Tips To Tame Restless Legs Syndrome with Dr. Aparna Bhat

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Sleeping isn't exactly a high-movement activity, which explains why restless leg syndrome isn't ideal for snoozing. Twitching and jerking legs don't exactly lend themselves to a peaceful night in bed. So what can you do to keep your legs still? That seems like a good question for sleep medicine specialist Aparna Bhat. Dr. Bhat is one of the many experts at Cleveland Clinic who pop into our weekly podcast to talk health. So now, let's see what she recommends to keep restless legs from moving you away from a good night's sleep.

Dr. Bhat, it is so nice to see you again. You're becoming a podcast regular.

Dr. Aparna Bhat:

Thank you for having me, yeah.

John Horton:

Well, we love when you have some time for us. And you're here today to talk about restless leg syndrome or RLS. And I got to be honest, when I started looking into this, I had no idea how common it is. I read where up to 10% of the population has the condition. No wonder nobody is sleeping well.

Dr. Aparna Bhat:

Yeah, that's right. Yeah. The global estimate for adults with RLS, or restless leg syndrome, is about 7%. And specifically in the U.S., we estimate 5 to 10% of the population has RLS, and it's actually more common in women and pregnant women as well.

John Horton:

Wow. All right. Well, we're going to get into all that in a little bit here. But let's start with what exactly restless leg syndrome is. I know I have an idea in my head. The name gives a little bit of it away, but what do people usually experience? How do they describe it?

Dr. Aparna Bhat:

Yeah, so restless leg syndrome is really what the name describes: It's a restlessness that people typically experience in their legs. But interestingly enough, the pathology isn't actually in the legs. The origin is in the brain. And the sensation is very hard for people to explain. People will use different terms, such as restlessness, an urge to move their legs, a cramping sensation, creepy crawly sensation, a discomfort, like an indescribable pain or sensation, bugs crawling — just various different things that people will use.

John Horton:

Yeah, that's really wide-ranging. I just thought of it as almost like your legs just twitch around and move a little bit, but it sounds like you can really get some ... like you said, I didn't think of it as being painful.

Dr. Aparna Bhat:

Yeah, for some. And for some patients who have dementia, this restlessness can be manifested as pacing in the evening time or around bedtime as well.

John Horton:

Oh, wow. All right. Do we know what causes this? I know you said it's triggered in the brain. So is there something that sets it off, or do we know what's behind it?

Dr. Aparna Bhat:

Yeah. Well, it's not fully understood, but what we know is that there's a complex interplay of a few different pathways. And to name a few, brain or whole-body iron deficiency, dopamine or a neurotransmitter dysfunction, there is a genetic predisposition as well. So brain iron deficiency is considered to be the major contributor, and there's a circadian or a body clock rhythm to iron and iron levels. And so individuals can have normal serum iron levels, but a low brain iron level. And so this is why we check iron levels, or ferritin, which is an iron storage form, especially in the morning time.

John Horton:

Yeah. It's hard to believe, just something gets a little bit off, and that it triggers this sort of movement and twitching and feelings while you're asleep. It's amazing to me how all this stuff in our body is so connected like that.

Dr. Aparna Bhat:

Correct, yes. Yeah.

John Horton:

It's pretty clear that restless legs is not going to enhance the sleeping experience. So let's talk about what we can do to address that. For milder cases, which I know covers the majority of folks who have this, what kind of things can be done to keep legs from dancing around at night?

Dr. Aparna Bhat:

Yeah, so actually you're right, most cases are mild. About 2% to 3% of patients have really moderate to severe symptoms that need pharmacotherapy or medications. So for the milder cases, there's quite a bit to cover, but temperature therapy is one.

John Horton:

OK.

Dr. Aparna Bhat:

Either warm or cold compresses can help. And ideally, this is technically a distraction tactic that can replace that unpleasant sensation that people have with a soothing one.

