Restless Legs Syndrome Foundation Blog

October 19, 2021

By Brian Schrag, PhD, RLS Foundation Member

“Always just beyond the edge of consciousness . . . like electricity. Toes. Ankles. Calves that have to move. RLS, a tailgater crowding my rearview mirror, a bully breathing down my neck, a whiff of something rotting just behind the wall. Always there. Always ready to twist a moment of peace and relaxation into a kicking, screaming fight to make the feeling leave.”

I teach people how to make artistic things that help them flourish. My own struggles with RLS have convinced me that communities affected by RLS could also benefit from developing habits of life-giving creativity.

My journey, resulting in this conviction, began in a village in the Democratic Republic of Congo. My wife and I helped start a project to translate the Bible into a language called Mono, encouraging speakers to integrate the new Scripture into their lives through their own types of singing, dancing, poetry, proverbs, storytelling, carving and so on. I eventually earned a PhD in ethnomusicology at UCLA and founded the Center for Excellence in World Arts (CEWA) at Dallas International University.

Along the way, I became more and more aware of the infinite range of suffering in the world, and saw how arts have often brought relief, soothing people’s anguish. So, I started studying music, dance, visual and other arts therapies, integrating their insights into our training, inviting experts to teach at the CEWA. Our students now spark healing creativity in communities in the US and around the world, to increase others’ well-being.

Two diseases forced me to take my own medicine. First, I learned that I have Huntington’s Disease (HD) — neurodegenerative, incurable — and started making songs, T-shirts, jokes, schticks and a snarky virtual alter ego to express and undermine my despair and fear. Everyone with HD eventually loses control of their movements in a way that makes them look drunk. (I’m not there yet.) Police kept accusing a woman in our HD support group of public inebriation, so I wrote the song, “HD Blues,” and made a T-shirt with “No sir, officer, I am not drunk…” on the front and a description of HD on the back. Protection and education neatly nestled on a bed of 100% cotton.

Then came RLS — in my humble opinion, Ridiculously Labeled Sickness. I was often awake all night. Exhaustion and hopelessness led to the excerpt from a longer lament at the beginning of this column. And its neurological roots and medications made me unable to take most of the antidepressants I need for HD’s emotional symptoms. RLS forced me to choose between sleep or sadness, rest or rage. You who have it bad can relate to this sampling of pleas from an RLS discussion board post: “Scared, appreciate any help;” “a living nightmare;” “suicidal now;” “am I in hell?” and “HELP!”

Despite these diseases — sometimes because of them — I found that it’s possible to craft a new normal life, one that even includes moments of purpose, joy and satisfaction.

Along with care from medical personnel and support groups, the arts can play a pivotal role. Expressive arts therapy experts Stephen Levine, PhD, DSSc, and Ellen Levine, PhD, MSW, write that “the therapeutic power of art rests not in its elimination of suffering but rather in its capacity to hold us in the midst of that suffering so that we can bear the chaos without denial or flight.”

That’s deep and mostly true. But I’ve seen things that arts can cure.

They can spark hope out of despair. Nurture community where there was loneliness. Replace ignorance with knowledge. Swap pacing or crumpled exhaustion on the floor with dancing. Exchange emotional and physical trauma with contentment.

Making, giving and experiencing artistry at any skill level can increase well-being. Your legs may still disobey, but with hope, pleasure, catharsis, understanding and community, it’s possible not just to endure, but to thrive.

Two possible action points: First, make something for yourself or someone else that feels good — some of you already do this. Everyone has a creative spark, and what you make doesn’t have to be seen or heard by anyone else. Try something. Embrace imperfection. Second, you can help build a virtual collection of arts produced by people affected by RLS, gathering songs, poems, stories, dances, paintings, jewelry, quilts, films, video games and many other forms. Email info@rls.org if you’d like to be part of getting this collection off the ground.

Let’s start an RLS Arts-Making Movement.

‘Cause sometimes pacing turns to dancing Sometimes lonely points to loved
And sometimes endless dark night brightens into hope'

Brian Schrag is a senior arts consultant with SIL International. For more, explore www.BrianAtPlay.com/restless-legs-syndrome.

