Novel Exercises for Restless Legs Syndrome

A Randomized, Controlled Trial

Eloise G. Harrison; BPhysio(hons); Jennifer L. Keating, PhD; GradDip ManipPT, BAppSc (Physio); Prue Morgan, PhD, MAppSc (research), BAppSc (Physio); Grad Dip Neuroscience

Disclosures

J Am Board Fam Med. 2018;31(5):783-794. 

In This Article

Abstract and Introduction

Abstract

Background: Restless legs syndrome (RLS) is a sensorimotor disorder that can have a considerable negative impact on quality of life and sleep. Management is primarily pharmacological; nonpharmacological options are limited. The objective of the present study was to determine the effect of tension and trauma release exercises on RLS severity compared with discussion group controls.

Methods: Participants satisfied RLS diagnostic criteria, did not have acute mental health conditions, and reported being physically able to complete exercises. Eighteen participants (stratified by age and RLS severity) were randomly allocated with concealment to once-weekly sessions of trauma release exercises (n = 9), exercises to stretch and fatigue lower limb muscles and invoke therapeutic tremors, or control discussion groups (n = 9) for 6 weeks. Outcomes assessed at baseline and each week were International Restless Legs Syndrome Rating Scale scores, global RLS severity ratings (visual analog scale, 0 to 10), global stress ratings (visual analog scale, 0 to 10), Pittsburgh Insomnia Rating Scale scores and Major Depression Inventory scores.

Results: There were no significant between-group differences at baseline except for more severe global RLS scores for controls (P = .003). There were no significant between-group differences at week 6 on any outcome. Significant improvements across time were seen for both groups on all outcomes.

Conclusions: In this exploratory study, tension and trauma release exercises and attending discussion groups were associated with similar outcomes. Participants in both groups improved similarly across time. Future research might establish score stability across a prolonged baseline before commencing intervention.

Introduction

Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a sensorimotor disorder characterized by an uncomfortable urge to move the legs.[1] The urge to move is usually accompanied by unpleasant sensations in the legs, which worsen in the evening or night and during rest or inactivity, and are relieved by movement.[2] RLS can have considerable negative impact on quality of life and sleep. People with RLS have a higher than typical prevalence of anxiety and/or depression, and approximately 50% to 85% experience troubling insomnia.[3] RLS has a prevalence of 5% to 15% in the general population,[3] however, is underdiagnosed[2] and often inadequately treated.[4] It is more common in women[5] and prevalence increases with age.[6] RLS may be primary (idiopathic), or secondary and associated with conditions such as iron deficiency anemia, pregnancy or end-stage renal disease.[2] As secondary RLS is addressed through management of the underlying condition, this study focused on idiopathic RLS. Periodic limb movements in sleep (PLMS) are repetitive movements of the lower extremities during sleep. Although PLMS is not specific to RLS and not an essential diagnostic criterion for RLS, a high PLMS index (number of PLMS per hour of sleep) supports a diagnosis of RLS.[2]

Medications for RLS can have serious side effects such as augmentation. This worsening of symptoms[2] is associated with dopamine agonists7 and levodopa.[8,9] Many people with RLS therefore seek alternate nonpharmacological options. However, high-quality guidelines published by Aurora et al[10] (AGREE assessment "recommended"[11]) concluded that there was insufficient evidence for nonpharmacological therapy. A recent review by the authors of eleven randomized trials[12–22] concluded that some nonpharmacological interventions including exercise and acupuncture seem beneficial for RLS symptoms; however, few studies were identified and the level of evidence was often not high. Given common unwanted side effects associated with pharmacological management, nonpharmacological treatment options may be valuable for symptom reduction.

Tension and trauma release exercises (TRE) invoke what protagonists refer to as "neurogenic tremors."[23] Although these exercises are promoted in Australia[24] and the United States,[25] reports of positive effects on RLS outcomes are anecdotal. Berceli and Maria[26] hypothesized that involuntary movements and tremors in the body may be part of the body's natural mechanism to relieve tension and restore homeostasis. TRE practitioners suggest that tremors, invoked by activities that fatigue muscles, behave to some extent like clonus. This clonus-like tremor seems to be under voluntary control, continuing until an attempt is made to overcome it. TRE practitioners report that tremors, once established, can increase in magnitude and "spread" to other parts of the body that have not undergone fatiguing exercises. The technique of allowing tremor is the focus of the TRE program. Berceli[23] proposed that the exercises release deep chronic tensions in the body. Proposed claims regarding the potential merit of TRE for RLS are built on the unsubstantiated hypothesis that RLS may be the result of chronic physiologic stress to the body. If the exercises release chronic tension, they may affect symptoms.

The primary objective of this exploratory trial was to investigate the effect of TRE on RLS severity compared with discussion group controls. Secondary aims were to compare TRE to control conditions on the outcomes of sleep quality, global stress, and depression. The null hypothesis was that there would be no difference in RLS severity scores for those allocated to intervention or control conditions.

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