John Horton:

Yeah. Is that even something where you said the warm therapy, is that like if you take a hot bath or a hot shower or a head of bed, will that kind of help tame it?

Dr. Aparna Bhat:

Yeah. Similarly, a hot bath or a hot shower will do the same thing.

John Horton:

So it sounds like that, heating pads, cold pads, I mean, how do you know whether you use hot or cold? Is it just whichever one works?

Dr. Aparna Bhat:

Yeah, it's a trial and error. Yeah. You have to try one, and if it works, wonderful. Continue with it. And if not, try cold. And if that works, just whatever is most comfortable for you.

John Horton:

Wow. Is there one that works better most of the time, or is it really just a coin flip sort of thing?

Dr. Aparna Bhat:

Yeah, I think most people do better with the warm compresses, but really, you're trying to get a soothing sensation to distract from the unpleasantness of RLS.

John Horton:

All right. So we hit the warm or cold therapy. What are some other things we can do, it sounds like, right around bedtime, to maybe limit restless legs?

Dr. Aparna Bhat:

Right. So massaging your legs or stretching your legs and feet can also work well for some people. Compression wraps that are around the feet can also apply pressure. So there's one called restiffic® that can help, and it really overrides the uncomfortable sensations of restless leg syndrome. And exercise for some people can actually help. And that really … what it does is it stretches the muscles and engages them so that you don't have the uncomfortable sensations at nighttime.

John Horton:

Yeah. Is that exercise during the day, I take it? Not right before bed.

Dr. Aparna Bhat:

Yeah, evening as well can be helpful. So evening exercise and evening stretching, massaging, those are things that can help with the sensation.

John Horton:

OK. You had mentioned compression wraps; would wearing compression socks to bed also maybe help with it?

Dr. Aparna Bhat:

Yeah, compression stockings or compression socks are mostly used for patients who might have some leg swelling, or some other reason for having compression socks to help with bringing fluid into the vessels and bring it back up to the heart. It's not typically something that we would use for restless leg syndrome. And I think we might talk a little bit about sleeping with socks, so we'll touch more on the usefulness of compression socks at that point. But yeah, typically, there are compression wraps around the feet or another device that's called Nidra® that is a wearable device that can stimulate the peroneal nerve or the nerve in your calves to trick the body into thinking that you're moving and help relieve restless leg symptoms.

John Horton:

OK. Well, so it's a very targeted compression wrap. So it's one of those things … it's not just throwing on socks or doing whatever. It's a very specific thing you probably need to do with the help of whatever doctor you're working with and get that lined up.

Dr. Aparna Bhat:

Yes.

John Horton:

All right. I also read something where if you engage your brain ahead of bed that you can distract the nerves and that might halt restless legs. Is this just doing the crossword puzzle ahead of bed or something like that?

Dr. Aparna Bhat:

Well, yeah, I think that's what all of these other therapies do, like the temperature therapy, the massaging, the exercise. They all help to engage the brain into distracting it and taking it away from the uncomfortable sensation. So I think other tactics — like managing anxiety and managing stress — and if that's doing a crossword puzzle or Sudoku, those can be helpful tactics as well.

John Horton:

Sudoku gets me every day, man. I got to do it. It becomes a little bit of an addiction.

So those are all things that we can do ahead of bed that can help limit restless legs, and seems like pretty simple things to work in your routine. What are some things that folks can do in the long term to tame that sensation and that feeling?

Dr. Aparna Bhat:

Right, yeah. So I mentioned iron. So iron supplementation, which we can do by increasing iron in our diet, or taking ferrous sulfate or ferrous gluconate pills, or IV iron. Those can all be different ways to supplement iron into your diet. And this is especially important for pregnant women who can have a higher risk of restless leg syndrome.

John Horton:

OK, now, before people start going out and just going, "Oh, I'm having some issues with this. I'm just going to start supplementing on my own," I take it this is something where you should probably get tested first to see where your iron levels are at before you start adding a bunch to your system?