October 6, 2021

Recognizing Sleep Issues in Childhood

In the 2013 Patient Odyssey Survey conducted by the RLS Foundation, nearly half (45%) of survey respondents reported the appearance of RLS symptoms before the age of 30. Recognizing sleep issues in childhood is important to prevent development of adverse mood, emotions, social skills, behavior and overall school performance in children and adolescents.

Restless sleep disorder (RSD) is a potential new sleep diagnosis for children and adolescents (ages 6 to 18). RSD represents a constellation of characteristics of disordered and disrupted sleep and often, impaired daytime function (tiredness, behavioral issues, poor school performance, etc.). Pediatric sleep researchers have developed eight criteria for a diagnosis of RSD:

1. Parent, caregiver, bed partner or patient gives accounts of “restless sleep.”
2. Movements of large muscle groups occur throughout the body and can include any combination of head and limb movements.
3. Movements take place during sleep or apparent sleep.
4. Five or more movements are observed during each hour of sleep.
5. Restless sleep is observed three or more times each week.
6. The patient exhibits restless sleep for a minimum of three months.
7. Restless sleep substantially impairs the patient’s life activities, including social, emotional, academic or occupational performance. Other effects include changes in emotional state, short attention span, tiredness, inattentiveness or lack of impulse control.
8. All behavioral, medical or sleep disorders have been eliminated as possible causes of the disrupted sleep, including a review of the patient’s current medications and dietary behaviors to determine whether the disrupted sleep may have another underlying cause.

All eight criteria must be present for a diagnosis of RSD. Restless sleep can co-occur with other disorders such as obstructive sleep apnea, asthma or eczema, so it is important to include screening for those disorders in the consideration of an RSD diagnosis.

Restless legs syndrome (RLS) shares similar features with RSD, such as difficulty falling asleep and staying asleep. Video polysomnography (videorecording of sleep studies) provides a visual picture that helps to differentiate RLS from RSD. In children with RLS, the primary visual feature is an increase in periodic leg movements; whereas in children with RSD, large body movements and repositioning that repeat throughout the night are highlighted on video. More importantly, in RLS, a verbalized “need to move” the legs while awake by the child or adolescent is the key diagnostic feature that is not characteristic of RSD.

In a 2018 study in the scientific journal Sleep, children with RSD were found to have low ferritin levels (lower than those found in pediatric RLS patients), and another study in 2021 showed RSD symptoms respond to oral or intravenous iron. Additional studies will further the understanding of this phenomenon and its possible relationship to the development of RLS.

Many adults with RLS report the emergence of RLS symptoms in their youth. RSD may account for some of these early symptoms that were part of their childhood and adolescence. If you suspect a child has a sleep disorder, a comprehensive medical evaluation by a pediatric sleep specialist will help to identify any potential sleep conditions that may be responsible for disrupting a restful night’s sleep.

References:

DelRosso LM, Bruni O, Ferri R. Restless sleep disorder in children: a pilot study on a tentative new diagnostic category. Sleep. 2018;41.

DelRosso LM, Ferri R, Allen RP, Bruni O, Garcia-Borreguero D, Kotagal S et al. Consensus diagnostic criteria for a newly defined pediatric sleep disorder: restless sleep disorder (RSD). Sleep Med. 2020;75:335-40.

DelRosso LM, Picchietti DL, Ferri R. Comparison between oral ferrous sulfate and intravenous ferric carboxymaltose in children with restless sleep disorder. Sleep. 2021;44.

September 5, 2021

By Karla Dzienkowski, RLS Foundation Executive Director

RLS awareness and education are two recurring themes for individuals living with RLS. Unfortunately, healthcare providers often lack awareness of the disease and/or the clinical knowledge to manage patients according to consensus treatment guidelines.¹

Three women based in the UK, Ireland and the Netherlands joined forces to do something about it. Julie Gould, Charlotte Deerenberg and Rachel Andrews met online and decided to address the lack of RLS training offered during medical school.

In the UK, the undergraduate and postgraduate training curriculum for physicians does not include a study component dedicated to RLS that introduces the diagnostic criteria, treatment considerations and long-term management of the disease. In the US as well, medical students lack training in diagnosing neurological sleep disorders like RLS.

