You were pretty sure you had it. Still, it was good to get the diagnosis. Are you looking for more restless legs syndrome info? Maybe cause, treatment? Here’s what you need to know…
Dopaminergic agents: These drugs, which increase dopamine in the brain, can reduce symptoms of RLS when taken at night.
If you or someone you care about has restless legs syndrome, you know how troublesome it can be.
You also know it doesn’t get the attention it deserves.
We started a two-part series on restless legs syndrome last week. In part one we defined it, reviewed its symptoms, and who’s more likely to have it.
Now it’s on to cause and treatment…
What causes restless legs syndrome
Like most of the conditions we discuss, the cause of restless legs syndrome (RLS) is unknown. That means we have to turn to triggers and scientific supposition to connect the dots.
If someone is experiencing RLS-like symptoms and any of the following are going on, the dots are connecting…
Family history of RLS
Parkinson’s disease/dopamine imbalance
Sleep deprivation and other sleep conditions, such as sleep apnea
Pregnancy or hormonal changes, especially in the last trimester
Use of alcohol, nicotine, and caffeine
Iron deficiency, even without anemia
Using medications, such as some anti-nausea drugs, antidepressants that increase serotonin, antipsychotics, medications that contain older antihistamines
End-stage renal disease and hemodialysis
What’s in the works?
Lots of mystery, supposition, and dot connecting going on when it comes to the cause of RLS. It’s terribly frustrating. But what can I say? It’s the brain.
The good news is the National Institute of Neurological Disorders and Stroke (NINDS) is funding a lot of fantastic research.
“Yeah, participating in a clinical trial is a great way to help the cause. Good idea, doc.”
Included: investigating changes in the brain’s signaling pathways with an emphasis on dopamine, discovering genetic relationships, studying the role of endothelial cells in the regulation of cerebral iron metabolism, using advanced MRI to measure chemical changes in the brain’s arousal system, testing non-drug therapies, such as a non-invasive nerve stimulation device to use during sleep.
If you’re dealing with it, you know that’s the kind of attention RLS deserves.
How is restless legs syndrome treated?
There is no treatment that directly addresses RLS. So to secure relief we have to focus upon contributing medical conditions, lifestyle habits, and self-care.
Let’s start with medical conditions – reference the “triggers” above. Here are medications frequently used in the treatment of RLS…
Iron supplements: Check with your physician first.
Anti-seizure drugs (anticonvulsants): The first-line prescription drugs for those with RLS. The U.S. Food and Drug Administration (FDA) approved gabapentin enacarbil (Horizant, Regnite) for the treatment of moderate to severe RLS. Other anti-seizure drugs, such as pregabalin (Lyrica), can decrease sensory disturbances and nerve pain.
Dopaminergic agents: These drugs, which increase dopamine in the brain, can reduce symptoms of RLS when taken at night. Ropinirole (Requip), pramipexole (Mirapex), and rotigotine (Neupro) are FDA-approved to treat moderate to severe RLS. Levodopa (L-Dopa) plus carbidopa (Lodosyn) may be effective, but can only be used intermittently.
Opioids: Drugs such as methadone (Dolophine, Methadose), codeine, hydrocodone (Hysingla ER, Zohydro ER), or oxycodone (OxyContin, Roxicodone) are sometimes prescribed to treat individuals with more severe symptoms of RLS who do not respond well to other medications.
Benzodiazepines: They are anticonvulsants. Medications such as clonazepam (Klonopin) and lorazepam (Ativan) are generally prescribed to treat anxiety, muscle spasms, and insomnia; and can help individuals get more restful sleep.
Lifestyle habits and self-care
Lifestyle habits and self-care have a major impact on distress. The following often provide relief for those with mild to moderate RLS…
Avoid or decrease the use of alcohol, nicotine, and caffeine
Change or maintain a regular sleep pattern
Moderate, regular exercise
Massage the legs or take a warm bath
Apply a heating pad or ice pack
Use foot wraps specially designed for people with RLS or vibration pads to the back of the legs
Aerobic and leg-stretching exercises of moderate intensity
With creativity, we can come up with more.
The attention it deserves
That’ll do it for our series. Restless legs syndrome makes life challenging for tens of millions worldwide. If you or someone close to you has it, that isn’t front page news.
No cause, no cure. So quality management options will have to hold us over as research continues.
But there’s plenty of hope because restless legs syndrome is finally getting the attention it deserves.
To get the full scoop on restless legs syndrome, be sure to read part one.
