Restless Legs Syndrome

Nonpharmacologic Treatment

The first step in the treatment of RLS is to assess the patient's lifestyle for factors that may exacerbate the condition. As mentioned in previous sections, a variety of factors, including medications and substances such as caffeine and alcohol (Table 6) and iron deficiency (with or without anemia) may worsen the symptoms of RLS. Having patients thoroughly review their eating and drinking habits and ingestion of over-the-counter medications or illicit substances, with use of a diary, may help to identify these factors.

Causes of decreased iron stores should be elicited during the clinical interview and treated appropriately. Serum ferritin levels have been shown to be inversely correlated with RLS symptoms; however, even patients with hemochromatosis have also been shown to have symptoms of RLS.165 Therefore serum ferritin levels should be obtained in all patients with a new onset of RLS symptoms or who have not previously had levels checked before commencing with iron supplementation. The symptoms of RLS in patients with low-normal levels (i.e., less than 40-50 ng/dL) may respond to treatment with iron supplementation.95,98,166,167 Typical oral supplementation includes 325 mg of ferrous sulfate three times daily, as tolerated, given with 100 to 200 mg of vitamin C to enhance absorption. Serum ferritin levels should be followed at three- to six-month intervals until iron therapy is discontinued, typically when serum ferritin levels reach 50 ng/dL or greater. Periodic rechecks may be necessary to determine the need for further iron treatment or when symptoms escalate. Studies have shown the effectiveness of the intravenous administration of iron dextran in patients with primary and ESRD-related RLS94,95,167; however, this treatment remains experimental. Often overlooked in the list of factors that may exacerbate symptoms of RLS is a history of frequent blood donation.47,168,169 Patients with RLS should be encouraged to have their serum ferritin levels checked before donating blood.

Physical activity in the evening hours, although not strenuous exercise, may delay the need for pharmacologic intervention into a time later in the evening. During times of forced immobilization, such as airplane flights, patients may find that mentally alerting activities such as playing computer games, performing intricate needlework, or reading an engaging novel may lessen their symptoms of RLS.