Sleep Soundly Every Night, Feel Fantastic Every Day (11 page)

Secondary RLS
can be caused or is associated with a number of disorders including iron deficiency, renal disease, diabetes, multiple sclerosis, and Parkinson's disease. Other known contributors of RLS include alcohol use, muscle overexertion, prolonged sitting, dehydration, and certain medications, such as antipsychotics, antidepressants (except Wellbutrin), and antihistamines (such as doxylamine often used in over-the-counter sleep aids and diphenhydramine (Benadryl)).

RLS is “one of the most prevalent neurological disorders in Europe and North America, affecting about 10% of the population, with women being afflicted almost twice as often as men.” Twenty percent of women have RLS symptoms during their third trimester of pregnancy. RLS is often common in people with fibromyalgia. In fact, one-third of women with fibromyalgia have RLS. This is believed
to be attributable to the fact that both may be related to abnormalities of the dopamine system. Surveys have demonstrated that 25% of the adults with RLS trace the onset of their symptoms to between the ages of 10 and 20. RLS is a significant contributor to both depression and anxiety disorders, probably due to sleep disruption.

Although commonly overlooked in children, about 2% of American children experience RLS. Unfortunately, past cases of children with RLS were misdiagnosed as “growing pains” and more recently as attention deficit hyperactivity disorder (ADHD). Inattention and hyperactivity among children are associated with symptoms of RLS and may actually be a manifestation of RLS. Further evidence from the survey of clinical studies (up through 2005) confirmed the association between ADHD, ADHD symptoms, and RLS. If your child has been diagnosed with ADHD, consider ruling out RLS or another sleep disorder to ensure the most effective treatment. (For more on ADHD and sleep disorders, see
chapter 13
.)

There is a strong genetic component. The genetic tendency in those suffering from RLS is a 40% chance of having a first-degree relative with the disease. In fact, the incidence is more than 90% in identical twins. A red flag for inheriting the disorder is the onset of symptoms in early life. One study to determine the age of onset in 250 adults with RLS found a distinction of onset between patients with family histories and those without the family etiology. The peak of onset occurred at 20 years of age, and a smaller peak of onset at 40 years for those with a familial component. Early onset is associated with increased severity, higher incidence of periodic limbs movements in sleep, and movements with micro-arousals during sleep resulting in a disrupted sleep pattern.

No one knows the exact cause of RLS, though a dopamine imbalance in the brain is highly suspected due to a decrease
in dopamine levels in cerebral spinal fluid. Dopamine is a neurotransmitter that sends chemicals for muscle control.

1.
 
The characteristics of RLS are the strong urge to move, accompanied or caused by uncomfortable or distressing skin sensations of the legs.

2.
 
People with RLS have unpleasant sensations in the legs, but the sensations can extend into the torso and arms.

3.
 
Patients have described the sensations as

    
a.
 
An itch you can't scratch,

    
b.
 
Aching muscles, penetrating pain,

    
c.
 
An unpleasant tickle that won't stop,

    
d.
 
Phantom limb pain,

    
e.
 
Crawling, as you brush the crawling thing off your arm, except when you look, nothing is there.

The unpleasant part of these sensations is they can start when you are watching television, reading a book, trying to sleep, or in that space of being awake, yet relaxed. Then the itch, cramp, tickle, or throbbing intensifies into discomfort that is usually relieved by movement like getting out of bed or the chair, walking slowly, and standing, then increasing the movement and stretching if possible.

These sensations tend to occur in the late evening and during the night. The solution is to walk for relief, or even trying Joan's method of a soak in hot water to relax.

I believe RLS is a disorder of the central nervous system, revolving around the metabolism of the neurotransmitter dopamine. More people with low total-body iron stores, measured by a blood test called ferritin, have a high incidence
of RLS. Iron is necessary for the formation of dopamine and explains why the most successful medications in treating RLS stimulate brain areas receptive to dopamine action. On a positive note, iron therapy normalizes ferritin levels and can resolve the disorder in many patients.

Treatment of RLS takes into consideration how to relieve symptoms, but also any discovered cause or associated medical condition such as neuropathy. For relief of RLS that seems sporadic, movement, stretching, and massaging the legs does help to relieve symptoms. You can also make lifestyle changes such as:

  
Eliminating caffeine, nicotine, alcohol, and over-the-counter drugs containing doxylamine (such as NyQuil) or diphenhydramine (Benadryl), since all of these substances seem to aggravate RLS.

  
Moderate daily exercise such as a 20-minute power walk or yoga stretches.

