As is often the case with many diagnoses ending in “Syndrome,” Restless Legs Syndrome (RLS) can be elusive and challenging to diagnose, treat, and understand. While we sometimes work with patients who come to us primarily for help with RLS (yes, we do treat it), more often they are seeking treatment for some other problem and happen to mention they have RLS. In an effort to promote understanding of this condition, we have compiled this summary from the limited literature on RLS as well as our clinical experience.
What is RLS?
RLS is generally characterized by an urge to move and feeling of unpleasant sensations inside the lower legs.1 Generally symptoms will affect both lower legs. Symptoms of RLS usually occur during periods of inactivity and resolve with movement or exercise. Typically night time when attempting to rest is worst, but problems can also be present in the day.
How is it Diagnosed?
As with many “syndromes,” there are no tests that absolutely confirm RLS. It is a diagnosis based purely on symptomology and the absence of other diagnoses that would account for the symptoms. The International Restless Legs Syndrome Study Group established criteria for diagnosis which include: a desire to move the limbs, usually associated with paraesthesia (pins and needles sensation) or dysaesthesia (abnormal sensation); motor restlessness; symptoms worse or exclusively present at rest; symptoms worse in the evening or night.2,3 Additional features that may accompany these signs or symptoms include: sleep disturbance, periodic limb movements in sleep, a normal neurological examination, chronic symptoms with exacerbations and remissions, and a positive family history.2 The establishment of such criteria indicate there are enough people with these complaints to justify studying them. However, establishing these criteria does not provide an explanation as to cause or treatment.
Why does it occur?
There are several unproven hypotheses attempting to explain RLS. The most common one cites iron deficiency, which can be identified with basic blood testing. But consider this: many people with iron deficiency do not have RLS, and many people with RLS do not exhibit iron deficiency. Then there are those with iron deficiency who still suffer with RLS even after their iron levels have been normalized. Certainly, normalizing iron levels in the body is desirable for many reasons. But logic dictates that this does not fully explain or address the problem for many individuals. If iron deficiency was the cause and the solution supplementation, then there would be no market for pharmaceuticals specifically targeting RLS. Yet the two most frequently prescribed medications, Pramipexole (Mirapex) and Ropinirole (Requip), are in high demand. Another proposed cause of RLS is dysfunction of dopamine (a neuro-transmitter affecting movement), although this also is unproven.
There is a growing body of literature and evidence supporting the phenomenon of myofascial trigger points, fascial densifications, and faulty movement patterns/habits as contributing to many neuro-musculo-skeletal dysfunctions. This is logical and believable when one considers the expansive network of muscle and fascia (connective tissue) throughout the body, and how tissue overload and trauma can lead to dysfunction. The symptoms of many of these disorders are similar to those associated with RLS. While at this time there are no studies proving a correlation, one must consider that there is no more evidence supporting iron deficiency as the primary cause of RLS.
How is RLS treated?
As discussed earlier, simple blood testing may identify iron deficiencies which should be addressed. More commonly, RLS is treated with medication as noted above.3 While these medications function to diminish the symptoms of RLS, they do not resolve any underlying cause. This necessitates long-term use, which can be expensive, and in 40% of users medications can cause undesirable side effects such as drowsiness, dizziness, and nausea. Other more severe symptoms can occur including cardiac arrest, delirium, and aneurysm although these are less common.
Currently there is very little research concerning the effectiveness of exercise on RLS. A small study that compared exercise (resistance and aerobic) to no intervention showed improvement in symptoms at 6 weeks and this improvement was maintained through 3 months (the length of the study).3 There has also been very limited research conducted to investigate the effectiveness of soft tissue techniques (massage, myofascial release) on symptoms, although case studies have shown promising results.4
It has been our clinical experience that addressing myofascial trigger points in muscles, fascial densifications in fascia, and faulty movement patterns that overload soft tissues in the trunk and extremities can help to diminish/resolve the symptoms of RLS. Our evaluation emphasizing movement assessment and palpation typically exposes soft tissue movement restrictions and biomechanical movement dysfunctions in the legs and other areas of the body.5 Very often, patients suffering with RLS demonstrate fascial restrictions in the feet and pelvic regions, which makes sense if you consider that the legs are then caught in the middle of a connective tissue tug of war. Often (although not always) RLS patients have a history of dysfunction involving the feet such as heel pain/spurs, plantar fasciitis, and bunions. Some relate a history dating back to childhood, often sadly diagnosed as “growing pains.”
Effective interventions we often utilize include a combination of dry needling, Fascial Manipulation®, and exercise including Postural Restoration® techniques. These approaches are utilized wherever needed throughout the trunk and extremities, as a global total-body approach is typically most successful. Home exercises are essential for addressing strength and movement issues that cause overload and dysfunction to the soft tissues. Education as to faulty habits and postures perpetuating problems is also essential to resolving the symptoms. Further information on these interventions is available on our website at www.aptfc.com.
Many people are unaware of the options available to them in the management and resolution of RLS. We hope that this article has been helpful for you, and strongly encourage anyone suffering with RLS to explore these options. For further information or to speak with one of our therapists please contact our office.
- Ekbom, K., & Ulfberg, J. (2009). Restless legs syndrome. Journal of internal medicine, 266(5), 419-431.
- Chaudhuri, K. R., Appiah-Kubi, L. S., & Trenkwalder, C. (2001). Restless legs syndrome. Journal of Neurology, Neurosurgery & Psychiatry, 71(2), 143-146.
- Aukerman, M. M., Aukerman, D., Bayard, M., Tudiver, F., Thorp, L., & Bailey, B. (2006). Exercise and restless legs syndrome: a randomized controlled trial. The Journal of the American Board of Family Medicine, 19(5), 487-493.
- Russell, M. (2007). Massage therapy and restless legs syndrome. Journal of Bodywork and Movement Therapies, 11(2), 146-150.
- Day, J. A., Copetti, L., & Rucli, G. (2012). From clinical experience to a model for the human fascial system. Journal of bodywork and movement therapies, 16(3), 372-380.