Dr. Aparna Bhat:

That's right, yeah. So too much iron is not good either. And this is why I mentioned testing your iron levels and iron storage levels called ferritin. And we do that specifically in the morning in order to understand the circadian rhythm or the body clock rhythm of iron. And it's important because iron is also a factor that helps in the synthesis or production of dopamine, which is a neurotransmitter in the brain as well. So it really is a big component of RLS therapy, understanding iron and iron metabolism.

John Horton:

I had no idea iron was that tied in with sleep, and the mechanisms in your body that bring that all together.

Dr. Aparna Bhat:

Yeah, everything is tied together.

John Horton:

All right. Well, let's look at … so iron is, it sounds like, the big thing and one of the major causes when we see that. What are some other long-term actions you can take to limit RLS?

Dr. Aparna Bhat:

So avoidance of triggers, and this comes in two parts. One is medication triggers and the other is lifestyle triggers. So when it comes to lifestyle triggers, nicotine can actually worsen restless leg syndrome, alcohol use, caffeine and high sugar or chocolate intake.

John Horton:

Yeah. All that makes a lot of sense when you think about what those things do to you and how you feel after you have them. I can see where they could end up with your legs twitching around at night.

Dr. Aparna Bhat:

Right. And then the other part is reviewing your medication list with your provider. So certain medications can worsen restless leg symptoms, and these include antidepressants, like SSRIs and SNRIs, mood stabilizers. Anti-seizure medications as well can do it, anti-nausea medications, allergy meds or antihistamines. So if you think about it, those over-the-counter sleep aids that people might take have antihistamines, and they can actually worsen or trigger restless leg symptoms. So we often discuss tweaks to medication regimens and coordinate care with other providers to help with symptom management.

John Horton:

Yeah. So you suddenly start taking a medication, and you notice you start getting restless legs, is this something you just talk to your provider and they can usually give you an alternative that might just, I guess, be a little easier on your system?

Dr. Aparna Bhat:

And for a lot of patients, that can really resolve symptoms or at least improve it to a certain degree.

John Horton:

Yeah, it's amazing sometimes just making those little tweaks can make a big difference.

Dr. Aparna Bhat:

So I want to review some very commonly prescribed medications for restless leg, and they are FDA-approved. Those include ropinirole, pramipexole, and rotigotine patches. And unfortunately, they can improve symptoms in the beginning, but then over time, they can actually worsen and augment the symptoms of restless leg symptoms in the long run.

John Horton:

Oh, that's not the way you want to go.

Dr. Aparna Bhat:

No. Very often, as a sleep physician, I will see patients who have been on these medications for months and years, and over time, they've had to increase the dosage and increase the frequency of this medication to help with symptoms. Because we know that restless leg symptoms typically happen at nighttime, but as they worsen or progress, they can seep into the daytime as well. And so it is really important that we look into that and start tapering patients off of it. This augmentation, it's inevitable. It happens to all patients who take them. And so we taper individuals off these medications while adding the first-line treatments, which are now gabapentin or gabapentin enacarbil, and pregabalin.

John Horton:

You had mentioned, too, I want to make sure, exercise. And it sounds like, if you get a steady exercise routine, it can help tame it. Is that just you tire yourself out a little bit more? I mean, how does that end up affecting whether your legs have this feeling at night?

Dr. Aparna Bhat:

Yeah, you don't want to tire yourself out, that's for sure.

John Horton:

OK, all right.

Dr. Aparna Bhat:

You want to have enough exercise that you're stretching your muscles and exercising them, but tiring yourself out might lead to worsened symptoms for some people.

John Horton:

You got to walk that line — sounds like you want to move enough to loosen the muscles up, but not so much that you're going to cramp and have some of those problems at night.

Dr. Aparna Bhat:

The other things that we think about are insufficient sleep. So people who don't get enough sleep can also worsen their restless leg symptoms. And along the same vein, sleep apnea, which we know can contribute to sleep quality and sleep duration, can also worsen restless leg symptoms.

