Teresa’s TCM Clinical Reflections (21)

My Legs Feel Uncomfortable at Night and I Keep Wanting to Move Them — What Could It Be?

Subtitle: What kind of nighttime leg discomfort should make us think about Restless Legs Syndrome?

By Teresa Shen, BHSc (Acupuncture), ACC Registered Treatment Provider, Registered Chinese Medicine Practitioner (NZ)

Some patients find it very difficult to describe what they feel in their legs.

They tell me it is not exactly pain. It is not ordinary numbness, and it does not feel like a calf cramp. But in the evening, especially when they sit down or lie in bed, there is a strange and uncomfortable sensation deep in the legs.

They cannot leave their legs still. They want to move them, stretch them, or sometimes get out of bed and walk around.

The interesting part is that movement makes the legs feel better. But once they stop moving and rest again, the uncomfortable sensation gradually returns.

When I hear this pattern, one condition comes to mind:

Restless Legs Syndrome, or RLS.

What Does Restless Legs Syndrome Feel Like?

When considering RLS, I do not focus only on how the patient describes the sensation. I pay particular attention to when it happens and what makes it better or worse.

There are several characteristic features.

First, there is an urge to move the legs, usually associated with an uncomfortable sensation. Patients may describe aching, tingling, crawling, pulling or an internal restlessness. Sometimes they simply say, “I don’t know how to describe it. My legs just don’t feel right.”

Second, the symptoms become worse during rest or inactivity. Sitting for a long time, lying in bed, travelling in a car or plane, or attending a long meeting can make them more noticeable.

Third, movement provides relief. Walking, stretching or moving the legs may reduce the discomfort, at least temporarily. Some patients also find that rubbing or massage helps.

Fourth, symptoms are usually worse in the evening or at night than during the daytime.

This pattern — an urge to move, worse at rest, improved by movement and more noticeable in the evening — is much more useful clinically than simply asking whether the patient’s legs hurt.

Some patients also have a clear family history. A parent, sibling or another family member may have experienced similar nighttime leg symptoms. This is particularly relevant in some people with primary RLS.

Another interesting feature is that routine neurological examination may be normal. Strength, sensation and reflexes may show no obvious abnormality, and there may be no specific tender point that explains the symptoms.

The patient’s discomfort, however, can still be very real.

Is It Primary or Secondary RLS?

Once I think a patient’s symptoms may fit RLS, the next question is:

Why is this happening?

Some people have no clearly identifiable underlying condition. This is often described as primary or idiopathic RLS, and a family history may be more common in this group.

In other patients, there may be an associated medical or physiological factor.

One important consideration is low iron stores. A patient does not necessarily need to have obvious anaemia for iron status to be relevant, so appropriate medical assessment may include iron studies when RLS is suspected.

RLS can also be associated with chronic kidney disease and pregnancy.

Medication history is another important part of the assessment. Some antidepressants, antipsychotic medicines, antihistamines and other medications can trigger or worsen RLS-like symptoms in some people.

This does not mean patients should stop prescribed medication themselves. If a medication may be contributing to the symptoms, it should be discussed with the prescribing doctor.

So when a patient says:

“My legs just feel uncomfortable at night,”

I need to go further.

Is this primary RLS, or is another problem contributing to these symptoms?

What Else Can Look Like Restless Legs Syndrome?

Not everyone who has uncomfortable legs at night has RLS.

Night-time leg cramps, for example, usually involve a sudden and painful muscle contraction. This feels quite different from the internal restlessness and urge to move that characterise RLS.

Peripheral neuropathy can produce numbness, burning, tingling or pins and needles. However, it does not necessarily follow the typical RLS pattern of becoming worse at rest and improving with movement.

If I suspect a lumbar nerve root or sciatic nerve problem, I look more carefully at the distribution of pain and numbness, muscle strength, sensation, reflexes and relevant neurological tests.

Other conditions can also cause uncomfortable legs. Circulatory problems, muscular pain, joint problems, medication effects and other causes of restlessness may sometimes produce symptoms that initially sound similar.

This is why the patient’s words “my legs feel uncomfortable” are only the beginning of the assessment.

Clinically, we need to understand what kind of discomfort it actually is.

How Does Chinese Medicine Look at Restless Legs Syndrome?

Chinese medicine does not stop at the diagnosis of “Restless Legs Syndrome”.

Once I understand the clinical presentation and have considered whether other medical factors need attention, I also look at the patient’s TCM pattern.

Some patients show more signs of Blood Deficiency or Qi and Blood Deficiency. Their legs may feel weak, tired, numb or uncomfortable, particularly at night. From a Chinese medicine perspective, this may be understood as insufficient nourishment of the muscles and channels.

Other patients may present more with Qi Stagnation, Blood Stasis and channel obstruction. In addition to restlessness, there may be more fixed aching, discomfort, pain or numbness.

If the legs feel heavy, achy and cold, and symptoms become worse with cold or damp weather, I may consider a pattern of Cold-Damp obstructing the channels.

In patients with a longer history, particularly when symptoms are accompanied by weakness of the legs or aching and weakness around the lower back and knees, Liver and Kidney Deficiency may also be considered within TCM pattern differentiation.

This means that two patients may both have a medical diagnosis of Restless Legs Syndrome but still have different Chinese medicine patterns.

The diagnosis helps me understand what the condition may be. Pattern differentiation helps me decide how I should approach this particular patient.