diana1


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Restless legs syndrome and impact on work performance

January-April, 2009January-April, 2009January-April, 2009January-April, 2009January-April, 2009                      Vol.28 - No.1                     Vol.28 - No.1                     Vol.28 - No.1                     Vol.28 - No.1                     Vol.28 - No.1

UNIVERSA MEDICINA

Diana Samara*

*Department of Occupational
Medicine, Faculty of Medicine,
Trisakti University

Correspondence
dr. Diana Samara, MKK
Department of Occupational
Medicine, Faculty of Medicine,
Trisakti University
Jl. Kyai Tapa No.260 - Grogol
Jakarta 11440
Phone: 021-5672731 ext.2101
Email: davidwp@cbn.net.id

Univ Med 2009; 28:34-40

ABSTRACT

Restless legs syndrome (RLS) is a neurological sensorimotor disorder characterized
by unpleasant sensations in the legs and an uncontrollable urge to move them for
relief. The RSL prevalence in the general population is 0.1% - 11.5%, and increases
with age, with the highest effect of producing a primary sleep disorder (70%-80%).
Women appear to be at increased risk, as do individuals with certain chronic
conditions, including renal failure and anemia. The pathophysiology of RLS is
incompletely understood, but it probably results from derangements in dopamine
and iron metabolism, and has a genetic component. RSL could be idiopathic or
secondary (usually related with iron deficiency, terminal renal failure, pregnancy,
and spinal cord lesions). RLS patients usually have sleep disorders, so the disease
can cause difficulties and problems in occupational and social life. Subjects with
RLS symptoms appear to experience significantly more daytime problems, including
being late for work, making errors at work, or missing work because of sleepiness.
The diagnosis of RLS is made by following the criteria of the International Restless
Legs Syndrome Study Group (IRLSSG). Pharmacologic RLS therapy, in which
dopaminergic drugs constitute the first line, is effective and may have a dramatic
effect on symptoms and quality of life. Identifying and treating RLS may improve
sleep quality, daytime function and work performance.

Keywords: Restless legs syndrome, sleep disorder, workers

INTRODUCTION

R e s t l e s s  l e g s  s y n d r o m e  ( R L S )  i s  a
n e u r o l o g i c a l  s e n s o r i m o t o r  d i s o r d e r
characterized by by unpleasant sensations in the
legs and an uncontrollable urge to move them
for relief. The patients complain of a burning
sensation, of worms moving, of a sudden

pulling movement of the leg, or of ants crawling
within the legs. The sensations range from
uncomfortable to irritating and painful.(1,2) The
urge to move the legs has a circadian pattern
most occur in the evening or at night when the
p a t i e n t  i s  n o t  a c t i v e ,  a t  w h i c h  t i m e  R L S
symptoms are manifested as sudden movements
of the legs, such that this condition is frequently



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accompanied by sleep disturbances.(2)

RSL may have a negative impact on the
quality of life because it causes unpleasant
waking up, chronic sleep disorders, and stress.
This condition has an effect on various aspects
of life, such as occupational and social problems
and difficulties in family life. Disturbed sleep
and intolerance to activities where the individual
has to remain without moving, may cause loss
of work, inability to enjoy life and relational
problems.(3)

Epidemiology
In the general population, the prevalence of

RSL ranges from 0.1% to 11.5%, with the
occurrence of a primary sleep disorder as the
highest effect (70%-80%).(4) Studies conducted
by The RLS Epidemiology, Symptoms and
Treatment (REST) have shown that among the
majority of patients seeking relief, only 6.2%
was diagnosed as RSL. The symptoms are more
frequently associated with conditions such as
back pain, arthritis, or peripheral neuropathy.(5)

The ratio of females to males with RLS is 2:1,
but this ratio does not differ significantly from
the female to male ratio of respondents in all
surveys6. A survey in Japan found that 5% of
respondents had symptoms of RSL, whilst
clinically significant RSL amounted to 1.5%.(7)

In the RLS Epidemiology, Symptoms, and
Treatment (REST) survey of 16,202 individuals
in the United States and 5 European countries,
which is perhaps the largest study conducted to
date, 7% of participants screened positively for
RLS.(8) A telephone interview of a random
sample of 1803 adults in predominantly rural
Kentucky found an age-adjusted RLS prevalence
of 10%.(9) Results were similar in the Wisconsin
Sleep Cohort, a prospective community-based
epidemiologic study, in which 10.6% of 2821
participants reported RLS symptoms occurring
at least weekly.(10) Rangarajan et al reported their
f i n d i n g s  o f  a  d o o r  t o  d o o r  s u r v e y  o n  a l l

individuals in Bangalore, India. They found a
prevalence of 2.1% based on the International
Restless Legs Syndrome Study Group (IRLSSG)
criteria, and 1.2% of RSL patients had sleep
disturbances.(11)

A high prevalence of RLS symptoms was
observed in one Idaho primary care population.
B a s e d  o n  t h e  R e s t l e s s  L e g s  S y n d r o m e
Questionnaire (RLSQ), this study found that 504
(24.0%) of the 2099 patients surveyed reported
all 4 basic diagnostic symptoms of RLS.(12)

Etiology
The main cause of RSL is not known. RSL

m a y  b e  i d i o p a t h i c  o r  s e c o n d a r y  ( u s u a l l y
associated with iron deficiency, terminal renal
failure, pregnancy, and spinal cord lesions).
A d d i t i o n a l  s t u d i e s  i n d i c a t e  t h a t  R S L  i s
associated with type 2 diabetes mellitus and
m u l t i p l e  s c l e r o s i s .  H a l f  o f  p a t i e n t s  w i t h
idiopathic RLS have a positive family history of
RLS.(2,4)

Several studies also found that caffeine,
alcohol, and tobacco may induce symptoms in
individuals with a predisposition for developing
RLS. A number of studies have shown that using
a reduced amount of the substances, or not using
them at all, may relieve the symptoms, although
it is unclear whether elimination of these
s u b s t a n c e s  c o u l d  a l t o g e t h e r  p r e v e n t  t h e
occurrence of RLS symptoms.(1)

Pathophysiology
The basic pathophysiologic mechanism of

RLS is incompletely understood. Pharmacologists,
physiologists, pathologists, and neuroradiologists
have found an association of RLS with dopamine
transmission. Dopamine is a messenger molecule
responsible for transmission of signals between
one area of the brain, i.e. the substantia nigra,
and the next relay station in the brain, which is
the corpus striatum, resulting in smoothly
coordinated activity of muscles as intended. It



44

is this dopamine transmission that is believed
to play a role in the development of RLS.(1,13)

Additionally, the development of RSL is also
thought to be associated with a low iron store
in the neurons of the substantia nigra and with
spinal cord dysfunction.(2,13)

Symptomatology
Patients with RSL have uncomfortable

sensations in the legs, particularly when sitting
or lying down, accompanied with an urge to
move the legs. These sensations are usually felt
in the legs between the knee and the ankle, but
occasionally also in the feet, thighs, arms and
hands. The sensations mostly appear on both
sides of the body (bilaterally), but may also be
on one side only (unilateral). Most of the
symptoms are ignored in daytime settings and
a r e  o n l y  f e l t  i n  t h e  e v e n i n g  o r  a t  n i g h t ,
particularly when asleep. Most of the symptoms
disappear by morning, when the patient is at
last able to get some sleep. The symptoms may
occur at any stage of life, but commonly become
increasingly frequent with advancing age.(1)

R e s t l e s s  l e g s  s y n d r o m e  a n d  w o r k
performance

Most patients with RLS suffer from a sleep
disorder called periodic limb movements in
sleep (PLMS). Individuals with both RLS and
PLMS have difficulty in falling asleep and
s t a y i n g  a s l e e p ,  a n d  u s u a l l y  f a l l  a s l e e p  a t
daytime because of difficulty in falling asleep
in the early morning hours.

The National Sleep Foundation 2005 poll
on 1,506 adults found associations for persons
at risk for RLS and sleep behaviors, who had
shorter durations of sleep (less than six hours
nightly) and had symptoms of insomnia. In
comparison to persons not at risk for RSL, they
also stayed up longer than intended (several
nights per week), took more than 30 minutes to
fall asleep, and had more daytime fatigue (p <

0.05).(14)

The RLS epidemiology, symptoms, and
treatment (REST) study in which 16.202 adults
aged > 18 years participated, showed that more
than 75% of the RLS sufferers reported at least
one sleep-related symptom. Disrupted sleep, an
inability to fall asleep, and insufficient hours of
s l e e p  a r e  e x p e c t e d  c o n s e q u e n c e s  o f  t h e
sensorimotor abnormalities of RLS, which are
worse at night and while at rest.(15) Consequently
persons suffering from RLS have problems at
w o r k ,  i n  s o c i a l  l i f e  a n d  i n  r e c r e a t i o n a l
activities.(16) They frequently come late to work
and make errors at work, due to sleepiness.(14)

The study by Ulfberg et al in 200 women
between 18-64 years of age, using multivariate
logistic regression, found that 11.4% of the
women suffered from RLS. These women with
RLS had more sleep disturbances than those
without RLS. The sleep disorder had an impact
on their daily life, where RSL sufferers were
f i v e  t i m e s  m o r e  l i k e l y  t o  c o m p l a i n  o f
headaches, and tended to have diminished
performance at work. In consequence, these
conditions caused 9 times more problems at
work among women with RSL.(17)

A  n u m b e r  o f  s t u d i e s ,  i n c l u d i n g  t h e
National Sleep Foundation 2005 Poll, have
consistently reported the presence of a strong
association between mental and physical health
problems on the one hand and RLS symptoms
on the other.(14,18,19)

Diagnostic criteria
Because of a lack of objective biological

diagnostic signs, the diagnosis is based on the
clinical criteria of the International Restless Legs
Syndrome Study Group (IRLSSG), consisting of
four essential and four supportive criteria. The
four essential criteria are (i) an urge to move the
legs, (ii) worse at rest or when inactive, (iii)
relief by activities such as walking, and (iv)
worse in the evening or at night. Supportive

