RESTLESS LEGS SYNDROME AND CHINESE MEDICINE

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND

Restless Legs Syndrome (RLS) is often thought of as an inexplicable movement of the legs at night. In fact, it is a neurological disorder characterized primarily by unpleasant sensations, particularly below the knees, that result in the movements. There are many different descriptions of the sensations, among them are: a crawling feeling; a creeping inside the calves; aches and pains in the legs; or pins and needles, a prickly feeling. These sensations are accompanied by an urge, often irresistible, to move the legs in order to provide relief from the discomfort. In other words, the distressing feelings include within them a sense that movement will alleviate them; movement usually does help. Since the restless legs condition occurs most often during inactivity, particularly at night, the best relief-getting up and walking around-disrupts sleep. But, so does the movement of the legs while in bed, which prevents easily falling asleep (or falling back to sleep after wakening). Restless legs syndrome is commonly discussed in the field of sleep disorders (1, 2).

The syndrome was first mentioned by an English doctor, Thomas Willis, in 1672. In 1861, a German doctor, Theodor Wittmaack, described it as Anxietas tibiarum (literally anxiety of the lower leg muscles: the tibialis). The Swedish doctor Karl Ekbom in 1945 reported his observations in 34 persons with the condition and used the term "restless legs;" later, he observed 70 additional typical cases. Ekborn founded the department of clinical neurology of Uppsala University in 1956, continuing his studies of restless legs, which was known for some time as Ekbom's Syndrome or Wittmaack-Ekbom Syndrome. Much progress in understanding the disorder has been made recently as new study techniques have been developed.

Restless Legs Syndrome may have a genetic component (especially when onset is before age 50), and it is partly related to dopamine activity in the brain affecting function of the cerebral cortex; this is the same neurotransmitter involved in Parkinson's disease. Dopamine agonists (drugs that stimulate the dopamine receptors in the same way dopamine does) and dopamine itself (e.g., l-dopa) are often effective in treating the condition. However, studies suggest that the specific dopamine systems in the brain differ in Restless Legs Syndrome versus Parkinson's disease; the two disorders can coexist when dopamine levels are quite low.

Restless Legs Syndrome mainly occurs past age 50, and affects about 10% of those in that age group; it is particularly common in women. Poor circulation in the legs-which may result from history of smoking, diabetes, lack of exercise, and other factors-contributes to the development of the condition. Nutritional deficiency, particularly lack of bound iron, is known to exacerbate the disorder. The syndrome may also occur temporarily during late pregnancy, possibly as the result of reduced circulation in the legs and lower levels of folate (a B vitamin, B9).

Tests have suggested that serum levels of both ferretin and folate are involved in nutritional aspects of Restless Legs Syndrome (3-5). The levels of these nutrients within cells may not be relevant, nor, apparently, are levels of hemoglobin or free iron. Administration of iron and folate in deficiency cases can provide some relief and sometimes resolve the problem entirely. Folate deficiencies can result from genetic defects, low absorption, or dietary insufficiency (recommended intake for adults is 400 μg/day). The following table displays good sources of folate (see the article Iron Deficiency Anemia for good dietary sources of iron; suggested daily iron intake is 7 mg for men; 12-16 mg for women). Some foods are rich sources of both folate and iron, especially liver (and, to a lesser extent, other meats), spinach (and, to a lesser extent, most green leafy vegetables), and several legumes (beans and peas). Fortified foods, such as breads and cereals, are also good sources of these nutrients. Folate was named for leaves (foliage) that were noted to be a significant source; the supplement form is called folic acid. Current recommendations suggest limiting intake of supplements with folic acid to 1,000 μg (= 1 mg) per day, but the concern for high doses is eliminated when vitamin B12 is also administered.

SOME DIETARY SOURCES OF FOLATE/FOLIC ACID*

Folate content of foods varies according to the source materials used and their processing. In this table, a + means the serving provides 40-100 μg; ++ provides 100-160 μg; +++ provides 160 μg or more.

POSSIBLE CHINESE MEDICINE APPROACHES TO RESTLESS LEGS SYNDROME

Traditional Chinese medicine approaches disorders that are not among the ancient disease categories, such as Restless Legs Syndrome, primarily through analysis of symptom patterns. The excessive movements of the legs are interpreted as being a manifestation of "internal wind," a condition that is related to liver blood deficiency. The fact that the disorder occurs more notably at night and disturbs sleep suggests that the weiqi that circulates at the surface during the day fails to fully return to the interior at night, a problem that is usually attributed to a fluid deficiency of the internal organs, such as yin and blood deficiency of the liver. Disturbance of sleep, a common aspect of the disorder, may also implicate deficiency of the heart. The limitation of the movements to the legs, which are said to be influenced by the liver-kidney system, suggests a deficiency of those two organs. The liver-kidney system is said to deteriorate with aging and to be responsible for many of the disorders that arise with aging, so this relationship may also explain the prevalence of the disease among the elderly. The strange leg sensations described by those who experience Restless Legs Syndrome may correspond to the "numbness" pattern that is attributed to blood deficiency and blood stasis in the traditional Chinese system.

