For those who have difficulty falling asleep to begin with, restless leg syndrome (RLS) is like driving a nail into the coffin of constant nocturnal wakefulness.
I haven’t been diagnosed but I do experience unpleasant sensations in my legs that feel akin to RLS. The uncomfortable feeling often starts in the calf of a random leg. I can feel the charge building, like Pikachu before a big Pokemon battle, while watching TV at night.
By the time I’m in bed and about to drop off to sleep, it’s become a nervy feeling that tingles, crackles and then, zap! My leg involuntarily shoots out from under the duvet, along with any shred of sleepiness I’d had. The nervy sensation is discharged but it’ll build up again each time I begin to fall asleep. It’s like an itch you can’t scratch and the knee-jerk reaction is like a sneeze you can’t stifle.
I might be one of those unlucky few; RLS is less frequently seen in Asian populations than in the US, according to Dr Lim Li Ling, a neurologist and sleep physician from Gleneagles Hospital. “In Singapore, the prevalence has been reported to be less than 1 per cent. In my practice,” she continued, “I may see RLS patients once or twice a month.”
(Photo: iStock/Olena Miroshnichenko)
Dr Shermyn Neo, a senior consultant from National Neuroscience Institute’s Department of Neurology, shared similar observations. In Singapore, “I see about five to 10 patients a year; some in my patients with Parkinson’s disease,” she said.
Then, Dr Neo mentioned something that set off all kinds of alarm in my head: “Parkinson’s disease is known to be associated with RLS”. (Parkinson’s disease is a degenerative brain condition that causes slowed movements, tremors and balance problems.)
There’s more. The class of medications used to treat RLS appears to have some worrying side effects, at least according to a BBC report. It noted that the prescribed drugs for movement disorders might lead to increased risky behaviours such as deviant sexual urges and a compulsion to gamble or shop.
On top of losing sleep, was I going to be broke and become a person of ill repute as well? I had to find out more.
A leg cramp might render the affected muscle hard, painful and immobile but with RLS, you’ll feel the need to move your leg instead. “The unpleasant sensations or urge to move is partially or totally relieved by movement such as walking or stretching,” said Dr Lim.
RLS sensations can begin or worsen during periods of rest or inactivity such as lying or sitting, she said, adding that they typically start or worsen in the evening or at night more so than in the day.
(Photo: iStock/okskaz)
The cause of RLS is “multifactorial”, said Dr Lim, citing factors such as genes (“RLS runs in families in up to 90 per cent of cases”) and “dysfunction in the nerve transmission involving dopamine and opioid pathways”.
RLS can also be a secondary symptom when seen in conditions such as kidney failure and iron deficiency, said Dr Lim. In addition, “RLS has been reported to occur in 23 per cent of women in the third trimester of pregnancy or to worsen during pregnancy in familial cases”.
Certain medications can trigger or worsen RLS as well, said Dr Neo. These include certain antidepressants, antihistamines and dopamine-receptor blocking agents.
“The relationship is likely to work the other way round,” said Dr Neo. “Parkinson’s disease is associated with a higher incidence of RLS. But the exact reason is not known.”
The research so far has also been conflicting, added Dr Lim. “Some studies show that there is no increased risk, while others show that having RLS confers an almost-doubled risk of developing Parkinson’s disease.”
(Photo: iStock/bymuratdeniz)
She explained: “One possible reason for such an association is that in both Parkinson’s disease and RLS, the common characteristic is that of dysfunction in nerve transmission involving the dopamine pathway”.
“Patients with RLS associated with Parkinson’s disease,” continued Dr Lim, “will have additional features such as tremors, rigidity of the limbs, slowing of movements and instability of posture with falls as well as an unstable gait.”
Researchers believe that RLS may be caused by an imbalance in the brain’s key neurotransmitter dopamine, which sends messages to control muscle movements.
So, it makes sense that dopamine agonist, a commonly used medicine to treat RLS, binds and activates the neurotransmitter’s receptor to mimic its effects; in this case, improving the control of muscle movements.
The thing is, dopamine also plays a role in impulse control. This brain chemical is what makes certain activities pleasurable, such as eating chocolate, shopping or scrolling through Instagram. But too much dopamine and you end up with an addiction.
And unfortunately, “impulse control disorder is one of the potential side effects that we counsel patients on dopamine agonists and enquire about at clinic visits,” said Dr Neo.
(Photo: iStock/Alexey Koza)
Also, “with dopamine agonists, we worry about the potential for augmentation, where RLS symptoms start to occur earlier in the day, increase in intensity or affect new areas of the body”, she added.
Dr Lim, however, is more optimistic about the use of dopamine agonists. “Generally, the doses of dopamine agonist medicines required are not as high for RLS (much less needed than for Parkinson’s disease), so there is typically no cause for concern for most patients.”
Dr Lim has not seen any risk-seeking behavioural change in her patients. “In all the years I have treated RLS patients and researched on this condition, I have not encountered any worrying behavioural tendencies, such as gambling or impulsivity,” she said.
“The doses of dopamine agonist medicines used in RLS are generally much lower than that used for Parkinson’s disease,” she reiterated.
Dopamine is responsible for many effects, including movement, mood and motivation. (Art: iStock/Jitendra Jadhav)
The situation, however, is very different when using dopamine agonists to treat Parkinson’s disease. “It’s not uncommon,” said Dr Neo about patients displaying worrying behaviours. “I had a patient gain 10kg after binging on food. They managed to arrest the weight gain after we stopped the dopamine agonist medication.”
Another patient of Dr Neo’s splurged S$10,000 on real estate investments after going on dopamine agonists. “We stopped the medication and the family kept a closer eye on their financial activities,” she said.
Yes, there are, including non-dopaminergic drugs such as gabapentin or pregabalin, said Dr Neo. “For more advanced cases, sedatives such as benzodiazepines and zolpidem, or opioid medication may be used,” said Dr Lim.
In mild cases of RLS, Dr Lim recommended walking and using “counter-stimulation” techniques, such as rubbing your legs or using hot or cold baths or ice packs, distracting mental activities such as playing games, and avoiding provocative situations such as long periods of sitting.
“Exercise can help RLS because the symptoms are typically relieved by movement. Massage is a form of ‘counter-stimulation’, which refers to a technique of relieving discomfort by providing an alternative sensory distraction from discomfort. So, massage can help RLS,” said Dr Lim.
(Photo: iStock/hxyume)
Handheld massage devices are worth considering, too, she said. “Devices which give vibration or electrical pulses have been used as non-drug approaches to relieve symptoms of RLS.”
It might also be a good idea to drink less caffeine and alcohol as well as quit smoking, advised Dr Lim. “Alcohol can worsen periodic limb movements in sleep, which are associated with RLS, in susceptible individuals.”
Only if you have a deficiency, said Dr Neo, such as an iron deficiency. For men, anaemia is typically defined as a haemoglobin level of less than 13.5g/dL and in women, less than 12g/dL, according to Singhealth. “Oral ferrous gluconate or ferrous sucrose can be used,” she said.
In fact, Dr Lim advocated that the iron levels of RLS patients should be checked, “especially those with a history to suggest acute or chronic blood loss”. “Iron supplementation has been reported to be effective in relieving RLS symptoms in elderly patients with low ferritin levels.”
As for the other supplements, Dr Neo hasn’t seen strong evidence that supports their uses. However, Dr Lim said that magnesium supplement may be worth looking into if you have a deficiency.
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I haven’t been diagnosed but I do experience unpleasant sensations in my legs that feel akin to RLS. The uncomfortable feeling often starts in the calf of a random leg. I can feel the charge building, like Pikachu before a big Pokemon battle, while watching TV at night.
By the time I’m in bed and about to drop off to sleep, it’s become a nervy feeling that tingles, crackles and then, zap! My leg involuntarily shoots out from under the duvet, along with any shred of sleepiness I’d had. The nervy sensation is discharged but it’ll build up again each time I begin to fall asleep. It’s like an itch you can’t scratch and the knee-jerk reaction is like a sneeze you can’t stifle.
I might be one of those unlucky few; RLS is less frequently seen in Asian populations than in the US, according to Dr Lim Li Ling, a neurologist and sleep physician from Gleneagles Hospital. “In Singapore, the prevalence has been reported to be less than 1 per cent. In my practice,” she continued, “I may see RLS patients once or twice a month.”
(Photo: iStock/Olena Miroshnichenko)
Dr Shermyn Neo, a senior consultant from National Neuroscience Institute’s Department of Neurology, shared similar observations. In Singapore, “I see about five to 10 patients a year; some in my patients with Parkinson’s disease,” she said.
Then, Dr Neo mentioned something that set off all kinds of alarm in my head: “Parkinson’s disease is known to be associated with RLS”. (Parkinson’s disease is a degenerative brain condition that causes slowed movements, tremors and balance problems.)
There’s more. The class of medications used to treat RLS appears to have some worrying side effects, at least according to a BBC report. It noted that the prescribed drugs for movement disorders might lead to increased risky behaviours such as deviant sexual urges and a compulsion to gamble or shop.
On top of losing sleep, was I going to be broke and become a person of ill repute as well? I had to find out more.
HOW IS RLS DIFFERENT FROM A MUSCLE CRAMP?
A leg cramp might render the affected muscle hard, painful and immobile but with RLS, you’ll feel the need to move your leg instead. “The unpleasant sensations or urge to move is partially or totally relieved by movement such as walking or stretching,” said Dr Lim.
RLS sensations can begin or worsen during periods of rest or inactivity such as lying or sitting, she said, adding that they typically start or worsen in the evening or at night more so than in the day.
(Photo: iStock/okskaz)
WHAT CAUSES RESTLESS LEG SYNDROME?
The cause of RLS is “multifactorial”, said Dr Lim, citing factors such as genes (“RLS runs in families in up to 90 per cent of cases”) and “dysfunction in the nerve transmission involving dopamine and opioid pathways”.
RLS can also be a secondary symptom when seen in conditions such as kidney failure and iron deficiency, said Dr Lim. In addition, “RLS has been reported to occur in 23 per cent of women in the third trimester of pregnancy or to worsen during pregnancy in familial cases”.
Certain medications can trigger or worsen RLS as well, said Dr Neo. These include certain antidepressants, antihistamines and dopamine-receptor blocking agents.
IF YOU HAVE RLS, ARE YOU LIKELY TO DEVELP PARKINSON’S DISEASE?
“The relationship is likely to work the other way round,” said Dr Neo. “Parkinson’s disease is associated with a higher incidence of RLS. But the exact reason is not known.”
The research so far has also been conflicting, added Dr Lim. “Some studies show that there is no increased risk, while others show that having RLS confers an almost-doubled risk of developing Parkinson’s disease.”
(Photo: iStock/bymuratdeniz)
She explained: “One possible reason for such an association is that in both Parkinson’s disease and RLS, the common characteristic is that of dysfunction in nerve transmission involving the dopamine pathway”.
“Patients with RLS associated with Parkinson’s disease,” continued Dr Lim, “will have additional features such as tremors, rigidity of the limbs, slowing of movements and instability of posture with falls as well as an unstable gait.”
HOW DOES DOPAMINE HELP RLS?
Researchers believe that RLS may be caused by an imbalance in the brain’s key neurotransmitter dopamine, which sends messages to control muscle movements.
So, it makes sense that dopamine agonist, a commonly used medicine to treat RLS, binds and activates the neurotransmitter’s receptor to mimic its effects; in this case, improving the control of muscle movements.
