Restless Leg Syndrome

Robert Janda, MA, DC 2007
Restless leg syndrome (RLS) is a condition in which there is a spontaneous movement of the lower extremities with a strong concomitant sense of discomfort, often resulting in a lack of sleep. It tends to occur more frequently in women than men, and more often as individuals age. Although studies are not consistent, RLS tends to be correlated with increased body mass index, decreased income, smoking, decreased exercise, decreased alcohol consumption, diabetis, arthritis, gastroesophageal reflex disease, inflammation of the viens, depression, pregnancy and anxiety. The variety of apparent correlated factors makes it difficult deduce a cause.

Because Parkinson’s disease (PD) and RLS both involve spontaneous leg motion, it has been assumed my many doctors that these two diseases are related, and to this day are treated with the same drugs. There are reasons for thinking they are related. For example, one study found a decreased iron content in the Substantia Nigra (the part of the brain that degenerated in PD and is rich in iron) (11). Studies have found decreased blood iron levels in RLS (13, 19, 28), however, others found no relationship with low iron levels at all (2,14, 26). One found it correlated with high ferritin levels (2). Treatment with iron has also yielded mixed results with some causing improvement (8,19) and some not (5).

Since PD is also associated with low dopamine (a brain neurotransmitter), medical treatment has also focused on replacing dopamine in RLS, either directly or with dopamine agonists such as Cabergoline. Again the results have been mixed with some producing positive results (18,27), but these are short lived and drug rotation is necessary to preserve symptom relief (14). This had lead some researchers to conclude that PD and RLS are not developmentally related (20, 29), but that other dopamine pathways might be involved (9). Wetter et al (32) have concluded that the etiology of RLS is unknown and all current treatments are symptomatic.

From a Chiropractic perspective what has been overlooked? Is the medical profession focusing on the wrong arena by researching and treating largely physiological and central nervous system causes? We believe so. Instead we believe the primary causes, in many cases, are to be found in the peripheral nervous system with problems arising from nerve irritation and nerve entrapments within the musculature and fascia. What evidence is there for this? First, RLS is associated with pregnancy, primarily in the 3rd trimester and is relieved after birth (16). F. Lewis (15) has postulated that RLS is caused by compression of the Saphenous nerve in the pelvis in pregnant women. This is consistent with nerve compression in the pelvis. Secondly, RLS is correlated with increased body mass which offers increased opportunity for nerve compression. RLS is also correlated with increased age, decreased income, smoking and hypertension – themselves correlated with increased muscle tension. It is also correlated with sleep apnea, loss of sleep and fatigue for similar reasons. It is decreased by exercise which relieves muscle tension.

Two other factors know to be related to RLS are worth considering in this light – diabetis and varicose veins. Both of these increase nerve sensitivity through free radical damage, which lowers the nerve sensitivity to compression and adhesions. Diabetis is known for nerve degeneration which can be prevented, in part, by alpha lipoic acid, an antioxidant free radical scavenger. Vericose veins can become sensitive and distended. They are full of nerve fibers as anyone can testify to who has had their blood drawn. Chronic irritation of the veins will chronically irritate the local peripheral nervous system and make it more responsive to pressure by the musculature. One researcher (13) reported that 22% of patients with vericosities had RLS and 98% responded to sclerotherapy (destruction of the vein which kills the nerve endings).

Further, entrapment syndromes have been correlated clinically with restless muscles. Crotti et al (4) have noted that in post surgical patients entrapment of the Crural nerve produces clinical features that are “the same as for the restless leg syndrome”. Another researcher (24) found that tarsal tunnel entrapments (in the ankle) produced ‘painful leg and moving toes.” Others have noted that Carpal Tunnel Syndrome may be associated with ‘restless hands’ analogous to RLS (30).
In our own clinic we have seen numerous cases of RLS, leg pain, as well as arm pain, resolve by treating peripheral nerve irritations anywhere from the spinal disc to the distal extremities. Usually patients start responding after the 1st visit. The specific location of the entrapments can be located with reasonable precision using chiropractic techniques developed in Applied Kinesiology and the symptoms relieved quite quickly. We feel these simple techniques should be tried first before using potentially damaging drugs which can harm the liver, and nervous system. Almost all patients with RLS will be found to have hypertensive musculature with palpation, but this simple exam is apparently rarely done and even more rarely correlated with the problem.

