Wednesday, April 25, 2018

Restless Leg Syndrome: Non-pharmacologic Strategies

I get lots of emails about tricks and tips to treat Restless Leg Syndrome other than medication. I discuss this a lot in office visits, and patients tell me about things they have stumbled upon which seem to work. Broadly speaking, I think it is always a good idea to consider non-pharmacologic options for any problem when reasonable and safe. First, many things can cause or unnecessarily aggravate RLS symptoms that should be treated as an underlying issue otherwise. For instance, iron deficiency, neuropathy, gastric bypass, kidney disease, sedentary lifestyle, lumbar stenosis, etc. can all cause RLS or worsen it and should be treated first to reduce unnecessary poly-pharmacy. Second, for many people, RLS is genetic, passed down to you no different than your eye color, but more of a bother. I think this is important to keep in mind, because sometimes it is just something that ends up really needing medication to treat, depending on its severity, and you can’t wish it away or think of it as some existential external thing that has come upon you. Sometimes, medications really are your friend. Third, although sometimes medications are just plain necessary, non-pharmacologic strategies always have a place in complementing prescription medications, to reduce the overall dose burden or frequency of baseline medication use and/or frequency/dose of breakthrough medication need.
So these tips/tricks are a compilation of things I know, or things patients have told me work for them. If you have RLS and are reading this, I would print it out and pragmatically work through the list on a trial basis a few weeks at time to see which element(s) work best for you. 

Exercise: Well, a sudden uptick in exercise, like weekend warrior exercise or a spontaneous fun run, or Fall-related leaf raking marathon or Spring-related garden planting for many people will aggravate their RLS symptoms. HOWEVER, regular walking in the evening/weight training or some such similar consistent—that is the key-- consistent amount can actually help reduce the RLS presence. There are many theories about why this may help. I have a theory that the endorphins released work on RLS symptoms indirectly through the pain pathway (dorsal horn of the spinal cord). The problem with this theory is that I am not sure why more exercise/sudden exercise is often counterproductive… perhaps through some lactic acid buildup mechanism and a reduction in pH. I am open to the literature on this question still. 

Soap under the bed: I have thought a lot about this. There is actually NO WAY for soap under your bed to physiologically directly reduce RLS symptoms. It is just not possible. BUT, I have patients who swear by it, so this is my theory. It is a valid use of the placebo effect. We know stress can bring out or exacerbate RLS symptoms, and if you believe soap will work, I believe the belief itself is a treatment, by reducing stress, and indirectly therefore truly helping. Unfortunately, if you just read this and believe me, then I ruined it for you. Sorry. 

Stress: Stress worsens symptoms, so I often recommend a strong pre-sleep calming ritual, deep breaths, a “worry journal” to help relieve immediate concerns until the next morning, etc.

Soak: Many patients swear by a pre-bedtime ritual of soaking the feet in cool water. I would think hot water for some reason (which I have also heard from patients), but more seem to report cool water benefits. Ice water = bad, though, as it can cause nerve injury. I have a patient who swears by Epson salts, cool water, and a short story (her “timer”) from a book of short stories every night as part of her ritual, to reduce the dosage of Mirapex used for her RLS. 

Heating pad: Ok, so not as many people like warm or hot water, but many people DO like heating pad use, wrapped around their feet WHILE IN BED. 

Iron: Iron deficiency is an obvious target, but many people don’t understand this point, so let me partially clarify. There have been many articles dedicated to this, but I just want you to understand my particular view on this. RLS is likely a heterogeneous group of “diseases” which are slightly different (which is why very different strategies work for different people). For some, it is utilization of dopamine in the right place at the right time in the brain (localized “storage centers” of iron and “production centers” of dopamine). For many people there is some poorly understood connection to the benzodiazepine receptor. For some it is possibly a slight general decrease in dopamine production, not enough to cause Parkinson’s but enough to cause RLS. And I believe that for others there is a problem making dopamine efficiently, specifically, converting its precursor, Tyrosine, into –L-dopa(mine). Numerous cofactors are needed to make this conversion, iron being a big one (along with indirect factors such as magnesium, zinc, Vit C & D & B3 & B6). Ferritin is protein that helps you store protein when available to be stored, a more sensitive test than testing for iron amount directly. A “normal” level of ferritin is 20 ng/mL, but for RLS individuals, it should be 50 ng/mL or more (more like 70 to 80 ng/mL). By the way, only about a third (or less, depending on the study) of patients with a low ferritin have a low serum iron level, the general iron level being what is usually checked by doctors. 

Folate: Try 5 to 30mg daily for a month. Some people, even with normal levels (10-12ng/mL) noted a subjective benefit.

Magnesium: Try magnesium oxide supplements 400-600mg about an hour before symptoms usually starts. I recommend trying 200mg or less increments, 2 weeks at a time while seeing what works and giving your stomach/intestines a chance to get used to the dose before trying higher doses. This seems to help for some people earlier in the diagnosis than in more progressed forms.

Review meds: These are the most common culprits I see: SSRIs, TCAs (Tricyclic antidepressants), Prochloperazine, Metoclopramide, Diphenhydramine.

Caffeine (including in chocolate), Alcohol, and Nicotine: These can all be associated with worsening RLS symptoms, sometimes hours after taking in a manner that is unexpected by the patient. 

Eating too late can worsen symptoms for a variety of reasons.  I will say that many patients have noted trends in what type of food can cause this, such as high fat, or salty food, but often, high carbohydrate food seems to be a common trend I hear. I suspect it has something to do with a change of blood flow to the GI system slightly away from the brain that somehow causes this.

Aspirin before bed. If you take aspirin, try taking at night before bed instead of the morning. If you don’t take aspirin, I would try 81mg  (enteric coated) before bed for a few weeks, then 2 of them before bed for 2 weeks if 81mg didn’t work, just to see if you are one of these people it helps. I don’t know mechanistically HOW it would help which means either there is a gap in my knowledge or ability to logically make the connection; there is a gap in Medicine’s knowledge; it is placebo effect; or it is working through another mechanism. I DO know that patients with vascular claudication, poor circulation to the legs, seem to notice less leg cramping and less non-classic RLS-like leg pain when placed on Plavix to help with blood flow to their legs… so if you are older and aspirin helps, I think you should probably at least ponder whether this possibility is relevant for you. 

For some people “mechanical” strategies seem to help, either by themselves early in the diagnosis, or as adjunctive strategy later, to complement medications or supplements and help reduce the medication dose burden. Common strategies include tight cotton socks or actual compression hoses. Sometimes just massaging your legs with your hands or with a device just before bed can be enough. I have had patients use weighted blankets folded over at the base of the bed too, and even electric hospital-grade pneumatic compression devices typically used in the hospital to prevent DVTs. Some people notice that vibration helps and will try plug-in vibrating blankets. 

I hope these strategies help. There are others of course, many of which I am SURE are JUST placebo (like Himalayan salt lights or Manuka honey spreads…) but these are the big ones that I find myself discussing with patients.