You’ve been having strange sensations in your legs and overpowering urges to move them. You can’t even sleep anymore. “Do I have restless legs syndrome?” Here’s what you need to know…
Do you think there’s a relationship between RLS, depression, and anxiety? Sure is. And one incites the other.
Restless legs syndrome can turn lives upside down.
If you’re one of the tens of millions struggling, or think you may be, here’s what you need to know. In fact, there are so many need to knows that we’ll go with a two-part series.
Let’s get after defining restless legs syndrome, reviewing its symptoms, and who’s more likely to have it. And we’ll come back in part-two with causes and what to do about it.
Off with us…
What is restless legs syndrome?
Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a neurological disorder characterized by unpleasant or uncomfortable sensations in the legs and an irresistible urge to move them. It can also affect other parts of the body.
The occurrence rate of RLS in North America and Europe is 7-10%. It’s believed to be quite a bit lower in Middle Eastern and East Asian countries.
What are the symptoms of restless legs syndrome?
Here are the primary symptoms – characteristics – of RLS…
Sensations – aching, crawling, tingling, itching, throbbing, pain, burning, tugging – that typically begin after being inactive and sitting for extended periods of time.
Relief of discomfort with movement of the legs (or other affected body part). Keeping them in motion may minimize or prevent the sensations. It may come down to pacing the floor or constant movement while sitting.
Worsening of symptoms at night with a distinct symptom-free period early in the morning.
Difficulty falling and staying asleep, which can worsen with a reduction of sleep due to events or activity.
With moderately severe RLS, symptoms may only occur once or twice a week, but often result in significant delay of sleep onset with some disruption of daytime functioning.
Periods of remission may occur for weeks or months, especially during the early stages of the disorder. But not only are they likely to reappear, they can become worse over time.
By the way, can you see why RLS is considered both a sleep and movement disorder?
“I love this show, but enough’s enough. It’s time to see the doc.”
Some 3% of RLS cases are considered severe, which means intense and persistent symptoms occur more than twice a week.
In addition to sensations and movement, mental distress, insomnia, and daytime sleepiness may present. And since RLS is worse when resting, those with severe cases may avoid daily activities that involve long periods of sitting.
But that’s not all. Sufferers of severe RLS are more apt to isolate socially and experience frequent daytime headaches, compromised memory, impaired concentration, and libido issues.
Do you think there’s a relationship between RLS, depression, and anxiety? Sure is. And one incites the other.
Who is more likely to have restless legs syndrome?
Just like our specialty, the mood and anxiety disorders, the root cause of RLS is unknown. When that’s the case, triggers help us identify who’s more likely to have a disorder.
Let’s take a look…
Family history of RLS
Sleep deprivation and other sleep conditions, such as sleep apnea
Use of alcohol, nicotine, and caffeine
Pregnancy or hormonal changes, especially in the last trimester. In most cases, symptoms disappear within four weeks post-delivery.
Medications, such as anti-nausea drugs, antipsychotics, antidepressants that increase serotonin, cold and allergy medications that contain older antihistamines (e.g., chlorphenamine, doxylamine, hydroxyzine)
Iron deficiency, even without a diagnosis of anemia
End-stage renal disease and hemodialysis
Heads up, right?
Come on back for part two
That’ll do it for part one. Whether you know you have restless leg syndrome or you’re considering the possibility, the information will lend you a hand.
It’s gotta’ stop. Not only are you waking up two hours before you want to, you can barely get out of bed when the time is right. And the depression is scary dark. Yeah, that’s enough.
Still, research tells us any misalignment of internal clock, sleep, and external light/dark cycle can generate mood changes…
The first version of this piece was written five and a half years ago. I’ve been hearing a lot of morning depression stories lately, so I decided to rework it and bring it to you again.
We’re going to be reviewing a whole lot of information. So maybe a couple of sittings or printing the piece will be helpful.
What is morning depression?
For some, having a rough time getting after it in the morning is no big deal. Eh, throw some caffeine and a shower at it and life’s good.
But there are those for whom most every morning is a depressive hell. And let’s throw some crippling anxiety on the heap.
Sure, they most often feel better as the day goes on; however, thoughts of another brutal go in the morning are hard to shake.
That’s morning depression. And that’s what we’re going to work toward understanding.
Diurnal mood variation
Gaining insight into morning depression begins with learning about something known as diurnal mood variation (DMV).
You guessed it, keyword: diurnal…
Behavior characterized by activity during the day, with a period of sleeping, or other inactivity, at night.
In putting this section together, I turned to a fascinating article written by Dr. Anna Wirz-Justice, “Diurnal variation of depressive symptoms.”
