Legs Syndrome has been more in the public eye lately.
I understand this is because of aggressive direct-to-consumer
advertising. I’m not much of a consumer, so I haven’t seen
the ads, but people tell me about them.
Whatever you think of DTC advertising, RLS is real, and it is a
significant problem for some people.
Years ago, it was discovered that RLS can be alleviated for some people
with carbidopa/levodopa. But that was an off-patent medicine.
When patented medicines [Requip (ropinirole) and Mirapex
(pramipexole)] became available, RLS became an opportunity, hence, the
Not all patients required medication. Sometimes, it was
possible to try an underlying cause. Iron deficiency is one
example, easily corrected. Others could benefit from
lifestyle changes. Quiting caffeine and/or alcohol helped
some people. Others benefited from sleep hygiene.
But some, particularly those with severe symptoms, do require
It seems that the focus for most people has been on interventions
involving medication. But if lifestyle and nutritional
interventions don’t solve the problem, is there any other
nonpharmacological intervention that is worthwhile?
The cause of RLS is not known, in that the precise pathophysiology has
not been determined. Heredity plays a big role in about half
Part of the pathophysiology involves dopamine. Some people
seem to have not enough in part of the central nervous system.
Some evidence points to a dopaminergic tract that descent to
the spinal cord. Other evidence points to the caudate nucleus
and putamen. Although the details are not known, it is
tempting to think that if a neurotransmitter is involved, then
medication is going to be the best solution.
Perhaps that temptation is misleading. Now there is a study
that shows pretty good results from group therapy.
behavioural group therapy to improve patients’ strategies for coping
with restless legs syndrome: a proof-of-concept trial
Journal of Neurology, Neurosurgery, and Psychiatry
Background: Restless legs syndrome (RLS) is a
usually chronic disorder accompanied by clinically relevant
psychosocial impairment. To date, no psychologically based approach is
available to improve the coping strategies and quality of life of RLS
Objective: To develop cognitive behavioural
therapy tailored to this disorder (the RELEGS coping therapy programme)
and present the results of this proof-of-concept study.
Methods: Twenty-five patients (five men, 20 women;
15 medicated, 10 unmedicated; mean (SD) age 56.1 (12.3) years) with
subjective psychosocial impairment due to RLS participated in one of
three consecutive therapy groups. The severity scales (IRLS and RLS-6)
indicated moderate to severe RLS symptoms at baseline. Exclusion
criteria were secondary RLS, foreseeable change of RLS medication
during the study period, serious physical or psychiatric comorbidity,
and severe cognitive deficits. Each group took part in eight group
sessions (90 min each with a break).
Results: At the end of the treatment, both the
RLS-related quality of life and the mental health status of the
subjects had improved significantly (QoL-RLS scale: from 28.6 (12.8) to
23.4 (13.1); SCL-90-R: from 51.3 (37.0) to 45.9 (32.9)). The
improvement remained at follow-up 3 months later. Subjective ratings of
RLS severity had improved at the end of therapy and at follow-up.
Psychometric scales not specific for RLS-related impairment remained
unaffected by the treatment.
Conclusions: The study establishes the feasibility
and high acceptance of the newly devised therapy programme. The
application of RLS-oriented specific psychological strategies is a step
toward an integrated treatment approach in RLS.
There are notable study limitations. The study was small, and
subjects comprised a highly-selected group. Also, the study
included both medicated and unmedicated patients.
The therapy was a modified form of cognitive-behavioral therapy.
It would not be likely that therapists trained in general CBT
could replicate this outcome without specialized training.
The programme integrates cognitive behavioural
elements and acceptance-based mindfulness approaches.
It sounds as though the initial intent was to improve coping in the
patients. The authors did not expect to see changes in
It is notable that the symptoms that improved were symptoms experienced
in the daytime; nighttime symptoms did not change. Even so,
patients felt better overall.
I particularly like the last paragraph in the discussion section:
A better understanding of the bio-psycho-social
consequences of chronic diseases over the last few years has resulted
in recognition of the importance of patient self-management and health
literacy. Increasing evidence shows that adequate coping strategies —
that is, adequate self-management — improves outcome and reduces
overall managed-care costs in chronically ill patients. Current
treatment trials in RLS still focus on drug therapy, and comprehensive
psycho-biological management strategies have yet to be developed for
this patient population. The therapy presented in this paper may be an
important step in the development of an integrated treatment approach
to RLS management.
This is an important point. It is important in many chronic
illnesses, not just RLS. Many chronic conditions can be
ameliorated — but only partly — with medication. Addition
of psychosocial interventions can make a big difference with the
disease burden that is not relieved by medication.
Sometimes, the additional interventions are obvious: better nutrition,
better sleep, more exercise, improved support. But sometimes
it takes detailed knowledge of the specific condition to refine the
precise interventions that are most needed.
Over the next few decades, health care probably is going to move away
from advanced, highly biomedical interventions. There will be
greater emphasis on simple interventions. However, that does
not mean that we can dispense with a full understanding of the disease