Dear Rosi,

Being a neurologist my focus is on pharmacological therapy mainly. I find that with my Parkinson's disease patients the dopamine agonist drugs ropinirole or pramipexole administered at low dose at bedtime tend to relieve RLS overnight effectively.

James

In addition to medications, some behavioral approaches like mental activation and mild exercise (cycling) is recommended for patients with RLS. More recently a study showed that medications which are calcium channel alpha 2 delta ligands (Gabapentin) are almost as effective as dopaminergic medications.

Hi Rosi

This isn;t a research-based answer, but my expereicne is that people with night symptoms like RLS or chronic pain notice these things more because that's the only sensory input they are getting.

Quiet music or scented candles can be simple tricks that give another sensory input that distracts from focussing only on the RLS.

Worth a try!

Hi, James,

My patients use some low dose dopamine agonists at night, and report the benefits last 5-6 hours. It doesn't help during the day when they come to my office. The RLS is more noticeable when they are "off", or for early stage patients who haven't started Sinemet. When the RLS is calm, they may even sleep soundly during treatments (even with nighttime meds, they still have sleep deficits!). However, it is unpredictable. They often need to get up to walk to relieve the discomfort, so I am looking for treatment interventions that can consistently affect RLS during sessions.

Do any of your patients complain of RLS when they sit or attempt to rest during the day? Do you have daytime strategies you recommend to them?

Thank you for your response.

Rosi

Dr. Khawaja,

What types of mental activation have been helpful? Do you mean meditation or mental imagery? Or focused awareness? All my patients engage in some kind of exercise. During sessions, getting up and walking around or SLS, eyes open and eyes closed, on a balance pad, or other standing movement relieves the RLS temporarily, but it's not always very relaxing.

Gabapentin was taken by one of my patients and discontinued due to side effects. It is also prescribed for nighttime RLS. I realize from both yours and Dr. Gratwicke's responses, I failed to clarify in my original questions that I am looking for a daytime solution for my office treatments.

Thank you,

Rosi

Hi, David,

There appears to be no consensus on the cause of RLS. I've noticed that mild massage will often trigger RLS; sometimes firm pressure and strokes to the plantar fascia and feet will relieve it. And, paradoxically, sometimes Yin Tui Na will relieve it or aggravate it. Sustained compressions to the paraspinal muscles seem to prevent it and allow deep restorative sleep during sessions. But not always, and I am attempting to control for variables.

I am curious about your line of thinking in terms of distracting sensory input. Can you expand on that some more? I sometimes use scented oils for different purposes in my sessions, to increase the parasympathetic response monitored by pulse oximeter, and to fire ipsilateral olfactory neurons for hemisphericity issues. I could easily test that as a RLS intervention, or, less easily, look through my chart notes for whether scents seemed to prevent RLS during sessions. Once RLS starts, the discomfort is so great that only getting up will relieve it.

Thank you,

Rosi

Hi Rosi,

For daytime symptoms, one can use Levadopa/Carbidopa as it helps right away and might be beneficial for patients with Parkinson's disease if they have not developed augmentation. For mental activity exercises, doing cross word puzzles have helped some patients.

Hi Rosi

I feel like I'm being a bit simplistic compared to some of the other responses, but if it helps someone I don't mind!

My background is in physiotherapy, and what I used to tell people is that at night they have limited visual input (they aren't really seeing anything), limited auditory input (not really hearing anything), limited taste or smelling input compared to what they expereince during the day.

So at night the brain, instead of receiving input from 5 senses more or less equally, is now primarily receiving input from one- that sense of touch / musculoskeletal sense. This becomes the primary neural input, which is why these symptoms feel so much worse at night.

If you give the brain some other sensory input stream, like auditory or olfactory input, it can de-emphasise the neural input from that other, over-riding sense.

Like I said, not research-based, not particularly profound, but something I've found in the past can be helpful.

Regards

David

David, and others,

I tried out David's suggestions on a client today. Both lively and calming music had no effect; neither did any of the scents. Manual therapy to relieve pain and muscular tension was mildly successful, as was inhibitory massage--for a while, then the RLS resumed.

He said Sinemet has seemed to make it worse (he just started it recently), and Ropinerole has been less effective than before he started Sinemet.

Any research you or anyone finds, please send my way. Thank you.

Hi Rosi

I should clarify my suggestions were for the client to trial at home at night, not in the clinic situation.

Good luck with it.

I am not a health professional, but am a patient with severe 24/7 symptoms if not treated.

My first suggestion is to get a copy of Clinical Management of Restless Leg Syndrome (2nd Edition) by Lee, Buchfuhrer, Allen and Henning. This provides a great number of suggestions for treatments.

For me, treatment with a dopamine agonist (pramipexole) worked for a while, but I have now supplemented that with gabapentin. The combined therapy seems to be working for me, but every RLS patient is different. Some have to move on to opiates.

As for the mental stimulation aspect, many RLS sufferers have found distraction such as video games, Sudoku or crossword puzzles an effective method of temporarily relieving the need to move symptoms.