Modern findings can also contribute to the Chinese medical understanding. The possibility of a brain metabolism defect may suggest deficiency of the kidney (since the brain is considered an outgrowth of the kidney system in the Chinese understanding) and a deficiency of the heart, which influences brain activities. The correlation of Restless Legs Syndrome with poor circulation suggests that blood stasis is affecting the legs. The deficiency of iron and folate in the blood may correspond to a blood deficiency syndrome (usually depicted as liver blood deficiency).

Therefore, the Chinese medical therapy would primarily involve tonifying the deficiencies and promoting blood circulation. The deficiency syndrome appears to mainly involve the liver and kidney (possibly also the heart), and the stasis mainly involves the legs. Certain herbs immediately come to mind, such as: rehmannia and cornus for nourishing liver and kidney; tang-kuei and peony for nourishing blood of liver and heart; millettia and achyranthes for nourishing and vitalizing blood (achyranthes is also relied upon to direct the blood flow to the lower body). Chaenomeles is often included Chinese formulas for contracture of the leg muscles, and is especially used in deficiency syndromes; the traditional pair of peony and licorice is typically given to reduce spastic activity, also in deficiency syndromes. In China, these deficiency syndromes would also be treated by consuming organ meats (such as liver), thus providing iron and folate.

Restless Legs Syndrome does not appear frequently in the modern Chinese literature. However, a small number of clinical trials have been reported. For example, in one study involving 21 patients (6), the formula given was a modified Peony and Licorice Combination (Shaoyao Gancao Tang). The basic pair of herbs (usually in equal quantities) was modified by adding three herbs for vitalizing blood circulation: achyranthes, salvia, and pueraria (use of pueraria as a blood vitalizer is an application developed during the past 30 years), and adding chaenomeles for the spastic movement. Another report of similar nature (7) involved the same treatment-except for the herb pueraria-for 18 patients. In both cases, all the patients were said to have improved (restless legs no longer a consistent problem), with only one case recurring after a year. Chinese therapeutic massage, acupuncture, and other therapies might also be utilized in the clinics.

In response to a question about treating Restless Legs Syndrome, Lin Zongguang (a clinician at the Shidong Hospital in Shanghai) reported on his experience treating more than 20 such cases (8). He said that he found the disorder related to "the deficiency and injury of the heart, liver, and kidney." For cases dominated by deficiency of liver and kidney, he suggested a modified version of Rehmannia Six Formula (Liuwei Dihuang Wan), adding ligustrum and tang-kuei. In cases of heat syndrome, he would use the standard modification of Rehmannia Six Formula that adds phellodendron and anemarrhena. For cases in which heart and liver deficiency dominated, he suggested a modified Ginseng and Longan Formula (Guipi Tang), adding rehmannia.

REFERENCES

1. Zucconi M, Ferini-Strambi L, Epidemiology and clinical findings of Restless Legs Syndrome, Sleep Medicine 2004; 5(3): 293-299.
2. Ondo W, et al., Long-term treatment of Restless Legs Syndrome with dopamine agonists, Archives of Neurology 2004; 61(9): 1393-1397.
3. Lee KA, Zaffke ME, and Baratte-Beebe K, Restless legs syndrome and sleep disturbance during pregnancy: the role of folate and iron, Journal of Woman's Health and Gender Based Medicine 2001; 10(4): 335-341.
4. O'Keeffe ST, Gavin K, and Lavan JN, Iron status and Restless Legs Syndrome in the elderly, Age and Aging 1994; 23(3): 200-203.
5. Botez MI, et al., Neurologic disorders responsive to folic acid therapy, Canadian Medical Association Journal 1976; 115(3): 217-223.
6. Shan Yipu, Treatment of 21 cases of Restless Legs Syndrome with modified Shaoyao Gancao Tang, Shandong Journal of Traditional Chinese Medicine 1986; (2): 17-18.
7. Fruehauf H and Dharmananda S, Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, 1997 ITM, Portland, OR.
8. Lin Zongguang, How to treat Restless Legs Syndrome with Traditional Chinese medicine, Journal of Traditional Chinese Medicine 23(4): 305-307.

APPENDIX

A standard "Restless Legs Formula" is provided in granule form (dried decoctions) made of equal parts peony, licorice, tang-kuei, rehmannia, cornus, dioscorea, achyranthes, millettia, pueraria, and chaenomeles. Based on the Chinese clinical reports, treatment duration with Chinese herbs is expected to be only 3-4 weeks; however, continued ingestion or iron and folic acid may be necessary for some individuals. Persons who have a severe folate deficiency syndrome due to malabsorption may require injections of folic acid to get the desired therapeutic effect in a short time. However, high oral intake of folate rich foods or supplemental folic acid (or once per month injections of folic acid) thereafter should maintain the effects. The body can store folic acid for several weeks.

February 2005