What non-pharmacological interventions can alleviate Restless Legs Syndrome (RLS) symptoms?

Non-Pharmacological Management of Restless Legs Syndrome

Start by checking iron status and addressing exacerbating factors, as these non-pharmacological interventions form the foundation of RLS management and may eliminate the need for medication in many patients. 1, 2

Iron Assessment and Supplementation

• Check morning fasting serum ferritin and transferrin saturation in all patients with clinically significant RLS, ideally after avoiding iron-containing supplements for at least 24 hours. 1, 2

• Supplement with oral ferrous sulfate if ferritin ≤75 ng/mL or transferrin saturation <20%—note this threshold is higher than general population guidelines because brain iron deficiency plays a key role in RLS pathophysiology even when serum iron appears normal. 1, 2

• IV ferric carboxymaltose is strongly recommended for patients meeting these iron parameters who don't respond to oral therapy or cannot tolerate it. 1, 2

• Continue iron supplementation indefinitely with ongoing monitoring every 6-12 months, as RLS symptoms may recur if iron stores decline below therapeutic thresholds. 1

Eliminate Exacerbating Factors

• Discontinue or reduce medications that worsen RLS, including antihistaminergic medications (diphenhydramine, hydroxyzine), serotonergic medications (SSRIs, SNRIs), antidopaminergic medications (metoclopramide, prochlorperazine, antipsychotics), and tricyclic antidepressants. 1, 2

• Eliminate or significantly reduce caffeine and alcohol consumption, as both substances directly exacerbate RLS symptoms. 2

• Screen for and treat untreated obstructive sleep apnea, which can worsen RLS symptoms. 1, 2

Lifestyle Modifications

• Implement moderate exercise programs, which have been shown in systematic reviews to significantly reduce RLS severity compared to control conditions. 3

• Smoking cessation should be implemented, as tobacco use worsens RLS symptoms. 2

• Good sleep hygiene is essential, including maintaining consistent sleep-wake schedules and optimizing the sleep environment. 4

Physical Interventions That May Provide Relief

• Massage of the affected legs has been reported to reduce RLS symptoms in clinical practice. 5

• Hot baths or temperate baths may provide symptomatic relief for some patients. 6, 5

• Compression devices were significantly more effective for RLS severity than control conditions in randomized controlled trials. 3

• Counterstrain manipulation showed significant effectiveness in reducing RLS severity. 3

• Standard acupuncture was significantly more effective for RLS severity than control conditions and improved some sleep-related outcomes. 3

• Infrared therapy demonstrated significant effectiveness in reducing RLS severity. 3

• Bilateral high-frequency peroneal nerve stimulation is a newer noninvasive treatment option with conditional recommendation based on initial success in short-term studies. 1

Mental Alertness Activities

• Performing mentally demanding tasks has been reported to reduce RLS symptoms, likely by providing distraction during symptom onset. 5

• Mental alerting activities should be encouraged when symptoms begin, particularly during evening hours when symptoms typically worsen. 7

Critical Pitfalls to Avoid

• Never use non-pharmacological interventions as monotherapy for clinically significant RLS without first addressing iron status—correcting iron deficiency may eliminate symptoms entirely. 1

• Avoid cold exposure for prevention of symptoms, particularly in patients who also have Raynaud's phenomenon. 8

• Be aware that some non-pharmacological interventions may cause placebo effects, but this doesn't diminish their clinical utility if patients experience relief. 3

• Do not delay iron supplementation while trying other non-pharmacological measures—iron therapy should begin immediately if ferritin ≤75 ng/mL or transferrin saturation <20%. 1, 2

When Non-Pharmacological Measures Are Insufficient

• If symptoms persist despite optimizing iron status and implementing non-pharmacological interventions, alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) are strongly recommended as first-line pharmacological therapy. 1, 2

• Many patients with intermittent RLS symptoms do not require medication and can achieve adequate symptom control with non-pharmacological measures alone. 4, 7