Elsevier

Sleep Medicine Reviews

Volume 38, April 2018, Pages 158-167
Sleep Medicine Reviews

Clinical Review
Complementary and alternative therapies for restless legs syndrome: An evidence-based systematic review

https://doi.org/10.1016/j.smrv.2017.06.003Get rights and content

Summary

Restless legs syndrome (RLS) is defined as an irresistible urge to move the legs, which is usually accompanied by paresthesias or dysesthesias at least twice weekly, and affects 2%–4% of adults in Europe and North America. This systematic review assesses the current complementary and alternative options for RLS and the potential benefits of those treatments on sleep quality, mood disorder, and quality of life. A systematic search of the PubMed, Embase, Cochrane, and Web of Science databases was conducted. Eighteen studies met the inclusion criterion, which included the use of the international RLS study group criteria. Complementary and alternative therapies have been found to be effective in both primary and secondary RLS. The severity of primary RLS symptoms can be significantly ameliorated by exercise training, transcutaneous spinal direct current stimulation, pneumatic compression devices, light therapy, repetitive transcranial magnetic stimulation, and acupuncture. Pneumatic compression devices and yoga also improve RLS-related disorders. Exercise training is highly efficacious in the reduction of symptom severity in uremic RLS and related effects such as poor quality of life. Endovenous laser ablation may be a good choice for patients with concurrent RLS and superficial venous insufficiency.

Introduction

Restless legs syndrome (RLS) is defined as an irresistible urge to move the legs. It is usually accompanied by paresthesia and dysesthesia, and the symptoms can be partly or totally relieved by physical activity [1], [2], ∗[3], [4], [5], ∗[6], ∗[7]. Patients with RLS describe the sensory discomfort using terms such as pain, tingling, creeping, burning, bugs, electricity, or nervousness [8]. It varies in symptom frequency, severity, and duration. The effects of RLS on the ability to function range from minor annoyance to negative effects on work, social activities, and emotional well-being [9]. However, sleep disruption induced by RLS and daytime fatigue are the most common reasons for seeking medical advice [10].

Bothersome RLS affects 2%–4% of adults in Europe and North America at least twice weekly and is more common among women [11], [12]. RLS is associated with female gender, pregnancy, elderly age, poor health, lower socioeconomic status, and positive family history [13], [14], [15], [16], [17], [18]. It can occur in an idiopathic form or secondary to other conditions such as renal failure, iron deficiency, pregnancy, or particular medications [19]. The pathophysiology of RLS is still unclear, although it is believed to result from iron deficiency and dopamine imbalance in the central nervous system [20].

Therapies for RLS can be divided into pharmacological and non-pharmacological treatments. Three dopamine agonists (ropinirole, pramipexole, and rotigotine) and one calcium channel alpha-2delta receptor ligand (gabapentin enacarbil) are currently approved by the Food and Drug Administration for pharmacological treatment of moderate to severe RLS [9]. Various clinical trials [1], [2], ∗[3], [4], [5], ∗[6], ∗[7] that have examined the efficacy of physiotherapy in the non-pharmacological treatment of RLS have demonstrated that it can alleviate the clinical symptoms. However, no systematic review has been published addressing the effectiveness and safety of non-pharmacological treatment for the relief of RLS symptoms. Hence, this systematic review was conducted to evaluate the efficacy and safety of complementary and alternative therapies for RLS, based on scientific evidence.

Section snippets

Data sources and search strategy

A systematic search of the PubMed, Embase, Cochrane, and Web of Science databases using the search terms ‘restless leg*’or ‘RLS’ was conducted in August 2016 to identify available data sources for complementary and alternative therapies for RLS. Only papers in English were included in the review. Further relevant trials were obtained by manually searching the conference abstracts and reference lists of all identified related publications to avoid omitting relevant randomized controlled trials

Results

The initial database search identified 1849 papers. Of these, only 18 studies met our inclusion criteria and were included in this systematic review. Twelve trials focused on primary RLS and the other six on secondary RLS.

Complementary and alternative therapies for primary RLS involved aerobic exercise training (n = 1), electrical stimulation (n = 3), vibratory stimulation (n = 1), enhanced external counter pulsation (EECP) (n = 1), pneumatic compression devices (PCDs) (n = 1), light

Discussion and conclusion

The results of this systematic review revealed that the severity of primary RLS symptoms can be significantly ameliorated by complementary and alternative options such as exercise training, tsDCS, PCDs, light therapy, rTMS, and acupuncture. With regard to secondary RLS, the application of intradialytic exercise training has consistently been shown to be highly efficacious in the reduction of uremic RLS symptom severity, and ELA has been proven to alleviate or relieve RLS symptoms in patients

Conflicts of interest

The authors have no conflicts of interest to disclose.