If symptoms persist, ask your health care provider to test you for low levels of iron, magnesium, and potassium. If necessary, you may need to add supplements to your diet. Other effective treatments not involving medications are pneumatic compression, massage, near-infrared light therapy, and programs of physical activity. Pneumatic compression involves a compression garment “sleeve,” also used to prevent blood clots from forming after surgery, that fits on the arm or the leg. Attached to the sleeve is an electric pneumatic pump that fills the garment with compressed air on a timed cycle. The cycled compression helps lymph to pump and blood to circulate.

In other studies in patients with spider veins, varicose veins, and other superficial varicosities, both sclerotherapy, in which a medicine is injected into the blood vessels to make them shrink, and laser ablation have proven to be
very effective. In a recent study of laser therapy, there was an 80% success rate.

A common misconception is to label involuntary movements of the limbs during sleep as RLS. These are periodic limb movements in sleep, and cause insomnia and daytime sleepiness. Although they are more common in people with RLS, they are not the same disorder. The differences are listed here.

 

 

Over the years, I have received numerous questions about RLS. RLS is a significant contributor to both depression and anxiety. I hope that my answers to these questions will help you:

1.
 
Understand how people experience the varied symptoms of RLS.

2.
 
Become more aware of the medications available for RLS, and know their side effects.

3.
 
Pay attention to the onset of unusual symptoms and discuss them with your doctor.

Q.
 
My husband has a problem with his feet. They hurt him so badly that at night he cannot stand to have anything touching them. He sleeps with the bedcovers off. His feet even go numb occasionally. He was tested for diabetes, but that was negative. Can you think of a reason his feet would hurt like this?

A.
 
The question is, do your husband's feet hurt only at night and when immobile? If this is the case, it might be RLS. On the other hand, if this is an ongoing problem regardless of the timing, and moving his legs does not relieve symptoms, this could be neuropathy. Although diabetes is a common cause of neuropathy, there are numerous other causes. Have a neurologist evaluate your husband. Many tests can determine the cause.

Q.
 
I consulted with a psychopharmacologist. I mentioned that I had RLS. He told me that the antidepressants like the one I was taking could cause RLS. Since stopping the medication, I no longer have an irresistible urge to move and rub my legs. I thought you might want to pass this on to your readers.

A.
 
Thank you for your suggestion to address this important issue. It is true that almost all antidepressant medications can cause or increase the symptoms of RLS. There is, however, one exception, and that is bupropion, also known as Wellbutrin. That is why I frequently recommend
Wellbutrin as the antidepressant of choice for a patient with RLS.

Q.
 
To get to sleep I must rub my feet together. I simply cannot sleep unless I do that. Sometimes this may go on for up to an hour before I can fall asleep. What is wrong with me?

A.
 
What you are describing could be RLS. People with RLS tend to develop their symptoms after dark. They frequently experience an irresistible urge to move or rub their legs. This is a common cause of an inability to either fall or stay asleep.

Q.
 
I have heard that there is a link between RLS and a gambling addiction. Do you know anything about that?

A.
 
Yes, I do. However, the RLS itself is not associated with compulsive gambling. It is one of the medications used to treat RLS. There is a risk that the medications for RLS could exacerbate problems if you struggle with compulsive shopping, gambling, or binge eating. Please note that this is a very rare occurrence.

Q.
 
My wife has RLS. She started on a medication called Requip. Since starting on it, she goes shopping every day, and it is costing us a lot of money. Is there any relationship? It seems like too much of a coincidence.

A.
 
Requip and some of the other medications used to treat RLS such as Mirapex have been associated with impulse control disorders. Problems include compulsive
gambling, shopping, or eating, and hypersexuality. These problems were reported in up to 7% of those using these medications. I would definitely bring this to the attention of your health care provider.

Q.
 
I have severe acid reflux. Four months ago, my doctor started me on the medication metoclopramide since the Prilosec I was taking was not effective. The new medication works. However, for the last few weeks, my legs drive me crazy at night. I get some tingling sensations that can only be relieved by walking or rubbing my legs. I think this might be RLS. Could there be a relationship to my new medication?

A.
 
The answer to both questions is yes. What you are describing is a classic example of RLS. Although it is not definite, the metoclopramide is a likely cause. Metoclopramide (Reglan) blocks the activity of a brain chemical called dopamine. This blocking effect on dopamine may be the basis for the development of RLS. It is important that you point out the symptoms to your physician.

Q.
 
I have had RLS for several years. I have been on a medication called Sinemet all this time and have been fine. Recently, the pain has returned and the symptoms are starting earlier in the day. It is worse than ever and has started in my arms as well. What could be happening and what can I do?