Lack of knowledge can have a negative impact on patients. Clinically significant RLS has an estimated prevalence of 2.7%, yet this common neurological sleep disorder is often misdiagnosed and undertreated.²

In 2017 an RLS Foundation-funded study published in Sleep Medicine found that training physicians in medical school to accurately diagnose RLS leads to lower overall healthcare costs and better health outcomes for patients.³

Deerenberg says, “Most individuals wait to see a physician until symptoms are more severe, affect daytime functioning and simple remedies (stretching, physical activity, massage) are no longer effective.”

A 2007 article in the Journal of Neural Transmission reported that it takes on average 12.7 years from the onset of symptoms for an RLS diagnosis to be made and treatment to begin – resulting in nearly 13 years of needless suffering.

When Gould, Deerenberg and Andrews recognized the absence of RLS in the curriculum to train physicians, they took a proactive approach to address this educational gap. Working together, they decided to raise awareness by creating a letter-writing campaign to educate key individuals (legislators, persons in the medical community, and leaders of organizations) about the disease. In August, 2021, The Lancet, a leading peer-reviewed medical journal, accepted and published their article, “A call for better training in restless legs syndrome.”

Andrews observes, “RLS evokes severe resistance in the medical community; individuals with RLS understand that resistance, and The Lancet overcame the resistance to RLS.”

September 23 is RLS Awareness Day. Gould says, “We seek more correspondence from The Lancet article and plan to continue our outreach to raise awareness of RLS and inclusion of restless legs syndrome in the medical school curriculum.”

Whether it is a group of concerned individuals meeting around a dining room table in Raleigh, North Carolina, to establish the RLS Foundation in 1992, or a small team collaborating online in 2021 to publish an article in The Lancet, one thing is clear to the RLS community: Our work is not yet done. Each of us needs to do our part.

What will you do to raise awareness and the need for medical education about RLS?

__________

¹Silber M, Buchfuhrer M, Earley CJ, Koo BB, Manconi M, Winkelman JW, for the Scientific and Medical Advisory Board of the Restless Legs Syndrome Foundation. The Management of Restless Legs Syndrome: An Updated Algorithm. Mayo Clin Proc.July2021;97(7):1921-1937. doi; 10.1016/j.mayocp.2020.12.026. Open Access Journal Article.

²Allen RP, Arthur S Walters AS, Montplaisir J, Hening W, Myers A, Bell TJ, Ferini-Strambi L. Restless legs syndrome prevalence and impact: REST general population study. Arch Intern Med. 2005 Jun 13;165(11):1286-92. doi: 10.1001/archinte.165.11.1286.

³Padula W, Phelps CE, Moran D, Earley CJ. Allocating provider resources to diagnose and treat restless legs syndrome: a cost-utility analysis. Sleep Med. 2017 Oct;38:44-49. doi: 10.1016/j.sleep.2017.06.034. Epub 2017 Jul 27.

August 18, 2021

The Buchfuhrers — Celebrating Father’s Day as Doctor Team

By Rich Archbold

When Julia Buchfuhrer was growing up, she had a special bond with her father, Mark Buchfuhrer, but, hard as he tried, he could not persuade her to become a doctor like he was.

‘No way, no way,” she told her dad. She was interested in other things, like maybe being a marine biologist. But her dad persisted.

He finally got his wish when his daughter decided to go to medical school and become a doctor, but that wasn’t the end of the story. Julia Buchfuhrer graduated from med school at Western University of Health Sciences, did her residency at UC Irvine and is finishing her fellowship training at the University of Arizona this month to become a specialist in rheumatology.

She then had to make another big decision: Where to work after finishing her fellowship training? She decided to open up her own practice in Downey next month with — guess who — her father, who has been a doctor for almost 40 years and is nationally known for his work with restless legs syndrome.

Julia Buchfuhrer will open the JB Arthritis and Rheumatology Center at her father’s office, 11480 Brookshire Ave., in Downey.

“I am extremely excited to be working side by side with my father,” she said in an interview at his house on the east side of Long Beach last week.