Now, Wirz-Justice refers to “variation of depressive symptoms” and we’re discussing “diurnal mood variation.” We’re in the same ballpark.
Okay, the good doctor kicks things off by stating diurnal variation (DV) with early morning worsening is considered a core feature of melancholia.
What’s that? Well, these days it’s used as a major depressive disorder (MDD) diagnostic specifier. It features symptoms such as loss of appetite, excessive guilt, early morning awakening and, yes, early morning mood worsening.
And, by the way, early morning worsening isn’t the only pattern, as an afternoon slump or evening worsening can occur.
Keep in mind, experiencing morning depression doesn’t 100% equate to having MDD with melancholic features. In fact, people considered to be “nonclinical” often have diurnal mood swings.
See, studies have shown that mood follows a circadian rhythm with the lowest values at around 4 a.m., the time when our core body temperature is at its minimum. And any interruption in circadian rhythm can result in a mood drop – for anyone.
I’ve always found comfort in explanations.
More from the doc
Need to share a few more interesting things from Wirz-Justice’s work…
A study showed that for those in the midst of a major depressive episode, the lowest circadian mood occurred around the time of awakening. That shifted to several hours later, post-episode.
Those diagnosed with MDD with melancholic features believe their mood variations are “uninfluenceable.” Nonclinicals believe their mood variations are almost exclusively related to their own activities and/or external circumstances.
Evidence exists that shows there are definitely circadian underpinnings to mood, and timing and duration of sleep can be a modifier.
Stable timing between internal rhythms such as temperature and sleep with respect to the external day/night cycle is crucial for overall well-being.
Dr. Wirz-Justice wraps things up by reiterating that mood changes throughout any given day are normal. If that’s the case, diurnal variation can’t be inherently pathological.
Still, research tells us any misalignment of internal clock, sleep, and external light/dark cycle can generate mood changes, especially in vulnerable individuals – like us.
Blood sugar levels and sleep
As long as we’re on the subject…
If you’re a frequent reader, you know I like to explore as many angles as possible. So let’s talk about the potential role of low blood sugar – hypoglycemia – in morning depression.
We’ll hit some biochemistry to get us started…
Insulin and glucagon
Our blood sugar levels are chemically regulated by the hormones insulin and glucagon. Glucagon increases blood sugar, insulin decreases it.
And wouldn’t you know it, the amount of sleep we get impacts the release of both. Hence, regulating our sleep patterns helps keep blood sugar levels within the norm during waking hours.
Now, blood sugar levels rise and fall during waking and sleeping hours. After at least eight hours of not eating, in a perfect world our blood sugar level is typically between 70-100 mg/dL. The level pops-up after eating; however, drops to less than 180 mg/dL two hours after.
With glucagon at work, our blood sugar levels start to rise in the evening and peak about three to four hours after falling asleep. And then along comes insulin to bring it down as an eight-hour sleep cycle ends. Could this drop generate morning depression? Hmm.
Sleep deprivation and other effects on blood sugar
Fact: “short-sleepers” have a much higher risk of developing impaired fasting blood sugar levels than “regular-sleepers.” Factors such as age, gender, and family history of diabetes can aid in determining the level of risk.
Some people deal with increased irritability or sad mood when they’re experiencing a rapid change in blood sugar level. That can be a decrease, but still in normal range (80-130 mg/dL), and it can be when levels are low (below 70 mg/dL).
Then there are those who may experience irritability or sadness when blood sugar levels are high (250 mg/dL+).
In either case, changes in mood tend to be temporary and will be reduced or cease when blood sugar levels return to target range.
Huge factor to explore, don’t you think?
The transitioning to reality crash
As we wrap up this info fest, I want to mention a phenomenon I’ve always believed to be at play with my morning depression – and anxiety.
I’ve even named it: the “transitioning to reality crash.” And it especially applies to those who, at baseline, lean toward the lowish-mood and/or anxious.
Even in particularly depressed or anxious times, most of us can manage to pull off at least a couple hours of sleep – leaving our woes behind. Yeah, but then it’s time to wake-up, and it doesn’t take long for our misery to resurface.
It’s my opinion the onslaught – transition to reality – can be hard to handle. And let’s keep in mind we haven’t had much time to crank up our trusted defenses. So we’re, um, raw.
Good news is, if we can get active, we can expect a significant improvement in fairly short order. The bad news is, getting through it is such a drag.
