Currently, there is no single diagnostic test for RLS. The disorder is diagnosed clinically by evaluating the patient’s history and symptoms. Despite a clear description of clinical features, the condition is often misdiagnosed or underdiagnosed. In 1995, the International Restless Legs Syndrome Study Group identified four basic criteria for diagnosing RLS: (1) a desire to move the limbs, often associated with paresthesias or dysesthesias, (2) symptoms that are worse or present only during rest and are partially or temporarily relieved by activity, (3) motor restlessness, and (4) nocturnal worsening of symptoms. Although about 80 percent of those with RLS also experience PLMD, it is not necessary for a diagnosis of RLS. In more severe cases, patients may experience dyskinesia (uncontrolled, often continuous movements) while awake, and some experience symptoms in one or both of their arms as well as their legs. Most people with RLS have sleep disturbances, largely because of the limb discomfort and jerking. The result is excessive daytime sleepiness and fatigue.

Despite these efforts to establish standard criteria, the clinical diagnosis of RLS is difficult to make. Physicians must rely largely on patients’ descriptions of symptoms and information from their medical history, including past medical problems, family history, and current medications. Patients may be asked about frequency, duration, and intensity of symptoms as well as their tendency toward daytime sleep patterns and sleepiness, disturbance of sleep, or daytime function. If a patient’s history is suggestive of RLS, laboratory tests may be performed to rule out other conditions and support the diagnosis of RLS. Blood tests to exclude anemia, decreased iron stores, diabetes, and renal dysfunction should be performed. Electromyography and nerve conduction studies may also be recommended to measure electrical activity in muscles and nerves, and Doppler sonography may be used to evaluate muscle activity in the legs. Such tests can document any accompanying damage or disease in nerves and nerve roots (such as peripheral neuropathy and radiculopathy) or other leg-related movement disorders. Negative results from tests may indicate that the diagnosis is RLS. In some cases, sleep studies such as polysomnography (a test that records the patient’s brain waves, heartbeat, and breathing during an entire night) are undertaken to identify the presence of PLMD.

The diagnosis is especially difficult with children because the physician relies heavily on the patient’s explanations of symptoms, which, given the nature of the symptoms of RLS, can be difficult for a child to describe. The syndrome can sometimes be misdiagnosed as “growing pains” or attention deficit disorder.
How is restless legs syndrome treated?

Although movement brings relief to those with RLS, it is generally only temporary. However, RLS can be controlled by finding any possible underlying disorder. Often, treating the associated medical condition, such as peripheral neuropathy or diabetes, will alleviate many symptoms. For patients with idiopathic RLS, treatment is directed toward relieving symptoms.

For those with mild to moderate symptoms, prevention is key, and many physicians suggest certain lifestyle changes and activities to reduce or eliminate symptoms. Decreased use of caffeine, alcohol, and tobacco may provide some relief. Physicians may suggest that certain individuals take supplements to correct deficiencies in iron, folate, and magnesium. Studies also have shown that maintaining a regular sleep pattern can reduce symptoms. Some individuals, finding that RLS symptoms are minimized in the early morning, change their sleep patterns. Others have found that a program of regular moderate exercise helps them sleep better; on the other hand, excessive exercise has been reported by some patients to aggravate RLS symptoms. Taking a hot bath, massaging the legs, or using a heating pad or ice pack can help relieve symptoms in some patients. Although many patients find some relief with such measures, rarely do these efforts completely eliminate symptoms.

In most cases, the cause of RLS is unknown (referred to as idiopathic). A family history of the condition is seen in approximately 50 percent of such cases, suggesting a genetic form of the disorder. People with familial RLS tend to be younger when symptoms start and have a slower progression of the condition.

In other cases, RLS appears to be related to the following factors or conditions, although researchers do not yet know if these factors actually cause RLS.

People with low iron levels or anemia may be prone to developing RLS. Once iron levels or anemia is corrected, patients may see a reduction in symptoms.

Chronic diseases such as kidney failure, diabetes, Parkinson’s disease, and peripheral neuropathy are associated with RLS. Treating the underlying condition often provides relief from RLS symptoms. Some pregnant women experience RLS, especially in their last trimester. For most of these women, symptoms usually disappear within 4 weeks after delivery.

Certain medications-such as antinausea drugs (prochlorperazine or metoclopramide), antiseizure drugs (phenytoin or droperidol), antipsychotic drugs (haloperidol or phenothiazine derivatives), and some cold and allergy medications-may aggravate symptoms. Patients can talk with their physicians about the possibility of changing medications.
Researchers also have found that caffeine, alcohol, and tobacco may aggravate or trigger symptoms in patients who are predisposed to develop RLS. Some studies have shown that a reduction or complete elimination of such substances may relieve symptoms, although it remains unclear whether elimination of such substances can prevent RLS symptoms from occurring at all.

What are common signs and symptoms of restless legs?

As described above, people with RLS feel uncomfortable sensations in their legs, especially when sitting or lying down, accompanied by an irresistible urge to move about. These sensations usually occur deep inside the leg, between the knee and ankle; more rarely, they occur in the feet, thighs, arms, and hands. Although the sensations can occur on just one side of the body, they most often affect both sides.

Because moving the legs (or other affected parts of the body) relieves the discomfort, people with RLS often keep their legs in motion to minimize or prevent the sensations. They may pace the floor, constantly move their legs while sitting, and toss and turn in bed.