“It’s the best Father’s Day present I could get,” her father said. “She is going to do great work and help a lot of people.”

Julia Buchfuhrer will be the third doctor in her family. Her mother, Laurie Buchfuhrer, practiced family medicine and was an addiction medicine specialist. She worked at Kaiser Permanente and Long Beach Memorial Medical Center. She got leukemia, though, when her daughter was 6 and retired early. Julia Buchfuhrer said her mom would always tell her to select a career she would enjoy.

“I think she was secretly proud that I followed in her footsteps,” Julia Buchfuhrer said. “When I made the Dean’s list in medical school, she told me how proud she was that I was doing medicine and doing it so well.”

Julia Buchfuhrer said she can’t wait to start working with her father. “I have so much respect for him and what he has done in his career,” she said. “I will be learning so much from him.”

Her father, though, sees it as a two-way street. “We will be learning from each other,” he said, sitting next to her in his home.

Mark Buchfuhrer was born on July 11, 1952, in Montreal, Canada. His parents were survivors of the Holocaust. His father, Norbert Buchfuhrer, was born in Poland and was a teenager when the Nazis sent him to a concentration camp in Warsaw. He escaped when he was 22 when he got on Oskar Schindler’s now-famed list. Schindler was a German businessman who saved more than a thousand Polish-Jewish refugees from the Holocaust by employing them in his factories during World War II.

Mark Buchfuhrer’s mother, Rose Katz, meanwhile, spent a year in a concentration camp in Hungary at the end of World War II and was saved. She met Norbert Buchfuhrer, her husband-to-be, on a boat going to Canada. She was a cashier in a hat design company in Hungary, but when she was asked her job skill in Canada, she said she was a hat designer — even though she had never actually designed hats, her son said. “But it turned out she had a skill in hat design and became very well known for her hat designs,” he said. She and her husband married in 1948 and had two children, Mark and his sister, Stephanie, who lives in Montreal.

Norbert Buchfuhrer died when he was 73, his wife died when she was 93.

“My mother used to tell me, ‘I’m going to live a long life to show you that you can, too,’” her son said. In high school, Mark Buchfuhrer said he wanted to be a scientist. “But my mother kept telling me to be a doctor, a doctor, a doctor. She said I could be successful as a doctor and take that skill anywhere and not be restricted to one place. She told me that 10,000 times.”

He finally listened and went to medical school at the University of Ottawa, graduating in 1977 and becoming the first in his family to become a doctor. He became a specialist in pulmonary medicine, treating diseases of the respiratory system. “My mom was overjoyed,” he said. He did his residency in Toronto where he met his wife-to-be, who was in her fourth year at medical school. They got married on June 22, 1980. They spent their honeymoon on an eight-day drive from Toronto to the Harbor-UCLA Medical Center in Torrance, where Mark had a fellowship in pulmonary medicine.

The couple spent a weekend in Seal Beach and liked the area so much they decided to live in Long Beach; they bought a condo in Marina Pacifica in Long Beach before buying a house on the east side near Long Beach State University, where they have lived for 37 years.

They have three children: David Buchfuhrer, 37, a software engineer; Michael Buchfuhrer, 35, a business owner; and Julia Buchfuhrer, 32. Mark Buchfuhrer was on the attending staff at various places, including Stanford University Medical Center, Harbor City; Downey Community Hospital (now PIH Health, Downey); USC Medical Center, Long Beach Community Hospital, and Good Samaritan Hospital, Los Angeles. He opened up his private practice in Downey in 2001 with his office now at 11480 Brookshire Ave. He became an expert, one of the few in the United States, in treating restless legs syndrome, which is a disorder causing pain and sleepless nights. The primary symptom of RLS, he said, is an urge to move one’s legs when trying to rest or relax. “This urge is often so compelling that RLS sufferers may have to walk, shake their legs, ride a bicycle, massage their legs, or stretch to alleviate their discomfort,” he wrote in a clinician’s manual on RLS. He has become beloved by his patients. “There isn’t a week that goes by without a patient telling me how my treatment has saved or changed their life,” he said.

