The Corpus Callosum

Restless 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 ads.

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 medication.

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 the cases.  

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.

Cognitive behavioural group therapy to improve patients' strategies for coping with restless legs syndrome: a proof-of-concept trial
Journal of Neurology, Neurosurgery, and Psychiatry 2008;79:823-825
doi:10.1136/jnnp.2007.138867

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 sufferers.

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 symptom severity.  

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 process.