By John D. Horowitz, MD
Restless legs syndrome (RLS) is a poorly understood true medical condition that has long been shown to be more symptomatic in patients with venous insufficiency and venous reflux. There are some in the medical literature that believe venous insufficiency is causative in RLS patients. RLS is most pronounced when patients are resting, especially at bed time and has become a major source of debilitating sleep deprivation disorder. Patients’ symp- toms seem to get better when they move around and frequently patients have to walk about in the middle of the night to get relief. Patients with venous insufficiency have tremendous lower extremity fluid shifts that create noticeable volumetric changes in the legs. This volume change in the lower extremity, which is clearly worse at the end of the day, causes an irritation and activa- tion of the sensory nerves in the lower extremity, giving rise to the creeping, itching, pulling, creepy-crawly, tugging, and gnawing symptoms that are so debilitating with RLS.
Similar to venous insufficiency, RLS is three times more likely in women than men. It tends to run in families as does venous insufficiency. Up to 25% of women develop RLS during preg- nancy but symptoms usually disappear after giving birth. Most likely the lower extremity fluid shifts that occur during preg- nancy and that are almost uniformly due to venous insufficiency provide the backdrop for patients to become symptomatic with RLS. As the lower extremity volumetric changes progress, many of these women return with recurrent symptoms of both venous reflux and RLS.
Although the first line of treatment is usually medication, there are significant side effects from all of them. There are currently two prominent medications that are FDA approved for the symp- toms of RLS: ropinirole (Requip) and pramipexole (Mirapex). There are other medications that have FDA approval for other conditions that are sometimes helpful. These drugs fall into four major categories: dopaminergic agents (eg. gabapentin), sleep- ing aids, anticonvulsants, and pain relievers. Clinical trials have shown that patients treated with medications for RLS with concomitant venous insufficiency had significantly lower medication requirements, if at all, once their venous reflux was resolved.
Other treatment considerations include dietary evaluation to ensure that there is no iron or vitamin deficiency, modifying or eliminating other prescription medications that may exacerbate the symptoms of RLS such as anti-hypertensives, anti-depres- sants, and anti-histamines. Eliminate alcohol intake. Employ lifestyle changes around the times when patients are required to be still such as activities that occupy the mind. Developing sleep habits that promote good sleep hygiene, such as eliminating coffee or other stimulants after noon will also help quell some of the symptoms.
In 2008, Dr. Kingsley reported a series of 35 patients with severe RLS (as determined by 2003 NIH RLS criteria) and duplex proven venous reflux. These patients were treated with en- dovenous laser therapy for their venous insufficiency and 89% enjoyed a decrease in their symptom severity score by 21.4 points, providing an average 80% improvement in their symptoms. Fifty-three percent of these patients had a symptom severity score of five or less after vein therapy, and thus had near complete reso- lution of their symptoms. Of note is that 31% of the patients in this study had a follow-up severity score of zero, indicating complete resolution of their RLS symptoms. This study led to the recommendation that venous reflux should be ruled out and resolved if discovered in all patients with RLS prior to initiating or continuing drug therapy.
At the Central Florida Vein and Vascular Center we have be- come a referral center for patients with symptomatic RLS to eval- uate and treat their underlying venous insufficiency in an attempt to decrease or eliminate their need for the RLS medications that have such a considerable side effect profile or that have lost their effectiveness.
John D. Horowitz, M.D. is Board Certified in both Vas- cular Surgery and Phlebology and is uniquely trained to offer patients the most advanced vein care possible. He graduated a member of the AOA Honor Medical Society from Temple University School of Medicine in 1986, from Temple University Hospitals General Surgery Residency in 1991, and from The Ohio State University Hospitals Vascu- lar Surgery Fellowship in 1993. Dr. Horowitz is an active member in many nationally recognized societies includ- ing the Southern Vascular, Florida Vascular and Society for Vascular Surgery, as well as the American College of Phlebology. He is nationally renowned for his innovative practice of Minimally Invasive Vein Therapy, has presented his work at many national society meetings and has au- thored numerous journal articles and book chapters. The Central Florida Vein and Vascular Society is routinely used as a training site for physicians seeking to learn Minimally Invasive Vein Therapy. Dr. Horowitz may be contacted at 407-293-5944 or by visiting www.cfvein.com.