Restless Legs Syndrome and Other Sleep-Related Leg Disorders

Description

Alternative Names

Treatment

The initial approach to a patient who complains of sleeplessness and restless legs syndrome is a nondrug one that aims at improving sleep and eliminating possible causes of RLS. A nondrug approach is a particularly important first step in elderly patients:

• The physician should first try to treat any underlying medical conditions that may be causing restless legs.
• If medications may be causing RLS, the physician should try to prescribe alternatives, if possible.
• If the cause cannot be determined, it is best to try sleep hygiene and relaxation methods, which are described below. Such approach provides added benefits, even if drug therapy is later required.

Possible Helpful Tips

Some people report help or relief from RLS with the following behaviors or devices:

• Hot baths or cold compresses.
• Ergonomic measures. For example, patients might find it useful to work at a high stool, where they can dangle their legs. In meetings or during air travel, it is helpful to obtain an aisle seat.
• Changing sleep patterns. Some patients report that symptoms dont occur if they sleep late in the morning, so, if feasible, changing sleep patterns may also be helpful.
• Avoiding caffeine, alcohol, and nicotine.

Alternative treatments that are sometimes advocated for RLS include acupuncture and massage. These treatments, however, have not been rigorously studied.

Dietary Approached for Iron Insufficiency

Because RLS is associated with iron insufficiency, people with the condition should be sure they have a diet that provides iron. Iron found in foods is either in the form of heme or non-heme iron:

• Heme Iron. Foods containing heme iron are the best for increasing or maintaining healthy iron levels. Such foods include (in decreasing order of iron-richness) clams, oysters, organ meats, beef, pork, poultry, and fish.
• Non-Heme Iron. Non-heme iron is less well absorbed. About 60% of the iron in meat is non-heme (although meat itself helps absorb non-heme iron). Eggs, dairy products, and iron-containing vegetables have only the non-heme form. Such vegetable products include dried beans and peas, iron-fortified cereals, bread, and pasta products, dark green leafy vegetables (chard, spinach, mustard greens, kale), dried fruits, nuts, and seeds.

The Effects of Food on Iron Absorption. The absorption of non-heme iron often depends on the food balances in meals. The following are foods that enhance absorption of non-heme iron.

• Meat and fish not only contain heme iron, the best form for maintaining stores, but they also help absorb non-heme iron.
• Increasing intake of vitamin-C rich foods can enhance absorption of non-heme iron during a single meal. In any case, vitamin-C rich foods are healthful and include broccoli, cabbage, citrus fruits, melon, tomatoes, and strawberries. One orange or six ounces of orange juice can double the amount of iron your body absorbs from plant foods. (Taking vitamin C supplements does not appear to have any significant effect on iron stores.)
• Foods containing riboflavin (vitamin B2) may help enhance the formation of hemoglobin from iron. Sources include liver, dried fortified cereals, and yogurt.

Certain nutrients impede the body's absorption of dietary iron. They include the following:

• Polyphenols (found in tea, coffee, red wine, berries, apples).
• Phytates (found in foods such as seeds, dried beans, soy, and bran). Such foods are typically high in fiber. (It is often believed that fiber itself impedes iron absorption, but researchers report that it has little or no effect.)
• Calcium. Calcium impairs the absorption of heme and non-heme iron. However, calcium intake must be quite high to cause any significant problems. For example, a 2002 study reported that cheese had no effect on iron absorption from meals rich in heme and non-heme iron.

The Effects of Cooking Methods on Iron. Cooking methods can enhance iron stores. Cooking in cast iron pans and skillets is well-known to increase the iron content of food. According to one study, boiling, steaming, or stir-frying in utensils composed of any material significantly increased the release of non-heme iron stored in vegetables.

Exercise

Exercise earlier in the day may be one of the best ways to achieve healthy sleep. It should be noted that vigorous exercise and stimulation (including sexual activity) within one to two hours of bed time may worsen RLS. A study found that people who engaged in brisk walking for 30 minutes, four times a week, improved minor sleep disturbances after four months. Another study reported that sleep improved in a group of elderly people who exercised regularly. Regular, moderate exercise, healthful in any case, may help prevent RLS. Patients report that either bursts of excessive energy or long sedentary periods worsen symptoms.

Behavioral Approaches for Preventing Insomnia

Prevention of sleeplessness is very much dependent upon the patients ability to relax and learn the art of sleeping well. A number of behavioral methods are aimed at achieving these goals. Behavioral techniques can actually cure chronic insomnia and studies report their effectiveness in nearly all patients with primary chronic insomnia. Although medications are equally effective for helping people with insomnia to sleep, behavioral methods act faster. Behavioral methods are effective in all age groups, including elderly patients. In addition, medications cannot cure this condition and prolonged use frequently results in dependency.

Studies have reported that between 70% and 80% of those who are treated with non-drug methods experience improved sleep with an average treatment duration of only five hours over a four-week period. Furthermore, studies report that 75% of those who have been taking drugs are able to stop or reduce their use.

Specific Behavioral Methods. Proper sleep hygiene is the first step and should be accompany any behavioral method. A number of approaches are available, but all have the same basic goals:

• To reduce the time it takes to go to sleep to below 30 minutes.
• Reduce wake-up periods during the night.