In my practice I find that levodopa medications may help somewhat in the short term but not alone in the long run - rebound effects seems to be stronger with these agents than with dopamine agonists such as pramipexol, or ropinirole which also often have a sleep supporting effect if taken in the evening or as CR preparations. For pure night time effect, the shortlasting versions of the agonists may help but also night time use of the rotigotine patch may work, especially if ordinary agonist tablets are too short lasting and you don't want the daytime "nodding off" effect which some patients get on CR agonists. Side effects of the agonists (often worse at night) must naturally be carefully considered, including impulsivity problems and hallucinations.

i used the pulsed electromagnetic field therapy in the 10 Hz and 2 mT for head of restless leg syn. for several times. i had good result and pleasant for patients

Strict adherence to sleep hygiene, and Feldenkreis back stretching/traction has helped get 6-7 hours of sleep for some of my class participants. If crimps in spinal nerve effects are unpredictable.

Dr. Hatef,

Could you provide more details of your treatment? How did you administer it? Frequency and dose? Did your patients only have RLS, or other conditions, like Parkinson's as well. Thank you.

Dear Rosi

at first time, a woman with chronic migraine was referred me for electromagnetic field (PEMF) therapy. she had high blood pressure and severe restless leg syn. surprisingly the intensity and duration of restless of her legs decreased. despite i used therapy on head, the leg discomfort was changed. i think because the PEMF increases the blood velocity and resets the vascular tonicity, each disorder affects vascular system like high blood pressure and restless leg may be treated by it. usually i use the PEMG 3 sessions at week for 2 weeks. each session 30 minutes of the 1-2 mT and 8-10 Hz rectangular pulse. this protocol is done for first time and other times will be less. sometimes only one session help to patient to keep same therapeutic effect.

i hope it is benefit for each restless leg syn patient

Regarding RLS, I have only anecdotal evidence, but I was told of positive results using "Pedal lymphatic pump." See: http://youtu.be/2fvltywN_yc

If effective the procedure may be taught to a family member.

Regarding Parkinson's patients, you may be interested by chapter 32 "The Patient with Parkinson's Disease" in: Somatic Dysfunction in Osteopathic Family Medicine. Nelson KE, Glonek T, eds. 2nd edition, Baltimore, MD: Wolters Kluwer / Lippincott, Williams & Wilkins; 2014.

Dear Rosi,

How about the following hypothesis: Suppose these patients have in day-time to much pressure in their abdomen and legs. You can check their abdominal tension and muscle tension in their legs. Cold legs and feet may be a sign too.

If this tension is present this may be a consequence of abarrent motion patterns. One consequence of this is that blood flow in the legs is hampered. At night when the patient relaxes, the blood flow restores, leading to the awkward sensations.

Therapeutic suggestion: have the patient relax a few times over the day (muscle relaxation, while laying down). This may have the following consequences: at first some tingling during the relaxation exercises, but also less problems during the night (after a few days). Let me know how this works out!

Dear Dr. Hatef,

I have referred one patient to find PEMF therapy locally. We shall see how that goes. Thank you

Rosi

I may have found a partial solution. I reasoned that if walking relieves the RLS, how about rhythmic and rapidly changing stimulation to the plantar surfaces of the feet? So far, it has been quite helpful for two of my patients.

The RLS contractions often present as a quick simultaneous dorsiflexion and plantar contraction. They have a rhythm. When I do variable, alternating, deep stimulation to the plantar surfaces and ROM of the ankle and metatarsal joints, hold the plantar contraction and anticipate the dorsiflexion, match it, and follow through, they are not awakened by the discomfort. The intensity of the contractions diminishes. They have some deep sleep during my sessions, and are much refreshed.

I am curious if anyone knows neurological causes of RLS? What is happening with the brain and CNS, or? What is it about the state of resting that triggers it?

I am looking to understand why this might be effective, and if so, what might make it more effective?

Is there a known rhythm to RLS? I know there is with PLMD, it can be clocked. This is not quite as regular as PLMD. My patients describe it as a buildup of discomfort that necessitates movement to relieve it, i.e., they can feel it coming. Perhaps the buildup of tension is what creates the apparent rhythm?

Thank you,

Rosi

The answer to your question of whether anyone knows the neurological causes of RLS is No. There is quite a bit of research into changes in dopamine concentrations in various areas of the brain and CS fluid, but nothing definitive has been concluded. There are ideas that involve the substantia nigra portion of the brain as well as the hypothalamus. There are also theories that involve cerebral iron levels, which tie to the local production of dopamine. My source on this is the clinical management guide referenced in my first note.

Recent research at Johns Hopkins may have identified issues with glutamate levels in these same areas of the brain. Elevated level of glutamate would trigger arousal, which could explain the insomnia issues associated with RLS and maybe even the relationship with trying to rest. Here is a link to a report on that study.

http://www.hopkinsmedicine.org/news/media/releases/restless_legs_syndrome_insomnia_and_brain_chemistry_a_tangled_mystery_solved

As for a rhythm for RLS similar to that of PLMS, my experience is similar to your patients that there is not. Maybe it is the conscious brain attempting to override a more subtle issue. But I can appreciate your client's description of building pressure since I have used the same analogy. If the pressure is relieved by moving (which is very difficult to do), there are reports that the nervous system will ultimately trigger an involuntary jerk that is very strong.