Acknowledgments

This work was supported by the National Key Clinical Specialties Construction Program of China for Neurology [The First Affiliated Hospital of Chongqing Medical University; grant no. (2014)27], as well as natural science foundation project of Chongqing science and technology commission (ID: cstc 2016jcy jA0423)

References (70)

  • S.S. Rajaram et al.

    Enhanced external counter pulsation (EECP) as a novel treatment for restless legs syndrome (RLS): a preliminary test of the vascular neurologic hypothesis for RLS

    Sleep Med

    (2005)
  • S.S. Rajaram et al.

    Enhanced external counter pulsation (EECP) for restless legs syndrome (RLS): preliminary negative results in a parallel double-blind study

    Sleep Med

    (2006)
  • A.P. Strafella et al.

    Therapeutic application of transcranial magnetic stimulation in Parkinson's disease: the contribution of expectation

    NeuroImage

    (2006)
  • F.E. Murtagh et al.

    The prevalence of symptoms in end-stage renal disease: a systematic review

    Adv Chronic Kidney Dis

    (2007)
  • M. Zucconi et al.

    The official World Association of Sleep Medicine (WASM) standards for recording and scoring periodic leg movements in sleep (PLMS) and wakefulness (PLMW) developed in collaboration with a task force from the International Restless Legs Syndrome Study Group (IRLSSG)

    Sleep Med

    (2006)
  • W.A. Hening

    Subjective and objective criteria in the diagnosis of the restless legs syndrome

    Sleep Med

    (2004)
  • R.L. Benz et al.

    Potential novel predictors of mortality in end-stage renal disease patients with sleep disorders

    Am J kidney Dis Off J Natl Kidney Found

    (2000)
  • W. Hening et al.

    Impact, diagnosis and treatment of restless legs syndrome (RLS) in a primary care population: the REST (RLS epidemiology, symptoms, and treatment) primary care study

    Sleep Med

    (2004)
  • C.J. Earley et al.

    Restless legs syndrome: understanding its consequences and the need for better treatment

    Sleep Med

    (2010)
  • C.D. Giannaki et al.

    Epidemiology, impact, and treatment options of restless legs syndrome in end-stage renal disease patients: an evidence-based review

    Kidney Int

    (2014)
  • G.K. Sakkas et al.

    Current trends in the management of uremic restless legs syndrome: a systematic review on aspects related to quality of life, cardiovascular mortality and survival

    Sleep Med Rev

    (2015)
  • A.S. Walters et al.

    Does the endogenous opiate system play a role in the Restless Legs Syndrome? A pilot post-mortem study

    J Neurol Sci

    (2009)
  • D. Garcia-Borreguero et al.

    A 52-week open-label study of the long-term safety of ropinirole in patients with restless legs syndrome

    Sleep Med

    (2007)
  • M.M. Aukerman et al.

    Exercise and restless legs syndrome: a randomized controlled trial

    J Am Board Fam Med JABFM

    (2006)
  • G.K. Sakkas et al.

    Intradialytic aerobic exercise training ameliorates symptoms of restless legs syndrome and improves functional capacity in patients on hemodialysis: a pilot study

    ASAIO J Am Soc Artif Intern Organs 1992

    (2008)
  • M. Mortazavi et al.

    Aerobic exercise improves signs of restless leg syndrome in end stage renal disease patients suffering chronic hemodialysis

    Scientific World J

    (2013)
  • C.D. Giannaki et al.

    A single-blind randomized controlled trial to evaluate the effect of 6 months of progressive aerobic exercise training in patients with uraemic restless legs syndrome

    Nephrol Dial Transplant Off Publ Eur Dial Transpl Assoc – Eur Ren Assoc

    (2013)
  • C.D. Giannaki et al.

    Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study

    BMC Nephrol

    (2013)
  • T.J. Wilt et al.

    Pharmacologic therapy for primary restless legs syndrome: a systematic review and meta-analysis

    JAMA Intern Med

    (2013)
  • C. Trenkwalder et al.

    Restless legs syndrome: pathophysiology, clinical presentation and management

    Nat Rev Neurol

    (2010)
  • R.P. Allen et al.

    Restless legs syndrome prevalence and impact: REST general population study

    Arch Intern Med

    (2005)
  • B. Phillips et al.

    Epidemiology of restless legs symptoms in adults

    Arch Intern Med

    (2000)
  • P. Yeh et al.

    Restless legs syndrome: a comprehensive overview on its epidemiology, risk factors, and treatment

    Sleep Breath = Schlaf Atmung

    (2012)
  • P.M. Becker et al.

    Diagnosis, comorbidities, and management of restless legs syndrome

    Curr Med Res Opin

    (2014)
  • M.M. de Oliveira et al.

    The pharmacological treatment for uremic restless legs syndrome: evidence-based review

    Mov Disord Off J Mov Disord Soc

    (2010)
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