Some experts currently list the following behavioral methods in order of effectiveness:

• Stimulus control (standard treatment, which receives a high degree of physician support). It may also be helpful for some patients with secondary insomnia caused by a medical or psychiatric condition.
• Progressive muscle relaxation (studies and physician reports reflect a moderate degree of confidence in its effectiveness). It may be helpful for older individuals and some patients with secondary insomnia caused by a medical or psychiatric condition.
• Paradoxical intention (studies and physician reports reflect a moderate degree of certainty in its effectiveness).
• Biofeedback (studies and physician reports reflect a moderate degree of certainty in its effectiveness).
• Sleep restriction (evidence inconclusive on its value).
• Cognitive behavioral therapy (evidence inconclusive although studies are increasingly reporting benefits not only for improving sleep in the short term, but in help maintain healthy sleep).
• Sleep hygiene, imagery training, and cognitive training only (experts unable to recommend these approaches as sole therapy).

Stimulus Control. Stimulus control is now considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:

• Go to bed only when ready to sleep or for sex.
• If unable to sleep within fifteen to twenty minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, such as read.)
• Maintain a regular wake-up time no matter how few hours are spent sleeping.
• Avoid naps.

Progressive Muscle Relaxation. Progressive muscle relaxation is another technique for inducing sleep that is effective for many people. In one study, it was as effective as anxiety management training, a short-term behavioral technique. It takes about 10 minutes and involves the following:

• Focus first on a specific muscle group, typically with the muscles in one foot. Inhale and tense the muscle group for about eight second until the muscles start to shake and be mildly painful. (Do this gently. It is not intended to cause severe muscles contractions.)
• Release the muscles quickly and let them become loose and limp. Stay relaxed for 15 seconds and then repeat the same muscle group.
• Focus on the next muscle group and repeat the sequence. Move progressively from each foot and leg up through the abdomen, chest, then to each hand and arm and then to the neck and shoulders and face.

Paradoxical Intention. Paradoxical intention is a psychological approach that is based on doing the opposite of what one wants or fears and take it to extreme. The first step is to make a plan to take such a paradoxical approach to insomnia.

• Instead of going through activities leading to sleep, the patient prepares for staying awake and doing something energetic.
• In some cases, people may take specific psychological barriers to sleep to an extreme limit. For example, if worry is a factor in insomnia, the patient intensifies the worries.

Biofeedback. Biofeedback is also effective but requires being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily.

Sleep Restriction Therapy. Sleep restriction therapy may be effective, although evidence is inconclusive. In one 2001 study, patients practiced sleep hygiene and sleep restriction. Sleep hygiene was very helpful during the first two months while sleep restriction led to sustained benefits and deeper sleep. The approach is a systematic method for achieving sleep and restricting the time spent in bed.

The first step is to calculate a person's sleep efficiency number:

• Keep a sleep diary for 14 days. Then calculate the average hours of actual sleep and hours in bed. Then divide the average hours slept by the hours in bed. The result, given as a percentage, is the sleep efficiency number. (For example, if a patient sleeps an average of five hours out of seven hours in bed then the result is .714 and the sleep efficiency percentage is 71%.)
• The patient's goal is to achieve sleep efficiencies of between 85% and 90%, which means only 10% to 15% of the time is spent staying awake in bed. (Sleep efficiency in older people may fall normally somewhere between 75% to 85%.)

To achieve this goal, the patient takes the following actions:

• Begin by going to bed 15 minutes later than usual the first week.
• If 85% sleep efficiency isn't reached by the end of the week, add another 15 minutes before going to bed. Refrain from going to bed even if tired, although bedtime should not be reduced below five hours.
• Once efficiency reaches 90% or more, then begin to go to bed 15 minutes earlier each week.

Other parts of the program include stopping any sleep medications and following good sleep hygiene. People using this treatment have reported lasting improvements after just eight weeks and studies report that it is significantly more successful than relaxation techniques.

Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep (such as, Ill never fall asleep). It also employs actions intended to change behavior. Studies have been mixed on its effectiveness, although a major 2003 analysis of six trials suggested that it might be helpful for older adults. As another example, a 2002 study reported that CBT used alone or in combination with medications resulted in improved sleep efficiency and better on-going maintenance of healthy sleep compared to medication alone or sham treatment. In other studies, CBT has even helped post-traumatic stress victims and people with insomnia caused by chronic pain, who are all commonly resistant to most therapeutic maneuvers. The success of this approach rests strongly on the skill of the therapist. The long-term benefits of CBT are not known, and refresher sessions may be needed.

Using Imagery. A 2002 study enrolled people whose chronic insomnia was associated with unwanted thoughts and worries. They were given specific positive mental tasks that gave them a sense of positive control (as opposed to their real life concerns, which felt out of their control.) Those images distracted them and allowed them to fall asleep faster. In support of this approach, a 2002 study evaluated patients with insomnia who were given a problem before sleep. One group was asked to think of the problem in images and the other in words. The group who used imagery fell asleep more quickly and woke up with less anxiety.

Sleep Hygiene. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep.