Exercise and Restless Legs Syndrome
Abstract & Commentary
By Allan J. Wilke, MD, Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of Medicine—Huntsville Regional Medical Campus. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: A program of resistive exercise and treadmill walking reduced the severity of restless legs syndrome symptoms.
Source: Aukerman MM, et al. Exercise and restless legs syndrome: a randomized controlled trial. J Am Board Fam Med. 2006;19:487-493.
Restless legs syndrome (RLS) is a movement disorder, characterized by four features:
1. An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs. (Sometimes the urge to move is present without the uncomfortable sensations and sometimes the arms or other body parts are involved in addition to the legs.)
2. The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting.
3. The urge to move or unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.
4. The urge to move or unpleasant sensations are worse in the evening or night than during the day or only occur in the evening or night. (When symptoms are very severe, the worsening at night may not be noticeable but must have been previously present.)1
All four criteria must be met to make the diagnosis, which is clinical. Risk factors for RLS are age, multiparity, sedentary lifestyle, obesity, and family history. It is also associated with iron deficiency, pregnancy, chronic renal disease, neuropathy, and medications, such as antipsychotics, tricyclic antidepressants, selective serotonin reuptake inhibitors, and metoclopramide; this is termed secondary RLS. The mainstay of treatment is drug therapy with dopaminergics, anticonvulsants, benzodiazepines, and opioids.
Although activity helps relieve symptoms, there are reports that exercise performed near bedtime can increase the risk of RLS. To confuse matters even more, there are data suggesting that lack of exercise contributes to RLS.2 Aukerman and colleagues devised a study to determine the effect of a conditioning program on RLS. The program consisted of thrice weekly lower body resistance exercises and walking on a treadmill. Exclusion criteria were inability to exercise, a recent coronary event, uncontrolled hypertension, chronic renal disease, and anemia. The exercise group and the control group both received education about modifiable RLS risk factors: cigarette smoking, alcohol use, excessive caffeine use, and sleep hygiene. At the baseline visit, subjects were examined by a physician to confirm the diagnosis of RLS and to obtain laboratory work, including hemoglobin and creatinine. Subjects were again seen at six and twelve weeks, and had telephone contact at three and nine weeks. The primary outcome measures were scores on the International RLS Study Group Scale and on an overall RLS severity 1-to-8 scale. The International Restless Legs Severity Scale (IRLS) is a validated, 10-item scale with a maximum score of 40. For both scales, the greater the score, the greater the severity.3 These scales were rescored at 3, 6, 9, and 12 weeks.
Forty-one (41) subjects were available for randomization. However, due to scheduling problems, 13 participants dropped out before the study began. At week 6, there were 11 subjects in the exercise group and 17 in the control group. At Week 12, only 12 participants remained in the study group. The average age of the subjects was 53 years. Despite randomization, the exercise group was taller (statistically significant) and had more males and were heavier (not statistically significant). At baseline the two groups had equivalent IRLS scores (20.6 for the exercise group, 22.5 for the control group) and severity scores (4.0 and 4.8, respectively). By week 6 the IRLS and severity scores diverged: 12.6 and 1.7 for the exercise group and 20.8 and 4.1 for the control group. The scores then remained steady: 12.1 and 2.0 for the exercise group and 21.5 and 4.3 for the control group. The difference in the scores at weeks 6 and 12 were statistically significant.
Commentary
This is not the definitive study of exercise as a treat-ment for RLS. It was too small and there were too many drop-outs. It does suggest, though, that exercise could be useful, either alone or as an adjunct to pharmaceutical therapy. As the authors point out, exercise has other benefits for older individuals, so there is little to lose by advising it (after proper medical clearance, of course) while we await larger, more robust studies.
References
1. Allen RP, et al. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Med. 2003;4:101-119.
2. Phillips B, et al. Epidemiology of restless legs symptoms in adults. Arch Intern Med. 2000;160:2137-2141.
3. Walters AS, et al. Validation of the International Restless Legs Syndrome Study Group rating scale for restless legs syndrome. Sleep Med. 2003;4:121-132.
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