John Horton:

You walked us through sleep apnea the last time you were with us. So if somebody wants to get the whole … all the info they can ever get on that, that would be the podcast to listen to.

What about just overall sleep hygiene? I mean, you always hear that those patterns we have at night can mean so much to sleep quality. Does that carry over to restless legs?

Dr. Aparna Bhat:

Yeah. It's important always to listen to your body when it comes to sleep and feeling sleepy. And we do have a circadian, or a body clock rhythm, that assists us in modulating the wake times and the bedtimes as well. And so it's important to listen to your body, and when you feel sleepy, go to bed. And that can really help with sleep duration, as well as insufficient sleep. So that is an important step in restless leg management, is getting enough sleep and listening to your body and getting enough duration.

John Horton:

Yeah. It seems like that comes up all the time on this pod. Listening to your body is key to everything, and you realize how often we ignore it.

Dr. Aparna Bhat:

That's right. We're always too busy to get enough sleep.

John Horton:

Well, so all of these things that you just brought up, they sound so simple. I mean, really kind of easy fixes. How likely is it if you adopt these that you'll take care of the problem and not have this issue at night?

Dr. Aparna Bhat:

Yeah. Everyone responds differently to treatment, but there are times very often that iron supplementation or discontinuing certain medications or treating sleep apnea can actually resolve restless leg symptoms. And there's mixed data on the association of restless leg symptoms with other medical conditions, such as your heart health and stroke health and blood pressure as well. So it's an important aspect to sleep quality and your overall health. So it can be important to treat in the long run. So if these treatment options don't help, then talk to your provider, and we're happy to look into other medications that might be helpful.

John Horton:

It is kind of interesting how restless legs seems to link over some of those other conditions, like you said, like you have heart issues or high blood pressure. I saw where it's tied to weight, even something like large tonsils. So these are all other health issues where if you look and address those, you might address the side issue of restless legs in the process.

Dr. Aparna Bhat:

There is mixed data on these associations. I think the modest data we have is really supporting restless leg and hypertension. But definitely poor sleep quality is going to impact your overall health and obesity, as you mentioned, and mood, anxiety and depression as well.

John Horton:

Yeah. At what point should you go see a doctor to get things checked out if restless legs keep coming back, or if it really seems severe?

Dr. Aparna Bhat:

Yeah. And the symptom severity is key here. So if someone is having restless leg symptoms several times a week, it's impacting their quality of life, it's impacting their ability to sleep, then I would encourage you to reach out to your medical provider for further guidance. If not, there isn't a lot of great data to say we have to treat everyone with the restless leg symptoms. So I would say it is very dependent on symptom severity.

John Horton:

All right. So it sounds like really try to do these simple things you can do at home to maybe tame it, make it a little less. And then, if it keeps getting bad, talk to your provider, and there might be some bigger solutions that they can help you work toward.

Dr. Aparna Bhat:

Yeah. You know what? Restless leg syndrome may sound simple, but symptoms can be really distressing for individuals, and it can really impact their quality of life and ability to sleep. So the first step is always considering lifestyle modifications, analyzing your prescribed medications and over-the-counter medications, and looking at other concomitant medical conditions, such as sleep apnea. Sometimes, prevention is a really important part of restless leg treatment, but there are medication options that are available that can really help with symptom control.

John Horton:

Well, Dr. Bhat, that sounds like a great way to get a better night's sleep. So thanks again for coming in, and as always, I think you help us rest a little easier.

Dr. Aparna Bhat:

Thank you so much for having me.

John Horton:

If restless legs keep you up at night, small lifestyle changes may help. Adding more movement to your day, using hot or cold therapy, and adding iron to your diet if your levels are low, might be enough to calm your legs down. But if symptoms continue, don't just suffer through it. Talk to your healthcare provider about your options.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Till next time, be well.

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