Meanwhile, his sons and daughter were growing up. Julia Buchfuhrer graduated from Hill Middle School, which has since been converted to the Sato Academy of Math and Science, before attending Poly High School where she became an outstanding student. In eighth grade, she won first place in the Press-Telegram Halloween Scary Story Contest.

She also became an excellent soccer player and was a member of the Belmont Shore Women’s Rugby team. “I got injured a lot playing rugby, but that’s where I saw how doctors could help people get better,” she said. “I liked the idea of helping people medically.”

She also became a huge fan of bike riding, which her father also liked. “We cycled together all the time,” she said. “We rode with a group in Irvine called the Orange County Rebel Riders. “We went on mountain rides and on past Father’s Days, we would go cycling for miles and come home for a family get-together.”

Julia Buchfuhrer had a scare one time when her bike hit a rock on an 8- mile trail in Rock Creek, 30 miles south of Mammoth Lakes. “I got thrown off my bike and suffered a nasty gash in my forehead,” she said. “Blood was gushing all over. Vultures were even circling in the sky. My dad bandaged me up, and hikers came by who helped us.” She still has a visible scar above her left eye.

And when she was 30, she got breast cancer, and she had a double mastectomy and reconstructive surgery. But she is a fighter. “The hardest part was enduring three-to-four months of chemotherapy, but I missed only two-to-three days of training,” she said.

Julia Buchfuhrer said she loves doing things with her father and listening to him tell stories. “He is a great storyteller. We have become great friends.”

“She’s my buddy,” her father said, putting his arm around her. “I’m so happy she’s here for Father’s Day.”

Julia Buchfuhrer said she will fly back to Arizona this afternoon, Sunday, June 20, to finish her medical training and won’t have time to do her traditional Father’s Day bike ride with her dad. But she will celebrate Father’s Day at a family get-together.

She is also already planning a few weekend trips to Mammoth Lakes in August to hike and make up for some lost bike rides. “Since we are both our own bosses, we can schedule as many of these trips together as we like,” she said with a grin.

Reprinted with permission from Rich Archbold, Press-Telegram. All rights reserved. Visit rarchbold@scng.com for more information.

https://www.presstelegram.com/2021/06/20/rich-archbold-the- buchfuhrers-celebrating-fathers-day-as-doctor-team/

July 12, 2021

The Management of Restless Legs Syndrome: An Updated Algorithm

Restless legs syndrome (RLS) is a common neurological disorder affecting up to 10% of the population in the United States, with nearly 3% experiencing severe symptoms that require daily medical treatment. An article in the Journal of Neural Transmission in 2007 reported that it takes nearly 13 years from the onset of symptoms to the initiation of a treatment plan for RLS.

Much has changed in RLS disease management in the last eight years, which has led to the update of the 2013 RLS treatment algorithm by the Scientific and Medical Advisory Board of the RLS Foundation. The updated algorithm was published in the July 2021 edition of Mayo Clinic Proceedings, a leading peer-reviewed clinical journal widely read by physicians and often cited in scientific papers. Publication in this journal will ensure the availability of this information to a broad group of clinicians, including primary care providers.

Scientific discoveries since 2013 have led to the better understanding of RLS and new approaches to disease management that include:

Clinical Advancements

• Untoward side effects of dopaminergic therapy; knowledge and understanding of the long-term risks of augmentation, impulse control disorders and rebound
• Consensus guidelines for the iron treatment of RLS
• Consensus guidelines for RLS diagnosis, treatment and management during pregnancy and lactation
• Appropriate use of opioid therapy in low total daily doses for refractory RLS
• Improved RLS diagnosis, treatment and management in children and adolescents

Research Advancements

• Clinical trials for pregabalin and oxycodone
• Adenosine and RLS relationship
• Identification and replication of 13 new RLS risk genes and confirmation of six previously identified RLS risk genes using GWAS (genome-wide association studies)

These advancements relate to ongoing research into the underlying causes of RLS and the search for durable treatments and potential cures for the disease.*

The 2021 RLS treatment algorithm is divided into sections that outline detailed guidance on clinical best practices in RLS disease management, including:

• General treatment considerations
• Alpha-2-delta ligands and iron treatment as first-line therapies
• Iron treatment guidelines for RLS
• Dopamine agonists as a second-line therapy
• Treatment for intermittent, chronic-persistent, and refractory RLS
• Special patient populations and potential future therapies

The new treatment algorithm describes medication selection, use, dose and side effects. Decision trees and tables provide visual guidance for treatment consideration. Nondrug therapies and other approaches are highlighted, which include activities to stimulate the mind and the avoidance of medications and substances known to worsen symptoms. For example, RLS specialists who practice at certified RLS Quality Care Centers report that augmentation from certain medications is the No. 1 reason that patients seek specialized care from a knowledgeable and experienced provider. The 2021 RLS treatment algorithm pays special attention to the use of combination therapies and the appropriate use of opioids in low total daily doses to treat refractory RLS – a common, yet manageable treatment challenge. For the first time, the new treatment algorithm also discusses RLS management in pregnancy, lactation and childhood.

The 2021 RLS treatment algorithm is a comprehensive approach to the management of RLS in the various stages of disease progression and across the life span. Michael Silber, M.B., Ch.B., lead author on the article and director of the Center for Sleep Medicine at Mayo Clinic, says, “This updated algorithm is based on current research, consensus documents and the combined practical experience of a team of practitioners highly experienced in the management of RLS. We hope it will provide practical guidelines for primary care providers and specialists who are needed to treat patients with this common and highly distressing disorder.”

The RLS Foundation has made this an open-access article, available for free download by patients, clinicians and researchers. The RLS Foundation encourages members to share this article with their healthcare providers at www.rls.org/21Algorithm. Executive Director Karla Dzienkowski says, “The publication of the 2021 RLS treatment algorithm is based on the latest scientific knowledge and clinical experience of RLS experts from around the globe who serve on our Scientific and Medical Advisory Board. I thank these members for their service to the Foundation and the RLS community and for their work on this seminal publication that furthers our mission and goals to educate and support RLS research leading to better treatments and a cure.”

*The RLS Foundation funds the only research grant program dedicated to RLS. Member support for the Foundation’s Research Grant Program has funded nearly $2 million for 47 grants to RLS researchers, whose research forms part of these key advancements. A revised RLS Research Grant Program protocol will be announced later this year to further the quest toward a cure.

June 29, 2021

Statement has been endorsed by more than 25 medical, scientific, patient, and safety organizations

A new position statement from the American Academy of Sleep Medicine emphasizes that sleep is a biological necessity, and insufficient sleep and untreated sleep disorders are detrimental for health, well-being, and public safety.

Published online in the Journal of Clinical Sleep Medicine, the statement notes that sleep is vital for health and well-being in children, adolescents, and adults. While awareness of the value of sleep has risen in the last decade, there is a significant need for greater emphasis on sleep health in education, clinical practice, inpatient and long-term care, public health promotion, and the workplace.

“Healthy sleep is as important as proper nutrition and regular exercise for our health and well-being, and sleep is critical for performance and safety,” said AASM President Dr. Kannan Ramar. “It is the position of the AASM that sleep is essential to health, and we are urging educators, health care professionals, government agencies, and employers to prioritize the promotion of healthy sleep.”

The statement was written by the members of the 2020 – 2021 AASM board of directors, comprising 11 sleep medicine physicians and a clinical psychologist. In recognition of sleep’s significant and multi-faceted connections to health and chronic disease, the authors outlined the following positions:

• Sleep education should have a prominent place in K-12 and college health education, medical school and graduate medical education, and educational programs for other health professionals.
• Clinicians should routinely inquire about sleep habits and symptoms of sleep and circadian rhythm sleep-wake disorders during patient encounters, and hospitals and long-term care facilities should optimize sleep conditions.
• Healthy sleep should be targeted by public health and workplace interventions to improve health-related outcomes, and behaviors that help people attain healthy sleep should be actively promoted.
• More sleep and circadian research is needed to further elucidate the importance of sleep for public health and the contributions of insufficient sleep to health disparities.

“Education about sleep and sleep disorders is lacking in medical school curricula, graduate medical education, and education programs for other health professionals,” said Ramar. “Better sleep health education will enable our health care workforce to provide more patient-centered care for people who have common sleep disorders such as obstructive sleep apnea and insomnia.”