The thing is, dopamine also plays a role in impulse control. This brain chemical is what makes certain activities pleasurable, such as eating chocolate, shopping or scrolling through Instagram. But too much dopamine and you end up with an addiction.
And unfortunately, “impulse control disorder is one of the potential side effects that we counsel patients on dopamine agonists and enquire about at clinic visits,” said Dr Neo.
(Photo: iStock/Alexey Koza)
Also, “with dopamine agonists, we worry about the potential for augmentation, where RLS symptoms start to occur earlier in the day, increase in intensity or affect new areas of the body”, she added.
Dr Lim, however, is more optimistic about the use of dopamine agonists. “Generally, the doses of dopamine agonist medicines required are not as high for RLS (much less needed than for Parkinson’s disease), so there is typically no cause for concern for most patients.”
IS IT COMMON TO HAVE PATIENTS SHOW WORRYING BEHAVIOURS WHEN ON DOPAMINE AGONISTS?
Dr Lim has not seen any risk-seeking behavioural change in her patients. “In all the years I have treated RLS patients and researched on this condition, I have not encountered any worrying behavioural tendencies, such as gambling or impulsivity,” she said.
“The doses of dopamine agonist medicines used in RLS are generally much lower than that used for Parkinson’s disease,” she reiterated.
Dopamine is responsible for many effects, including movement, mood and motivation. (Art: iStock/Jitendra Jadhav)
The situation, however, is very different when using dopamine agonists to treat Parkinson’s disease. “It’s not uncommon,” said Dr Neo about patients displaying worrying behaviours. “I had a patient gain 10kg after binging on food. They managed to arrest the weight gain after we stopped the dopamine agonist medication.”
Another patient of Dr Neo’s splurged S$10,000 on real estate investments after going on dopamine agonists. “We stopped the medication and the family kept a closer eye on their financial activities,” she said.
ARE THERE OTHER MEDICATIONS, EVEN NON-DRUG OPTIONS, AVAILABLE?
Yes, there are, including non-dopaminergic drugs such as gabapentin or pregabalin, said Dr Neo. “For more advanced cases, sedatives such as benzodiazepines and zolpidem, or opioid medication may be used,” said Dr Lim.
In mild cases of RLS, Dr Lim recommended walking and using “counter-stimulation” techniques, such as rubbing your legs or using hot or cold baths or ice packs, distracting mental activities such as playing games, and avoiding provocative situations such as long periods of sitting.
“Exercise can help RLS because the symptoms are typically relieved by movement. Massage is a form of ‘counter-stimulation’, which refers to a technique of relieving discomfort by providing an alternative sensory distraction from discomfort. So, massage can help RLS,” said Dr Lim.
(Photo: iStock/hxyume)
Handheld massage devices are worth considering, too, she said. “Devices which give vibration or electrical pulses have been used as non-drug approaches to relieve symptoms of RLS.”
It might also be a good idea to drink less caffeine and alcohol as well as quit smoking, advised Dr Lim. “Alcohol can worsen periodic limb movements in sleep, which are associated with RLS, in susceptible individuals.”
ARE THERE SUPPLEMENTS THAT CAN HELP?
Only if you have a deficiency, said Dr Neo, such as an iron deficiency. For men, anaemia is typically defined as a haemoglobin level of less than 13.5g/dL and in women, less than 12g/dL, according to Singhealth. “Oral ferrous gluconate or ferrous sucrose can be used,” she said.
In fact, Dr Lim advocated that the iron levels of RLS patients should be checked, “especially those with a history to suggest acute or chronic blood loss”. “Iron supplementation has been reported to be effective in relieving RLS symptoms in elderly patients with low ferritin levels.”
As for the other supplements, Dr Neo hasn’t seen strong evidence that supports their uses. However, Dr Lim said that magnesium supplement may be worth looking into if you have a deficiency.
Continue reading...