Let’s get to work
Well, that’s a wrap. I realize we didn’t get into remedies, but there’s only so much space. Besides, now you have all sorts of info to get you started on your research and custom solutions.
Morning depression: scary dark, for sure. However, with knowledge, tenacity, and creativity, a peaceful coexistence is ours for the taking.
It always comes down to anxiety, depression, and stress, doesn’t it? “Sure, the meds and therapy help, but isn’t there something creative I can add to the mix?” Let’s talk about the vagus nerve…
When the vasovagal response is triggered, a sudden drop in heart rate and blood pressure occur. When that happens, blood vessels in the legs may widen…
If we rely solely upon meds and therapy for mood and anxiety disorder relief, we’re doing ourselves a disservice.
There are all sorts of creative intervention targets and techniques we can add to our treatment regimen. We’re going to discuss one of them – the vagus nerve.
Because there’s so much valuable information to share, we’ll do this in two parts. In this piece we’ll get to know the vagus nerve and we’ll get into how to deal with some of the problems it can present, and manage, in part two.
What is the vagus nerve?
Before we get rolling, why should we even bother with learning about the vagus nerve?
Absorb these excerpts from “Vagus Nerve as Modulator of the Brain-Gut Axis in Psychiatric and Inflammatory Disorders.” The article, written by S. Breit, A. Kupferberg, G. Rogler, and G. Hasler, appears on Frontiers in Psychiatry…
…discuss various functions of the vagus nerve which make it an attractive target in treating psychiatric and gastrointestinal disorders
…preliminary evidence that vagus nerve stimulation is a promising add-on treatment for treatment-refractory depression, posttraumatic stress disorder
…stimulation of vagal afferent fibers in the gut influences monoaminergic brain systems in the brainstem that play crucial roles in major psychiatric conditions, such as mood and anxiety disorders (my note: monoaminergic refers to the monoamine neurotransmitters: dopamine, epinephrine, norepinephrine, serotonin)
Much more in their article, but can you see why learning about the vagus nerve is well worth the bother?
The vagus nerve is the tenth of our twelve cranial nerves. They’re noted by Roman numerals. What makes cranial nerves unique is their emergence in pairs – left and right side – directly from the brain, not from segments of the spinal cord.
Ten of the twelve cranial nerves, including the vagus, are components of the peripheral nervous system. In short, it’s the relay between the brain, spinal cord, and the rest of the body.
The vagus nerve – right side
The vagus nerve, cranial nerve X, is in green in our featured image and you can see its path in the image above.
Vagus comes from the medieval Latin: “wandering.” And I’m sure the name was chosen because the cord-thick nerve originates in the brainstem, extends through the neck and chest, and terminates in the abdomen. Remember, there are two “vagal nerves.”
The vagus nerve is our primary parasympathetic nerve. Parasympathetic “rest and digest” action down-regulates our fight/flight response when a threat has passed. So it restores order in our mind and body.
The vagus nerve is also the connection between the central nervous system and the enteric nervous system (gastrointestinal). It’s known as the brain-gut axis.
Finally, the vagus nerve is a major player in inflammation management.
No wonder the vagus nerve supplies sensory and motor fibers to all of the major organs of the head, neck, chest, and abdomen.
What does the vagus nerve do?
In handling its assorted jobs, the vagus nerve controls or regulates involuntary functions such as…
Heart rate, blood pressure, sweating, muscle contractions and glandular secretions in the gastrointestinal system, immune system response, mood, mucus and saliva production, skin and muscle sensations, speech, taste, urine output, gag reflex
Are you beginning to see why the vagus nerve deserves our attention?
Vasovagal response and vasovagal syncope
The vasovagal response (aka vasovagal reflex) occurs when there’s excessive activation of the vagus nerve in the face of significant stress. “Vaso” referring to blood vessels, “vagal” to vagus. It’s a parasympathetic – “rest and digest” – overcompensation.
Here are some of the things we may experience…
Blurred or tunnel vision, cold and clammy skin, turning pale, feeling warm, sweating, dizziness, light-headedness, nausea, ringing in the ears, loss of bladder control, fainting
But what triggers the vasovagal response? These are the most commonly reported…
Emotional stress, a blood draw, the sight of blood, fear, gastrointestinal illness, a bowel movement, heat, physical pain, standing for a long time, standing up quickly, trauma
So we know what the vasovagal response looks like and its common triggers. But what’s the biology behind it all?
When the vasovagal response is triggered, a sudden drop in heart rate and blood pressure occur. When that happens, blood vessels in the legs may widen, which can cause blood pooling in the legs. And that can lead to a further drop in blood pressure.