According to the authors, chronic insufficient sleep and untreated sleep disorders are linked to increased health and safety risks such as cardiovascular disease, diabetes, obesity, workplace accidents, and motor vehicle crashes. Data from surveys conducted by the Centers for Disease Control and Prevention and the Maternal and Child Health Bureau show that 34.1% of children, 74.6% of high school students, and 32.5% of adults in the U.S. fail to get a sufficient duration of sleep on a regular basis. Therefore, helping people get enough sleep is one of the goals of Healthy People 2030, which provides 10-year, measurable public health objectives for the U.S.

The AASM position statement declaring that sleep is essential to health has been endorsed by more than 25 medical, scientific, patient, and safety organizations:

• Alliance of Sleep Apnea Partners
• American Academy of Cardiovascular Sleep Medicine
• American Academy of Dental Sleep Medicine
• American Academy of Neurology
• American Academy of Otolaryngology—Head and Neck Surgery
• American Academy of Physician Assistants
• American Association of Clinical Endocrinology
• American Association of Sleep Technologists
• American College of Preventive Medicine
• American Geriatrics Society*
• American Society for Metabolic and Bariatric Surgery
• American Society of Addiction Medicine
• American Society of Anesthesiologists*
• American Thoracic Society
• Circadian Sleep Disorders Network
• International REM Sleep Behavior Disorder Study Group
• National Safety Council
• National Sleep Foundation
• Obesity Action Coalition
• Project Sleep
• Restless Legs Syndrome Foundation
• Sleep Research Society
• Society for Research on Biological Rhythms
• Society of Anesthesia and Sleep Medicine
• Society of Behavioral Sleep Medicine
• Start School Later
• Wake Up Narcolepsy
• World Sleep Society

*The American Geriatrics Society supports the general principles in the document and believes it is of general benefit to its membership. The American Society of Anesthesiologists’ Administrative Council approved support for the position statement with qualifications; since the document has neither been presented to nor approved by either the ASA Board of Directors or House of Delegates, it is not an official or approved statement or policy of the Society. Variances from the recommendations contained in the document may be acceptable based on the judgment of the responsible anesthesiologist.

June 14, 2021

Magnesium and RLS

By Maddie Lionberger, RLS Foundation Research Coordinator

Magnesium is a naturally occurring mineral in our bodies that plays an essential role in a diverse array of biochemical processes, including protein synthesis, muscle and nerve function and blood glucose control. Deficiencies in magnesium can lead to muscle contractions, cramps and problems with conduction of electric signals along nerves. Because of magnesium’s important function in the nervous system, considerable attention has been given to using magnesium supplements to relieve the symptoms of restless legs syndrome (RLS). However, the evidence behind magnesium as an RLS treatment is largely anecdotal. To assess whether taking a magnesium supplement could benefit you, consider the normal values and functions of magnesium and the research as it pertains to RLS.

Magnesium Intake

According to the Office of Dietary Supplements of the National Institutes of Health (NIH) the adult body contains about 25 milligrams (mg) of magnesium. Total magnesium level is tightly regulated by the kidneys, which excrete about 120 mg of magnesium in the urine per day. The Food and Nutrition Board of the National Academy of Medicine recommends an average daily intake of about 240 to 420 mg for men and 240 to 320 mg for women. These recommendations vary by age and sex and are higher during pregnancy. Most people can obtain daily recommended magnesium levels through diet alone – for example, by eating dark green, leafy vegetables such as spinach and kale; nuts and seeds; fish like mackerel and tuna; beans and lentils; avocados; bananas and low-fat or nonfat dairy products. Consuming caffeine, on the other hand, can decrease magnesium levels. Magnesium is also present in dietary supplements and in some medicines, such as antacids and laxatives.

Overall magnesium status is difficult to assess, with 50% to 60% of magnesium present in the bones and the rest mostly in the blood and soft tissues. The most common method for assessing magnesium is by measuring serum magnesium concentration. Normal serum magnesium concentrations range between 0.75 and 0.95 millimoles per liter (mmol/L). Other methods for assessing magnesium status include measuring concentrations in erythrocytes (red blood cells), saliva and urine. However, no single test is considered sufficient without comprehensive laboratory tests and clinical assessment.

