What are the non-medication treatments for restless leg syndrome (RLS)?

Non-Medication Treatments for Restless Leg Syndrome

The first step in managing RLS should be addressing exacerbating factors, such as alcohol, caffeine, antihistaminergic, serotonergic, antidopaminergic medications, and untreated obstructive sleep apnea. 1

Iron Supplementation

Iron deficiency is a key factor in RLS pathophysiology and should be evaluated in all patients:

• Check serum iron studies including ferritin and transferrin saturation in all patients with RLS 1
• Testing should be done in the morning, avoiding iron-containing supplements/foods for 24 hours prior to blood draw 1
• Iron supplementation guidelines for RLS differ from general population:
  • Oral iron supplementation if ferritin ≤75 ng/mL or transferrin saturation <20% 1
  • IV iron if ferritin is between 75-100 ng/mL 1
  • For children, supplement if ferritin <50 ng/mL 1

Evidence-Based Non-Pharmacological Interventions

Strongly Supported Interventions

1. Bilateral High-Frequency Peroneal Nerve Stimulation

   • Recommended by AASM with moderate certainty of evidence 1
   • Can significantly reduce RLS severity

2. Exercise

   • Significantly effective for reducing RLS severity 2
   • Improves sleep quality in RLS patients

Other Potentially Effective Interventions

1. Compression Devices

   • May reduce RLS severity and improve sleep-related outcomes 2
   • Pneumatic compression devices apply pressure to legs

2. Repetitive Transcranial Magnetic Stimulation (rTMS)

   • Shown to be significantly more effective than control conditions for RLS severity 2

3. Acupuncture

   • Standard acupuncture may reduce RLS severity and improve some sleep parameters 2

4. Counterstrain Manipulation

   • May be effective for reducing RLS severity 2

5. Infrared Therapy

   • Some evidence suggests effectiveness for RLS severity 2

Interventions with Limited Evidence

1. Vibration Pads

   • May improve some sleep-related outcomes but ineffective for reducing RLS severity 2

2. Cryotherapy

   • May improve some sleep parameters but ineffective for RLS severity 2

3. Yoga

   • May improve sleep-related outcomes 2

4. Transcranial Direct Current Stimulation

   • Ineffective in reducing RLS severity based on current evidence 2

Implementation Algorithm

1. First: Identify and address all exacerbating factors

   • Eliminate alcohol, caffeine
   • Review medications for antihistamines, serotonergics, antidopaminergics
   • Screen for and treat obstructive sleep apnea

2. Second: Check iron status and supplement if needed

   • Follow RLS-specific iron parameters (not general population guidelines)

3. Third: Implement non-pharmacological interventions

   • Start with high-frequency peroneal nerve stimulation and/or regular exercise
   • Add compression devices if needed
   • Consider rTMS, acupuncture, or infrared therapy as adjuncts

Pitfalls and Caveats

• Quality of evidence for non-pharmacological interventions is generally not high 2
• Placebo effects may be significant in non-pharmacological RLS studies 2
• Some patients may require combination of non-pharmacological approaches
• If symptoms significantly impact sleep or daily activities despite non-pharmacological approaches, pharmacological treatment may be necessary 3
• Regularly reassess iron status, especially when symptoms worsen 1, 4

Special Populations

• Pregnancy: RLS is common in pregnancy; non-pharmacological approaches should be first-line 1
• End-stage renal disease: Consider vitamin C supplementation 1
• Elderly patients: Exercise programs may need modification for safety and compliance