even though the drug is effective to begin with – an effect which is known medically as augmentation. For this reason, doctors try to keep the dose of these drugs as low as possible.

Levodopa, an agent that increases the amount of the messenger substance dopamine, and, in severe cases, painkillers from the opioid class can also be used.

In cooperation with the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen – IQWiG).

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