What non‑pharmacologic interventions can be used to manage restless‑legs syndrome and periodic limb‑movement disorder?

Non-Pharmacologic Management of Restless Legs Syndrome and Periodic Limb Movement Disorder

The most critical non-pharmacologic intervention for RLS and PLMD is iron supplementation when ferritin ≤75 ng/mL or transferrin saturation <20%, combined with elimination of exacerbating substances (alcohol, caffeine, nicotine) and medications (antihistamines, antidepressants, antipsychotics). 1

Mandatory Initial Assessment

Check serum ferritin and transferrin saturation in all patients with clinically significant RLS or PLMD, drawn in the morning after avoiding iron-containing supplements for at least 24 hours. 1, 2 This is a good practice statement from the American Academy of Sleep Medicine and represents the single most important non-pharmacologic intervention.

Iron Supplementation Strategy

The iron thresholds for RLS/PLMD differ substantially from general population guidelines:

• Adults: Supplement if ferritin ≤75 ng/mL or transferrin saturation <20% 1, 2
• Children: Supplement if ferritin <50 ng/mL 1, 2
• ESRD patients: Supplement if ferritin <200 ng/mL and transferrin saturation <20% 1, 2

First-line iron options:

• Oral ferrous sulfate 325-650 mg daily (65 mg elemental iron) for ferritin ≤75 ng/mL—conditional recommendation with moderate certainty 2
• IV ferric carboxymaltose 1000 mg single infusion—strong recommendation with moderate certainty, the only IV formulation with this level of evidence 2

When to choose IV over oral iron:

• Ferritin 75-100 ng/mL (oral iron poorly absorbed in this range) 2
• Oral iron not tolerated or ineffective after 3 months 2
• Need for rapid symptom improvement 2

Critical pitfall: Iron sucrose lacks efficacy for general RLS patients and should only be used in ESRD 2. The slow-release, higher-dose formulations like ferric carboxymaltose enable the H-ferritin binding and macrophage iron uptake necessary for CNS penetration, which fast-release formulations cannot achieve. 2

Elimination of Exacerbating Factors

Substances to Avoid

Eliminate or significantly reduce these substances, especially within 3 hours of bedtime: 1, 3

• Alcohol 1
• Caffeine 1
• Nicotine 1

The National Comprehensive Cancer Network explicitly recommends avoiding these substances too close to bedtime as part of sleep hygiene for RLS patients. 1 Even moderate consumption, particularly in the evening, can significantly worsen symptoms and should be eliminated as a first-line intervention. 1

Medications That Worsen RLS/PLMD

Review and discontinue or switch the following medication classes when clinically feasible: 1, 4, 5

• Antihistaminergic medications 1
• Serotonergic antidepressants (SSRIs, SNRIs—particularly mirtazapine and venlafaxine) 1, 4, 5
• Antidopaminergic medications (antipsychotics, antiemetics) 1, 4, 5
• Lithium 5

Exception: Bupropion may actually reduce RLS symptoms rather than worsen them and can be considered if an antidepressant is needed. 3, 4, 5

Treatment of Comorbid Sleep Disorders

Address untreated obstructive sleep apnea, as this is an independent exacerbating factor for RLS. 1 Mild obstructive sleep apnea and upper airway resistance syndrome can masquerade as PLMD. 6

Behavioral and Environmental Modifications

Sleep Hygiene Measures

• Ensure the sleep environment is dark, quiet, and at a comfortable temperature 1
• Increase exposure to bright light during the day while avoiding bright light at night 1
• Avoid heavy meals or drinking within 3 hours of bedtime 1

Exercise Recommendations

Regular exercise in the morning and/or afternoon is recommended, but avoid vigorous exercise close to bedtime as this may worsen symptoms. 1 RLS symptoms are more pronounced in the evening or night, making the timing of physical activity particularly critical. 1

Temperature Considerations

Avoid cold exposure for symptom prevention, particularly in patients who also have Raynaud's phenomenon. 1

Emerging Non-Pharmacologic Therapy

Bilateral high-frequency peroneal nerve stimulation is a newer noninvasive treatment option with conditional recommendation based on initial success in short-term studies (moderate certainty of evidence). 1 This represents the only device-based non-pharmacologic intervention currently recommended by the American Academy of Sleep Medicine.

Special Population Considerations

Pediatric Patients

• Oral iron supplementation is recommended when ferritin <50 ng/mL, with monitoring for constipation 1, 2
• Behavioral management strategies should be implemented 4

Pregnancy

• Iron supplementation is particularly important given pregnancy-specific RLS prevalence 1, 2
• Oral iron formulations are preferred throughout gestation due to favorable safety profile 2

End-Stage Renal Disease

• IV iron sucrose when ferritin <200 ng/mL and transferrin saturation <20% 1, 2
• Vitamin C supplementation to enhance iron utilization 1, 2

Monitoring and Follow-Up

• Reassess iron studies every 6-12 months and continue supplementation as needed 1, 3
• IV ferric carboxymaltose may require up to 12 weeks to achieve full clinical benefit 2
• Check serum phosphate levels after repeat IV iron courses to monitor for hypophosphatemia 2

Critical Pitfalls to Avoid

• Do not use general population ferritin cutoffs (<15-30 ng/mL) for RLS/PLMD—higher thresholds (≤75 ng/mL) are required 2
• Do not perform iron studies while the patient is taking iron supplements—wait ≥24 hours after the last iron-containing product 2
• Do not assume "normal" consumption of caffeine or alcohol is acceptable—even moderate amounts in the evening can significantly worsen symptoms 1
• Do not assume all IV iron formulations are equivalent—only ferric carboxymaltose has strong evidence; iron sucrose lacks efficacy except in dialysis patients 2