Nonpharmaceutical approaches to alleviating restless leg syndrome symptoms

As many medical students know, after just a few short months into medical school, your family and friends begin saturating you with medical questions, which is exactly what piqued my interest in researching restless leg syndrome (RLS).

I have a close friend who had mentioned his RLS diagnosis several times before we got to talking about it in more detail. Once we discussed it further, I learned how significant of an impact this diagnosis had on his daily life. It was hard for me to believe that no one had been able to provide him with any beneficial therapies to help control his symptoms. Yet, it amazed me how he had adapted so well to the daily loss of sleep, fatigue and relationship burden.

Due to the resulting poor quality of life, I never understood why my friend did not give medications a try until I did more research on their side effects and overall effectiveness. With a new perspective in mind, I decided to use my background as a DO student to look into nonpharmaceutical approaches to alleviating RLS symptoms that might help my friend. I offered some suggestions to him. He ultimately found that abstaining from caffeine and alcohol improved his symptoms the most. He also said that shifting his exercise routine to the morning helped him sleep better.

Below is some more information about RLS, existing treatments and some alternatives to medication that may help your patients.

What is restless leg syndrome?

Restless leg syndrome affects up to 15% of the population and is thought to be a disorder of the central nervous system that causes an irresistible urge to move the legs. This is typically more prominent during the evening and most commonly will cause sleep disturbance due to the intense jerking throughout the night. Patients often describe their symptoms as itching or tingling in the legs, usually between the ankle and toe. The disorder is characterized by worsening symptoms at rest and alleviation with movement.

RLS can be a primary diagnosis, or it can present secondary to things such as pregnancy, iron deficiency and chronic kidney disease. Primary RLS has been linked to certain genetic loci and there tends to be an increased prevalence in patients with a family history. It is usually idiopathic, with a poorly understood pathogenesis, making universal therapy difficult to achieve.

RLS and pharmaceutical therapies

There are pharmaceuticals available to treat the symptoms of primary RLS, but these are reserved for the more severe cases. Gabapentin, pregabalin, dopamine agonists and even opioids are some of the medications known to improve RLS. All of these interventions have long-term side effects, and many have serious drug-drug interactions. For example, with use of dopamine, a first-line agent for RLS, symptoms tend to worsen over time, which requires increasing the dosage. Eventually this can lead to augmentation, when baseline symptom severity has become worse after starting the medication. On the other hand, if the RLS is secondary to an underlying condition, then treatment of that condition should be the primary approach to therapy.

Many patients experiencing symptoms causing sleep disturbance, fatigue and overall poor quality of life are hesitant to take medication due to potential side effects and lack of effectiveness. Yet, studies have shown that there may be ways to manage RLS symptoms aside from medications. By taking a holistic approach and teaching nonpharmaceutical options, we can positively impact the lives of patients who otherwise may choose to continue living with unpleasant symptoms that tend to get worse over time.

Alternative treatments

Foods/supplements to help with RLS:

• Foods rich in iron, including leafy greens (spinach), eggs, red meat, beans, lentils and many others. Since many cases of RLS can be linked to an iron deficiency anemia, it is suspected that the incorporation of dietary iron may help relieve symptoms secondary to idiopathic RLS.
• Vitamin D supplementation, either in the form of natural sunlight or over-the-counter supplements. Few foods are high in vitamin D, so it is difficult to achieve sufficient levels solely through food intake. A study of patients with RLS showed significantly decreased vitamin D compared to non-RLS counterparts.

Beverages to avoid:

• Caffeine: In the form of coffee, tea, soda, energy drinks and pre-workout drinks. It is especially important to avoid this at least six to eight hours before bed because the half-life of caffeine is about four to six hours.
• Alcohol: For unknown reasons, alcohol tends to exacerbate symptoms of RLS. In fact, in a study of patients with either alcohol or opioid use disorder, withdrawal from these substances caused the development of RLS in 21.7% and 50.8% of patients, respectively.

Other remedies that have shown to improve symptoms:

• Exercise: A recent survey indicated that over 50% of patients with restless leg syndrome reported improvement of symptoms with morning exercise and exacerbation of symptoms with evening exercises.
• Massage therapy: The MMF07 Foot Massager was studied in a group of people with RLS; patients using the foot massager reported significant improvement in RLS severity and overall quality of life compared to a control group.
• Temperate therapy: Numerous studies have shown effectiveness of hot compresses or temperate baths in the reduction of RLS symptoms. ­­Some studies suggest cool baths may also help.
• Sleep hygiene: It is important to educate patients on regular sleep-wake cycles, encourage them to prioritize getting sufficient sleep and discourage frequent naps throughout the day. Patients should avoid electronics for more than 30-60 minutes before bed since blue light can decrease melatonin levels and make it more difficult to fall asleep. Keeping a consistent bedtime routine that includes dimming the lights and taking time to wind down is also important.

The takeaway

Many of these remedies are based on clinical outcomes and responses generated by patients. When a patient is struggling with their symptoms of RLS and medications are not an option, you as a physician can still advocate for them by teaching and trialing these more holistic methods. They could be a great start toward symptom alleviation and can put your patient on the road to a better quality of life.

Related reading:

Preventing illness and injury: Is it ever too late to adopt a healthy lifestyle?

6 ways to be a physician without practicing clinical medicine