Most people find the symptoms to be less noticeable during the day and more pronounced in the evening or at night, especially during the onset of sleep. For many people, the symptoms disappear by early morning, allowing for more refreshing sleep at that time. Other triggering situations are periods of inactivity such as long car trips, sitting in a movie theater, long-distance flights, immobilization in a cast, or relaxation exercises.

The symptoms of RLS vary in severity and duration from person to person. Mild RLS occurs episodically, with only mild disruption of sleep onset, and causes little distress. In moderately severe cases, symptoms occur only once or twice a week but result in significant delay of sleep onset, with some disruption of daytime function. In severe cases of RLS, the symptoms occur more than twice a week and result in burdensome interruption of sleep and impairment of daytime function.

Symptoms may begin at any stage of life, although the disorder is more common with increasing age. Sometimes people will experience spontaneous improvement over a period of weeks or months. Although rare, spontaneous improvement over a period of years also can occur. If these improvements occur, it is usually during the early stages of the disorder. In general, however, symptoms become more severe over time.

People who have both RLS and an associated condition tend to develop more severe symptoms rapidly. In contrast, those whose RLS is not related to any other medical condition and whose onset is at an early age show a very slow progression of the disorder and many years may pass before symptoms occur regularly.

How is Restless Legs Treated?

Physicians also may suggest a variety of medications to treat RLS. Generally, physicians choose from dopaminergics, benzodiazepines (central nervous system depressants), opioids, and anticonvulsants. Dopaminergic agents, largely used to treat Parkinson’s disease, have been shown to reduce RLS symptoms and PLMD and are considered the initial treatment of choice. Good short-term results of treatment with levodopa plus carbidopa have been reported, although most patients eventually will develop augmentation, meaning that symptoms are reduced at night but begin to develop earlier in the day than usual. Dopamine agonists such as pergolide mesylate, pramipexole, and ropinirole hydrochloride may be effective in some patients and are less likely to cause augmentation.

In 2005, ropinirole became the only drug approved by the U.S. Food and Drug Administration specifically for the treatment of moderate to severe RLS. The drug was first approved in 1997 for patients with Parkinson’s disease.

Benzodiazepines (such as clonazepam and diazepam) may be prescribed for patients who have mild or intermittent symptoms. These drugs help patients obtain a more restful sleep but they do not fully alleviate RLS symptoms and can cause daytime sleepiness. Because these depressants also may induce or aggravate sleep apnea in some cases, they should not be used in people with this condition.

For more severe symptoms, opioids such as codeine, propoxyphene, or oxycodone may be prescribed for their ability to induce relaxation and diminish pain. Side effects include dizziness, nausea, vomiting, and the risk of addiction.

Anticonvulsants such as carbamazepine and gabapentin are also useful for some patients, as they decrease the sensory disturbances (creeping and crawling sensations). Dizziness, fatigue, and sleepiness are among the possible side effects.

Unfortunately, no one drug is effective for everyone with RLS. What may be helpful to one individual may actually worsen symptoms for another. In addition, medications taken regularly may lose their effect, making it necessary to change medications periodically.

What is the prognosis of people with restless legs?

RLS is generally a lifelong condition for which there is no cure. Symptoms may gradually worsen with age, though more slowly for those with the idiopathic form of RLS than for patients who also suffer from an associated medical condition. Nevertheless, current therapies can control the disorder, minimizing symptoms and increasing periods of restful sleep. In addition, some patients have remissions, periods in which symptoms decrease or disappear for days, weeks, or months, although symptoms usually eventually reappear. A diagnosis of RLS does not indicate the onset of another neurological disease.

What research is being done?

Within the U.S. Federal Government, the National Institute of Neurological Disorders and Stroke (NINDS), one of the National Institutes of Health, has primary responsibility for conducting and supporting research on RLS. The goal of this research is to increase scientific understanding of RLS, find improved methods of diagnosing and treating the syndrome, and discover ways to prevent it.

NINDS-supported researchers are investigating the possible role of dopamine function in RLS. Dopamine is a chemical messenger responsible for transmitting signals between one area of the brain, the substantia nigra, and the next relay station of the brain, the corpus striatum, to produce smooth, purposeful muscle activity. Researchers suspect that impaired transmission of dopamine signals may play a role in RLS. Additional research should provide new information about how RLS occurs and may help investigators identify more successful treatment options.

The NINDS sponsored a workshop on dopamine in 1999 to help plan a course for future research on disorders such as RLS and recommend ways to advance and encourage research in this field. Participants’ recommendations for further research included the development of an animal model of RLS; additional genetic, epidemiologic, and pathophysiologic investigations of RLS; efforts to define genetic and non-genetic forms of RLS; establishment of a brain tissue bank to aid investigators; continuing investigations on dopamine and RLS; and studies of PLMD as it relates to RLS.

Research on pallidotomy, a surgical procedure in which a portion of the brain called the globus pallidus is lesioned, may contribute to a greater understanding of the pathophysiology of RLS and may lead to a possible treatment. A recent study by NINDS-funded researchers showed that a patient with RLS and Parkinson’s disease benefited from a pallidotomy and obtained relief from the limb discomfort caused by RLS. Additional research must be conducted to duplicate these results in other patients and to learn whether pallidotomy would be effective in RLS patients who do not also have Parkinson’s disease.

In other related research, NINDS scientists are conducting studies with patients to better understand the physiological mechanisms of PLMD associated with RLS.