Restless Legs Syndrome Foundation Blog

New research has found that nerve activity outside the central nervous system may play a role in restless legs syndrome (RLS) symptoms.

In a study published in the Journal of Physiology, scientists report that nerve cells supplying muscles in the legs behave differently in people who have RLS.

Until now, RLS research and treatment has focused largely on processes deep within the brain. First-line RLS treatments target the brain's dopamine and glutamate systems, and brain iron deficiency is also known to be a factor in RLS.

In the new study, the researchers applied electrical stimulus to motor and sensory axons (or nerve fibers) of the median nerve, which is one of the major nerves along the arm. Study participants who had RLS showed higher activity in the motor axons but not the sensory axons, compared to participants who did not have RLS. In their paper, the researchers stated, “Taken together, our results suggest an increase in the excitability of motor units in RLS that could enhance the likelihood of leg movements.”

While the study was small, involving 33 RLS patients and 38 healthy controls, its findings open new avenues for exploration – including medications that could be developed to potentially treat RLS by targeting the nervous system outside the brain and spinal cord.

The research was conducted by the University of Gottingen in German, in collaboration with the University of Sydney in Australia, and Vanderbilt University in the US. RLS Foundation Scientific and Medical Advisory Board member Art Walters is a co-author of the study.

RLS Foundation Returns to Washington

In November, an RLS Foundation delegation again joined the Health and Medical Counsel of Washington (HMCW) in Washington, DC, to visit the offices of legislators and federal agencies involved in health care policy.

The meetings took place at a critical juncture in the midst of the nationwide opioid crisis. The government is moving to implement H.R. 6, the SUPPORT for Patients and Communities Act. This law, passed in October, calls for tactics to promote treatment and recovery from opioid addiction, and to improve prevention.

Many people with severe RLS find themselves caught in the crossfire. Even though there is no federal legislation or policy that prohibits prescribing opioids for RLS, the increased scrutiny of prescribing practices has physicians increasingly reluctant to use them; some have stopped prescribing opioids altogether.

"The Foundation's opioid advocacy initiative has already made significant progress, but the issue is far from resolved,” says Lew Phelps, chair of the RLS Foundation Board of Directors. “We were successful in ensuring that Congress didn't include anything in the recent opioid legislation that would have harmed the ability of RLS patients to obtain needed and appropriate treatment. However, the implementation of this legislation still presents potential challenges. We have to stay engaged to help ensure that physicians continue to be allowed to prescribe opioids for RLS."

In the DC meetings, a Foundation team led by Executive Director Karla Dzienkowski emphasized that opioids are a legitimate and critical treatment for severe RLS. About 1 in 33 Americans – 3 percent of the US population – has RLS that is severe enough to need daily medical treatment. When all other treatments have failed, opioids at low total daily doses are highly effective at alleviating RLS symptoms, and clinical guidelines are available for healthcare providers to use them appropriately.

“It’s important to spread the word that there are medically appropriate uses of opioids taken in low total daily doses,” says John Winkelman, MD, PhD, director of the RLS Quality Care Center at Massachusetts General Hospital. “We need to help doctors with safe prescribing – not overprescribing, but more effective and safe prescribing.” With support from the RLS Foundation, Dr. Winkelman is conducting a study to better understand the long-term safety of opioids in RLS.

Dr. Winkelman and Jeffrey Durmer, MD, PhD, of Fusion Health, joined the delegation on behalf of the Foundation’s Scientific and Medical Advisory Board. Sandra Katanick represented the RLS Foundation Board of Directors, and also the RLS patient community.

In the meetings the Foundation also stressed the importance of federal funding for research for the National Institutes of Health and the Department of Defense, both of which have growing portfolios in sleep disorders research.

Agency meetings: Making the RLS patient voice heard

The Foundation team met with the US Department of Health and Human Services (HHS) Pain Management Inter-Agency Task Force, led by Vanila Singh, MD.

The new opioid legislation requires HHS to study the impact of federal and state laws and regulations that limit opioid prescribing and submit a report to Congress. The Pain Management Inter-Agency Task Force is specifically charged with finding any gaps or inconsistencies in existing clinical best practices for managing acute and chronic pain.

It is critical for this report to acknowledge that opioids are used differently to treat RLS than to treat chronic pain, so that RLS patients continue to have appropriate access to opioid medications. Dr. Singh and her colleagues showed a strong understanding of RLS and the need for this accommodation, says Dzienkowski. “They were very receptive to the needs of the RLS community.”

The HHS Task Force will soon publish a draft of its recommendations, and the public will have the opportunity to comment over a 90-day period. The Foundation will notify the RLS community when this comment period begins with a call to action through its eFriends monthly newsletter and other channels. (Sign up to receive eFriends.)

The Foundation also met with the Centers for Disease Control and Prevention (CDC), which has issued a guidelines for prescribing opioids for chronic pain; and with the Substance Abuse and Mental Health Services Administration (SAMHSA), whose representatives sit on advisory groups to health care policy committees and working groups throughout the federal government. These meetings were a strong first step in building relationships within the two agencies. In follow-up, the Foundation will meet again with the CDC in December.

Congressional visits: ‘We now have RLS champions in Congress’

The RLS Foundation met with staff in the offices of Sen. Lamar Alexander (R-TN), Sen. Elizabeth Warren (D-MA), Sen. Bill Nelson (D-FL), Sen. Kamala Harris (D-CA), Sen. John Cornyn (R-TX), Sen. Johnny Isakson (R-GA), Rep. Rosa DeLauro (D-CT), Rep. Frederica Wilson (D-FL), Rep. John Yarmouth (D-KY) and Rep. John Lewis (D-GA).

Many of the Congressional staff members said that they are hearing from their constituent communities about barriers to treatment or providers unwilling to prescribe opioids in light of the new law.

Katanick observes, “I think we made a very compelling argument for the safe prescribing of opioids for conditions other than chronic pain, and the legislators’ duty to be certain that any rulemaking is not so restrictive that it actually harms patients.”

“We now have RLS champions in Congress,” says Dzienkowski. “In this round of meetings in Washington, we’ve seen a definite increase in awareness and support for the RLS community.”

“I want to thank everyone who has made donations to the Foundation’s advocacy initiative, responded to our calls to action, or met with their elected officials. At the Foundation, we are hearing from many people with severe RLS who are having trouble accessing their opioid medications. With your help, we are making a difference – for the RLS community today and for generations to come.”

The meetings were coordinated by HMCW, a government relations organization with nonprofit and health care industry expertise that is partnering with the RLS Foundation to guide its advocacy efforts. Also attending were Kris Schanilec of the RLS Foundation; and Dale Dirks, Dane Christensen, and Peter Herzog of HMCW.

To make a financial gift in support of the RLS Foundation Advocacy Initiative, visit www.rls.org.

More information

• Learn more about RLS advocacy and how to take action.
• Learn how to participate in the National Opioid RLS Registry.
• Read about the Foundation’s advocacy trips to Washington in February and June 2018.
• Watch for a complete update on RLS advocacy in the next issue of NightWalkers magazine, coming in February.