Dr. Bob's Psychopharmacology Tips

Restless leg syndrome

Date: Sun, 10 Sep 95 0:49:41 EDT
From: Max Mastellone <mastello@pilot.njin.net>
Subject: Clonazepam for restless leg syndrome

I have a mild case of RLS. The current treatment among GPs appears to be Klonopin (clonazepam). I have used it for myself with success.

From: Charles.Enzer@UC.Edu (Charles Hart Enzer, M.D.)
Date: Sun, 10 Sep 1995 02:06:55 -0500 (EST)
Subject: Excercises for restless leg syndrome

My nephrologist friends deal with cramping of legs when patients are on dialysis.

They find that vertical push-ups against the wall help by stretching ligaments in the anti-popliteal space:

• Stand about arm's length from wall.
• Place palms on wall.
• Relax elbows while keeping body straight.
• Keep soles flat on surface.
• Repeat 10 times bid but not if too uncomfortable.

They tell me the shower is a convenient place if not slippery.

Date: 11 Sep 95 15:15:56 EDT
From: Troy Caldwell <75112.1676@compuserve.com>
Subject: Restless leg syndrome

The three I've heard most about are:

1. Klonopin
2. Sinemet
3. bromocriptine.

My most recent case failed the first two but responded to the third. She had concurrent panic disorder.

From: jonathan.pulman@bbs.synapse.edu (Jonathan Pulman)
Subject: Excercises for restless leg syndrome
Date: Sun, 17 Sep 1995 10:40:00 -0400

I also have mild RLS. I get it if I don't excercise regularly (x 3 or 4 a week). Worse with alcohol.

When I get it in bed I do a horizontal version of the above:

1. Lie on back, one leg lifted up.

2. Using both hands pull hard on ball of foot (dorsiflexing foot) and try to pull leg over head (with hands). Pull hard enough to produce pain. Hold for 2-3 minutes. Enjoy the pain. There is a *good* feeling to it which goes beyond ordinary masochism. The leg does not need to be straight (I am pretty inflexible, so my knee is not at all straight).

3. The effect is to stretch all the muscles at the back of the leg. It does feel to me that the muscles in the popliteal fossa are the ones needing a stretch.

4. Repeat with other leg.

5. Explain to awakened partner that this is not some sort of new way of doing it and that he/she does not have to join in.

Date: Wed, 20 Sep 1995 20:54:41 -0400
From: Whit Garberson <jwgg@world.std.com>
Subject: Excercises for restless leg syndrome

If you are really looking to stretch that spot behind the knee, you need to hit hamstrings, gastrocs, and heelcords. If you don't have a physical therapist to do this for you, try the following exercise, which my physical therapist taught me. You should be seated straight up in a chair, without shoes.

1. Elevate your left leg and place your left heel on the seat of a 2nd chair. Your leg should be straight out in front of you. The chair supporting your foot should be roughly the same height as the chair you are sitting in.

2. Loop a doubled belt (a rope or rolled towel will serve) around the ball of your left foot, holding one end of the belt in each hand.

3. Straighten your leg and put gentle tension on the belt until you feel the pull starting in your calf.

4. Now, *keeping your back straight*, gently lean forward while maintaining tension on the belt. (If you bend your back while doing this, you will be stretching your back instead of your legs.) Easy does it.

5. Hold the stretch for about 30 secs.

6. Repeat with right leg.

Do both sides b.i.d., and you'll be loose as a goose.

From: RMRich1@aol.com (Roberta M. Richardson, M.D.)
Date: Wed, 13 Nov 1996 20:02:53 -0500
Subject: Restless leg syndrome

I've got restless legs, and I don't mean mild. It was really getting to be a serious problem at night by the time I researched it at the library one Sunday.

In addition to the already suggested remedies, I found that pergolide is being recommended more recently by some sleep specialists.

I didn't want to take pergolide or bromocriptine or Sinemet or even clonazepam, so I decided to look into "alternative" medicine. My chiropracter suggested calcium, taken before sleep.

That was a couple of years ago. I take 1500 mg of calcium citrate (which seems to work better than calcium carbonate) one hour before sleep and rarely experience the sensations anymore. If I miss it or cut the dose even once, the sensations are back.

I might add that I actually take calcium citrate *complex*, which contains magnesium zinc, manganese, copper, and vitamin D.

I have suggested this to several patients, and only one so far has reported relief.

Date: Thu, 14 Nov 1996 08:16:29 -0700
From: Doug Russo <dtr01@PRIMERA.ORG>
Subject: Magnesium for restless leg syndrome

Excellent advice. Often times simple, natural based therapy is effective, is less expensive, and causes fewer adverse effects than the big gun prescription approach. Popoviciu L et al. report their work on restless leg syndrome caused by magnesium deficiency in: Revue Roumaine de Neurologie et Psychiatre, 31 (1): 55-61, Jan-Mar 1993.

Date: Thu, 17 Apr 1997 22:22:52 -0700
From: [non-member of psycho-pharm]
Subject: Caffeine and restless leg syndrome

I quit drinking coffee about 6 months ago and have had no attacks, since. That may be too short a period for validity.

From: [non-member of psycho-pharm]
Date: Thu, 4 Sep 1997 10:46:28 +0000
Subject: Restless leg syndrome

I have had this condition on and off (very much on at the moment) for around 20 years.

Here's some observations I haven't seen anyone else mention so far:

• When on long flights or car journeys, if I pack up the seat so that my thighs are inclined down, I can go for hours before onset of the sensation. This is vital in buying me a few hours on those long flights.

• Vibration can help! I noticed that if I rested my leg on the transmission tunnel of a clunky old car I had, the jiggling effect on my leg at least masked the RLS sensation.

• Conversely, sitting in a deep settee can bring it on very quickly.

• I've noticed the last item particularly after a good meal!

• Heat, in particular on the face, can have a major negative effect. I noticed this when I used to go for supper with friends who have open fires in both their dining and sitting areas. I used to end up lying flat on the floor behind the settee (in a convenient draft) to avoid the combination of the deep settee and the heat.

• Many favorite exercises in bed for stretching the muscles involve raising the legs over the body -- which runs counter to what I've been saying about keeping the legs down. Sitting on the floor, one leg in front, one to the side, then stretching forward over the leg in front, can give the leg a good pull, but it's still not quite like having your ankle up by your neck...

• I feel that my state of mind can have some influence. Listening to "right-brain" music can help me get to sleep, although I am unsure what direct link there is to the RLS sensation. It's as if the music helps me relax overall in the face of the RLS sensation, rather than getting into the "Oh no, not again" loop. It's not guaranteed to work, and you often wake up again.

• Similarly, I can sometimes overcome my instinctive reaction to the onset of the sensation, which is to tighten every muscle I can in my legs. It's as if a really successful "relaxation" can ease the sensation for a few minutes -- but it's only a few minutes before it comes on again, and it ramps up to the usual level of "drives-you-nuts-ness".

The only benefit to RLS is that all this stretching must help joint suppleness, which is great if you like riding horses like I do.

Date: Tue, 23 Sep 1997 19:33:49 -0700
From: Jaime Smith <evb@yknet.yk.ca>
Subject: Fluvoxamine for restless leg syndrome

I have a patient, about 50, who has obtained relief from fluvoxamine 50 mg hs. He is athletic and fit, but the restless legs were a constant problem. We tried many different agents, even obtaining zolpidem from Alaska (not available in Canada) and finally settled on fluvoxamine as the best psychopharmacological agent.

Date: Wed, 24 Sep 1997 00:35:12 -0400
From: William Braden <braden@brown.edu>
Subject: Restless leg syndrome

There are articles, they recommend:

• opiates
• antiparkinsonian agents (eg, amantidine, bromocriptine).

From: PEARLMAN.CHESTER_A_DR@BOSTON.VA.GOV
Subject: Restless leg syndrome
Date: 24 Sep 97 08:31 EDT

This subject was thoroughly reviewed in:

Sachdev P. Akathisia and Restless Legs. Cambridge Univ Press, 1995; 326-41.

L-dopa/carbidopa 100/25 to 250/25 was recommended after clonazepam; then opioids (propoxyphene has been studied most -- about 100 mg 1-2 hr before bed time). Many other agents have had anecdotal success.

Date: Wed, 24 Sep 1997 22:43:24 -0400
From: "John M. Rathbun" <73162.3513@compuserve.com>
Subject: Restless leg syndrome

To the other drugs mentioned, I would add propranolol.

Date: Fri, 26 Sep 1997 22:59:40 -0700
From: Lee Dante <ldante@pol.net>
Subject: Opiates for restless leg syndrome

I took a course at the APA probably 10 yrs ago devoted to the anatomy and physiology of the basal ganglia. One of the presenters showed a videotape of a person with an akathisia that had been treated with codeine. The akasthesia was completely gone but could be instantly reactivated using Naloxone (naltrexone) (quite a convincing demonstration on video). The catch was that it took 2-3 weeks for the codeine to take effect and, more importantly, the reversal of the akathisia only lasted 6 to 12 months before the patient became tolerant. The researcher said that familial akathisias responded and did not become tolerant although I've never encountered someone I could say had an inherited akathisia.

From: WoodwardB1@aol.com (Burns Woodward, M.D.)
Date: Sun, 28 Sep 1997 10:21:08 -0400 (EDT)
Subject: Restless leg syndrome

I have a patient with severe restless legs as well as bipolar disorder whose mood is stable on carbamazepine. Neurologic and sleep specialist consultations have not yielded effective remedies for the nocturnal leg movements. We were using clonazepam, which was helpful for weeks to months and then stopped working. She found in a lay publication the recommendation for Tylenol #3 (acetaminophen 300 mg + codeine phosphate 30 mg). We discontinued the clonazepam and tried one Tylenol #3 at HS, which was helpful (perhaps a 50% reduction in leg movements) for several months. Then, alas, it stopped working. For the last couple of years we have been alternating between clonazepam and Tylenol #3. Restless legs is a very difficult problem!

From: PEARLMAN.CHESTER_A_DR@BOSTON.VA.GOV
Subject: Opiates for restless leg syndrome
Date: 29 Sep 97 09:30 EDT

I have treated two patients with propoxyphene who got relief.

Date: Mon, 29 Sep 1997 17:01:39 -0700 (PDT)
From: "M. Cashman" <cashman@u.washington.edu>
Subject: Dopaminergic agents for restless leg syndrome

Sinemet 25/100, one before bedtime, perhaps advancing after a few days to two before bedtime.

Subject: Gabapentin for restless leg syndrome
Date: Tue, 7 Oct 97 23:32:18 -0400
From: Steven Grenell <sgrenell@ix.netcom.com>

Neurontin (gabapentin), which, after four years on the market, has no known drug interactions or late appearing side effects, is a sovereign remedy for restless legs syndrome without the symptom augmentation which limits treatment with Sinemet, the amnestic problems with clonazepam or the orthostatic hypotension which characterizes pergolide. Side effects are those of any anticonvulsant with ataxia and sedation at doses much higher than those needed to treat RLS. Start at 100 mg hs and increase by 100 mg nitely until symptoms subside.

Date: Mon, 10 Nov 1997 06:05:24 -0500
From: "Willie K. Yee, MD" <wyee@mhv.net>
Subject: Tyrosine for restless leg syndrome

A couple of cases of restless legs have responded to l-tyrosine, 500 mg h.s.

Date: Fri, 21 Nov 1997 11:02:37 -0500
From: [non-member of psycho-pharm]
Subject: Amitriptyline for restless leg syndrome

I was surprised to find that there was actually a name for a condition I've had ever since I can remember. I'm now being treated at VA hospitals (they diagnosed it) and they have put me on a very inexpensive antidepressant called amitriptyline which has the happy side effect of relieving neuralgic symptoms and symptoms of RLS. It's worked like a charm, and I'd recommend it to anyone.

From: [non-member of psycho-pharm]
Date: Fri, 21 Nov 1997 23:35:30 -0500 (EST)
Subject: Trazodone for restless leg syndrome

I take 50 mg of trazodone to aid in my sleeping. To my surprise I found that it eliminated my restless leg problem for 2 or 3 days. No more turning and tossing trying to get to sleep. I sure hope this will work for others.

Date: Tue, 9 Jun 1998 15:38:06 -0400 (EDT)
From: Joe Benezra <joeben@interport.net>
Subject: Quinine for restless leg syndrome

Quinine sometimes helps.

Date: Tue, 09 Jun 1998 16:07:58 -0500
From: Evan Peterson <dovetail@mc.net>
Subject: Restless leg syndrome

This page lists dopaminergic agents, benzodiazepines, opioids, and antiseizure medications as all possibilities for restless legs.

From: AMIROT@aol.com (Adam Mirot MD)
Date: Tue, 9 Jun 1998 18:03:05 EDT
Subject: Restless leg syndrome

I recently attended a sleep disorders update in Toronto. The short version:

If you're sure this is RLS (and not akathisia, ADHD, peripheral neuropathy, uremic urticaria, narcotic-seeking, etc.), then the 1st line treatment is a dopamine agonist -- Sinemet 25/100 qam plus Sinemet CR 50/200 qhs to start -- you can add 25/100 in the afternoon and early evening as well. If this doesn't do the trick, a benzodiazepine like Klonopin is the next choice; alternatively, you can use Ambien (zolpidem). You can also try trazodone as a 2nd line agent. Finally, a 3rd line agent would be a narcotic (Darvon (propoxyphene), codeine) or an anticonvulsant (Neurontin, Depakote (divalproex)). Be sure and check iron studies, including ferritin, as iron deficiency can represent a reversible cause.

From: johncarp@webtv.net (john carpenter)
Date: Tue, 9 Jun 1998 19:18:27 -0700
Subject: Restless leg syndrome

We tried Permax (pergolide) on a female patient and had good results at 1 mg QID. The drug is pretty expensive. It should be gradually titrated. N = 1.

From: MARriposa@aol.com
Date: Wed, 10 Jun 1998 07:59:05 EDT
Subject: Restless leg syndrome

I had restless legs at one time and a type of hypnosis-imagery worked very well.

From: RMRich1@aol.com (Roberta Richardson)
Date: Wed, 10 Jun 1998 19:49:25 EDT
Subject: Restless leg syndrome

I have done a lot of research into the medical and alternative literature about this, for my own benefit, and have talked with many other sufferers as well. I strongly recommend a trial of magnesium, or, probably better, calcium-magnesium complex. Dosages of magnesium from 500-800 mg are really quite safe, unless the patient has some metabolic reason to have too much magnesium. I have found magnesium alone to be helpful, and cal-mag to be a bit more so.

I have read that our soils are increasingly depleted of magnesium. When I was discussing this with my primary care physician, she said she and her partner have commented that low magnesium levels on blood tests seem to be more and more common. Magnesium is important for proper nerve function. Interestingly, magnesium poisoning results in very poor nerve conduction to the muscles, to the point of near-paralysis in severe cases. Since restless legs certainly feels like a hyperactive nerve, it makes intuitive sense to me that magnesium might help.

Other alternative treatments that can be helpful are folic acid in doses in the 5-10 mg range and acupuncture. (This is in addition to stretching, exercise, avoiding caffeine...)

Conventional medicine favors dopaminergic agents; pergolide is the current favorite. Some prescribe Sinemet (levodopa/carbidopa) but the RLS is most troublesome at night, and if you give the Sinemet at night, many get rebound problems during the day and have to take more Sinemet.

Codeine has also been recommended.

Date: Wed, 10 Jun 1998 23:11:52 -0700 (PDT)
From: Ronald Shlensky <3004rs@west.net>
Subject: Vitamin B6 for restless leg syndrome

Vitamin B6 200 mg daily has been useful in my experience.

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