Samara                                                                                           Restless legs syndrome



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clinical conditions include (i) family history of
RSL, (ii) response to dopaminergic therapy, and
(iii) periodic movement of the extremities at
sleep or when awake but relaxed, and (iv)
chronic symptoms occurring with varying
degrees of sleep disturbance and generally
w i t h o u t  n e u r o l o g i c a l  a b n o r m a l i t i e s  o n
examination (Table 1). ( 2 0 ) The movements
usually occur periodically, on average at 20-
second intervals. The most common movement
is dorsoflexion of the ankle and flexion of the
knee or hip.(3) In a number of dubious cases,
neurophysiological examinations, such as
polysomnography and/or immobilization tests,
may be needed for confirmation of RSL.(4)

Management
N o t  a l l  p a t i e n t s  w i t h  R L S  n e e d

pharmacological treatment. Confirmation of
diagnosis and reassurance is sufficient for most
patients with RLS, and only approximately 20%
of all RLS patients may have symptoms severe
enough to merit pharmacological treatment.(21)

RSL can be cured, although determining the
most suitable treatment and dosage may take
time, and treatment may occasionally have to
be individually modified. Treatment should
begin by examining the patient’s lifestyle and
looking for opportunities to initiate lifestyle
changes, especially with regard to substances
known to exacerbate symptoms (Table 2).(22)

Table 1. Diagnostic Criteria for Restless Legs Syndrome(20)

Abbreviation: RLS, restless legs syndrome

Table 2. Factors influencing treatment of RLS(22)



46

T h e  p r i n c i p a l  d r u g s  u s e d  i n
pharmacological management of RSL are L-
DOPA, dopamine agonists, anticonvulsants
and benzodiazepines. Significant recovery
with therapy occurs after a sufficiently long
period of time.(2)

T h e  s t u d y  c o n d u c t e d  b y  M o n t a g n a
indicated that dopaminergic drugs constituted
the first line in pharmacology for treatment
of RSL, at least for a short period of time
(Table 3).(23)

A l t h o u g h  m o s t  p a t i e n t s  r e q u i r e
pharmacologic treatments, non-pharmacologic
treatments are available from which patients
m a y  a l s o  b e n e f i t . ( 2 4 ) M o s t  o f  t h e  n o n -
pharmacologic treatments for RLS are from
case series or case reports; however, one small
randomized study assessed the effects of
e x e r c i s e  o n  R L S  i n  2 8  i n d i v i d u a l s . ( 2 5 )

Participants were assigned to no exercise
(n=17) or thrice weekly lower body resistance
training and treadmill walking (n=11). Severity
as measured by the International Restless Legs
Syndrome (IRLS) scale decreased by 39%
during the first 6 weeks of the intervention.
This improvement was maintained for the
remaining 6 weeks of the study period. In

addition to moderate exercise, good sleep hygiene,
including rising and going to bed at the same times
e a c h  d a y,  s h o u l d  f o r m  t h e  b a s i s  f o r  n o n -
pharmacologic treatment of RLS. (26,27) Little
information is available about the effects of
lifestyle on the symptoms of RLS. Limiting
caffeine, tobacco, and alcohol use may improve
s y m p t o m s .  A c t i v i t i e s  t h a t  p r o v i d e  m e n t a l
stimulation may also provide relief. One survey
showed a higher prevalence of RLS in persons who
were sedentary and overweight.(28) Many experts
recommend abstaining from alcohol, caffeine, and
nicotine. Activities that improve mental alertness
(crossword puzzles, video games) may also reduce
R L S  s y m p t o m s ( 2 9 ) H o t  b a t h s ,  m a s s a g e ,  a n d
stretching may also improve symptoms.(30)

Prognosis
RLS has a variable course, but symptoms

tend to progress with advancing age. Some
i n d i v i d u a l s  m a y  e x p e r i e n c e  s p o n t a n e o u s
improvement in their symptoms for a period of
time, but symptoms tend to recur.(31) Individuals
with RLS secondary to an underlying condition
m a y  h a v e  i m p r o v e m e n t  o f  s y m p t o m s  i f  t h e
underlying condition is treated. Medications,
when needed, may provide relief of symptoms.

Table 3 Recommendations for primary RSL therapy(23)

Abbreviation: RLS, restless legs syndrome; PLMS : periodic limb movements in sleep

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CONCLUSIONS

RLS is a disorder that frequently causes
sleep disturbances, which if sufficiently severe
will result in impairment of daily activities of
life and thus may cause work-related problems.
Therefore an accurate diagnosis of RLS needs
to be made to prevent increasing the numbers
of patients with sleep disturbances, which will
have an impact on their work. The physician
should have an increased understanding and
a w a r e n e s s  o f  t h e  c o n d i t i o n ,  t o  p r e v e n t
m i s d i a g n o s i s  a n d  c o n s e q u e n t  i n e ff e c t i v e
treatment. Identifying and treating RLS may
improve sleep quality and daytime function.

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Samara                                                                                           Restless legs syndrome