Magnesium Deficiency

Symptomatic magnesium deficiency due to low dietary intake is uncommon. Symptoms of deficiency are more likely to arise from excessive losses of magnesium due to certain health conditions and medications. Early signs of magnesium deficiency include loss of appetite, nausea, vomiting, fatigue and weakness. As deficiency worsens, numbness, tingling, muscle contractions and cramps, seizures and personality changes may develop. In severe cases, magnesium deficiency can result in hypocalcemia (low blood calcium) or hypokalemia (low blood potassium). Individuals more likely to be at risk of magnesium inadequacy include those with gastrointestinal diseases such as Crohn’s disease, celiac disease and enteritis (small bowel inflammation); Type II diabetes; or alcohol dependence. Older adults in general are more at risk because they typically consume insufficient amounts of magnesium in their diets or have medical conditions requiring medications that reduce magnesium absorption in the gut.

Supplementation

In the event of a deficiency, magnesium can be taken as a supplement. There are several different doses and forms available, including magnesium oxide, citrate and chloride. Absorption depends on the type of magnesium. Although magnesium oxide is the most commonly available oral supplement, studies reported by the NIH suggest that magnesium in the aspartate, citrate, lactate and chloride forms is absorbed more completely than magnesium oxide or sulfate. Magnesium sulfate can also be administered intravenously (IV), but that method is generally reserved for more severe cases of hypomagnesemia (low levels of magnesium in the blood). The most common use of IV magnesium sulfate is for the prevention of seizures in pregnant women with preeclampsia, eclampsia or toxemia. The Food and Drug Administration recommends against prolonged use of magnesium sulfate; too much magnesium sulfate, or excessive amounts of any supplement for that matter, can be toxic. It is important to consume plenty of fluids while taking magnesium supplements. Consult your doctor before making any changes to your medication regimen.

One of the main roles of magnesium in the nervous system is to block the calcium channel in nerve cells. In other words, magnesium needs to be removed for signaling to occur. Thus, low magnesium levels or magnesium deficiency can result in an over-excited state and eventually cell death of the neuron called excitotoxicity (a pathological process by which neurons are damaged and killed by overactivation). Abnormal neurotransmission of this kind has been implicated in many neurological disorders, including migraine, chronic pain, Alzheimer’s disease and Parkinson’s disease. In a 2018 analysis, "The Role of Magnesium in Neurological Disorders," by Anna E. Kirkland et al., researchers reviewed literature on the role of magnesium in the prevention and treatment of certain neurological disorders. One study showed that high magnesium concentrations were associated with a reduced risk of Parkinson’s disease. However, research examining magnesium levels in people with Parkinson’s has yielded mixed results overall.

Effective for RLS?

With the similarities that RLS and Parkinson’s disease share in pathologies to the dopamine system, it may seem intuitive to try magnesium as a preventive measure for RLS symptoms. However, there is little to no research to support the use of magnesium for idiopathic RLS. Much of the research addressing magnesium and RLS involves symptoms during pregnancy. It is likely that taking magnesium is perceived as an effective therapy for RLS when magnesium deficiency is a contributing factor, i.e., the supplement provides relief for muscle cramps that are easily confused with RLS symptoms. An existing magnesium deficiency may also explain why some individuals report that caffeine triggers their RLS symptoms. If this is the case, it may be beneficial to test magnesium levels. Despite the lack of any scientific correlation with low magnesium levels and RLS, there are many anecdotal reports of people with RLS benefiting from taking magnesium supplements. However, since there is a very strong placebo response for any potential RLS treatment, it is difficult to determine whether these reports truly reflect a benefit for magnesium supplementation and RLS. Large double-blinded medical trials would be necessary to prove that magnesium would be helpful for RLS symptoms.

If you suspect that a magnesium deficiency may be contributing to a worsening of your RLS symptoms, discuss this with your healthcare provider and follow their recommendations and guidelines before making any changes to your medications or supplements.