References:
1: J Am Board Fam Med. 2006 Sep-Oct;19(5):487-93.


Exercise and restless legs syndrome: a randomized controlled trial.
· Aukerman MM,
· Aukerman D,
· Bayard M,
· Tudiver F,
· Thorp L,
· Bailey B.

Department of Kinesiology, Pennsylvania State University, Pennsylvania, USA.
BACKGROUND AND OBJECTIVES: Restless legs syndrome (RLS) is a common, underdiagnosed neurological movement disorder of undetermined etiology. The primary treatments for restless legs syndrome are pharmacological. To date, no randomized controlled trials have examined the effectiveness of an exercise program on the symptoms of RLS. METHODS: Study participants (N = 41) were randomized to either exercise or control groups. 28 participants (average age 53.7; 39% males) were available and willing to begin the 12-week trial. The exercise group was prescribed a conditioning program of aerobic and lower-body resistance training 3 days per week. Restless legs symptoms were assessed by the International RLS Study Group (IRLSSG) severity scale and an ordinal scale of RLS severity at the beginning of the trial, and at 3, 6, 9, and 12 weeks. RESULTS: Twenty-three participants completed the trial. At the end of the 12 weeks, the exercise group (N = 11) had a significant improvement in symptoms compared with the control group (N = 12) (P = .001 for the IRLSSG severity scale and P < .001 for the ordinal scale). CONCLUSIONS: The prescribed exercise program was effective in improving the symptoms of RLS.

PMID: 16951298 [PubMed - indexed for MEDLINE]




#2 1: J Neurol. 2002 Sep;249(9):1195-9


Iron metabolism and the risk of restless legs syndrome in an elderly general population--the MEMO-Study.
· Berger K,
· von Eckardstein A,
· Trenkwalder C,
· Rothdach A,
· Junker R,
· Weiland SK.

Institute of Epidemiology and Social Medicine, University of Muenster, Domagkstr. 3, 48149 Muenster, Germany. bergerk@uni-muenster.de
BACKGROUND: Low iron and ferritin blood levels have been observed in patients with Restless Legs Syndrome (RLS) with an inverse relation between symptom severity and ferritin level. All reports are based on single cases or case series of hospitalized patients or those from outpatient clinics. No data from population studies are available. METHODS: Cross-sectional study examining the associations between 5 measures of iron metabolism and RLS in an elderly general population in southern Germany. All 365 participants, aged 65 to 83 years, were examined neurologically and interviewed using standardized questions addressing the four minimal criteria for RLS. Iron, ferritin, transferrin, soluble transferrin receptor and C-Reactive Protein were analysed with standard laboratory methods. RESULTS: The prevalence of Restless Legs Syndrome in this population was 9.8 %. Odds Ratios associated with Restless Legs were significantly increased in the fourth quintile of iron (OR 3.08 95 % CI 1.02-9.29) and transferrin saturation (OR 5.68 95 % CI 1.18-27.26) compared with the third (middle) quintile. Increases in the first (lowest) quintile of both measures were not or borderline significant. No associations with ferritin and soluble transferrin receptor were found. CONCLUSIONS: No evidence was found that iron or ferritin deficiency are a major cause of RLS in this population study. The results support the hypothesis that changes in the complex regulation of iron metabolism contribute to the occurence of RLS.

PMID: 12242538 [PubMed - indexed for MEDLINE]




#3 1: Arch Intern Med. 2004 Jan 26;164(2):196-202


Sex and the risk of restless legs syndrome in the general population.
· Berger K,
· Luedemann J,
· Trenkwalder C,