What non-pharmacological interventions can help relieve restless legs syndrome symptoms at night?

Non-Pharmacological Management of Restless Legs Syndrome at Night

The American Academy of Sleep Medicine recommends implementing several non-pharmacological interventions concurrently, including moderate exercise, smoking cessation, alcohol avoidance, caffeine reduction or elimination, and discontinuation of medications that may worsen RLS. 1

Sleep Hygiene and Behavioral Modifications

• Avoid stimulants and detrimental behaviors before bedtime, including caffeine, alcohol, and nicotine, as these can significantly worsen RLS symptoms at night 2, 1
• Adjust sleep patterns if possible—avoid night shift work routines that disrupt normal circadian rhythms 2
• Time activities strategically: RLS symptoms worsen with inactivity and in the evening/at night, so plan sedentary activities (watching TV, reading) for earlier in the day when symptoms are less severe 2, 3

Physical Interventions That Provide Relief

• Regular moderate exercise should be recommended as it has demonstrated effectiveness in reducing RLS severity 1, 4, 5
• Massage the affected legs when symptoms occur—this has been reported to reduce RLS symptoms 3, 6
• Take hot (temperate) baths before bedtime, which can provide symptom relief 3, 6
• Engage in mentally demanding tasks during symptom onset, as cognitive distraction can reduce symptom intensity 6

Compression and Mechanical Devices

• Pneumatic compression devices (PCDs) applied to the legs have shown significant effectiveness in reducing RLS severity and improving sleep-related outcomes 4, 5
• Compression devices in general significantly improved both RLS severity and sleep quality in controlled trials 4

Alternative Therapies with Evidence

• Standard acupuncture was significantly more effective than control conditions for reducing RLS severity 4
• Infrared therapy showed significant benefit for RLS severity reduction 4
• Yoga significantly improved some sleep-related outcomes, though evidence for RLS severity reduction is insufficient 4, 5

Medication Review—Critical First Step

• Review and discontinue medications that exacerbate RLS, including antihistamines, serotonergic medications (SSRIs), antidopaminergic medications (antipsychotics), anxiolytics, antidepressants, antimuscarinics, decongestants, and certain pain medicines 2, 1
• Adjust timing of necessary medications (diuretics, diabetes medications, antiparkinsonian drugs) to minimize nighttime symptoms 2

Iron Status Assessment—Often Overlooked

• Check serum ferritin and transferrin saturation in all patients with clinically significant RLS, ideally in the morning after avoiding iron supplements for at least 24 hours 1
• Supplement iron if ferritin ≤75 ng/mL or transferrin saturation <20%—this threshold is different from general population guidelines and specific to RLS 2, 1

Interventions to Avoid (Insufficient Evidence)

• Vibration pads were ineffective in reducing RLS severity 4
• Cryotherapy did not reduce RLS severity, though it improved some sleep outcomes 4
• Valerian is specifically recommended against by the American Academy of Sleep Medicine 2, 1

Common Pitfalls

The most critical error is failing to check iron status before assuming non-pharmacological measures alone will suffice—even patients with "normal" ferritin by general standards may benefit from supplementation if levels are below the RLS-specific threshold of 75 ng/mL 1. Additionally, many patients continue taking antihistamines or SSRIs without realizing these medications directly worsen their RLS symptoms 2, 1.