What it all comes down to is compromised blood flow to the brain.
By the way, we all have different vasovagal response strengths. Some may faint at the mere mention of blood or a hint of coming trouble. Others may never experience the response.
So far we’ve talked about feeling faint during the vasovagal response. Well, fainting is a real possibility. It’s called vasovagal syncope – a fancy word for fainting. The loss of consciousness typically lasts a few minutes and in most cases it’s on with the show in short order.
Being prepared is important, isn’t it? Well, here are some things we can do if a vasovagal response episode is knocking on the syncope door…
Lie down for ten minutes or so, lower our head between our knees, drink some water, don’t stand up quickly, during bowel movements: try to stay relaxed, sit on the toilet with head down and legs crossed. Keeping a sufficient and steady blood pressure is the goal.
If you’re experiencing numerous or intense vasovagal response episodes, with or without fainting, be sure to chat with you doc.
See you in a bit
No doubt, meds and therapy can bring relief for symptoms of anxiety, depression, and stress. But why not add more to our treatment mix?
Breathing: it’s automatic. But breathing correctly isn’t. And that can be a problem for those of us living with a mood or anxiety disorder. So maybe it’s time to get back to the basics…
’It’s believed most of us only use around one third of our lungs when we inhale, which can cause all sorts of health problems.’
If someone with, say, panic disorder came to me for help and the first thing out of my mouth was “Are you breathing correctly?” I might have to duck.
Fact is, though, some researchers believe those with panic disorder are chronic hyperventilators, so correct breathing is essential. Actually, it’s imperative for anyone on the mood and anxiety disorder side of the fence.
Tell you what, when getting into subjects out of one’s realm, it’s best to bring in the experts…
Introducing Meera Watts
Meera Watts is a yoga teacher, entrepreneur, and mom. Her writing on yoga and holistic health has appeared on popular websites, including Elephant Journal and OMTimes. Ms. Watts is the founder and owner of Siddhi Yoga International. She runs intensive residential trainings in India and Indonesia.
What you’re about to read is the bulk of one of Ms. Watts’ articles. And it includes a great video at the end.
I posted the original piece in 2018. The information is so strong I decided to rework it and bring it to you again. There’s a lot of info, so why not favorite or print the article for ongoing reference?
The floor’s yours, Ms. Watts…
Yoga breathing techniques for beginners
Breathing is an important part of everyday life. We need it to live and we need it in order for our brain to function properly.
Unfortunately, most people don’t breathe to their full lung capacity (5.8 L for males and 4.2 L for females). They also forget to breathe correctly all together.
There are breathing techniques that can help teach you not only to breathe properly, but also to use as much of your total breathing capacity as possible. They are yogic breathing techniques that are used within the practice.
Total breathing capacity
Total breathing capacity is the maximum amount of air that your lungs can hold when they are fully inflated. It is the inspiratory reserve volume, tidal volume, expiratory reserve volume, and residual volume all added up.
This can vary according to age, height, fitness level and where you live. People living at higher elevations need more oxygen for their bodies and brains to function properly.
Inspiratory Reserve Volume: The maximum amount of additional air that you can bring in after a normal inhalation
Tidal Volume: The volume of air that is moved in and out of your lungs during quiet breathing
Expiratory Reserve Volume: The maximum additional air that you can exhale from your lungs after a normal exhale
Residual Volume: The air that is still in your lungs after a full exhale
When we exercise, we need to breathe in more air, which increases our total breathing capacity. It can actually increase as much as 15% during exercise in order to meet metabolic rates that your body needs when it is exercising.
What is breathing?
Breathing is when we move air in and out of our lungs, bringing oxygen in and flushing carbon dioxide out.
Lungs can’t inflate by themselves, expanding only when there is an increase in the thoracic cavity. This is done through the diaphragm as well as the intercostal muscles.
When air fills the lungs, the diaphragm and rib cage expand, connecting them to the sternum, the cervical vertebrae and the base of the skull. During exhalation, all of the muscles relax and the chest and abdomen return to normal, or resting position.
Most people don’t even realise how they breathe, they just do. But if people actually stopped to think about how they were breathing they may realise that they are actually doing it all wrong. Meaning they are not breathing through the diaphragm and the rib cage.
Are you breathing correctly?
It’s believed most of us only use around one third of our lungs when we inhale, which can cause all sorts of health problems.
Not breathing fully can lead to us feeling stressed, anxious, depressed, and lethargic. It can also affect how we sleep.
We breathe around 20,000 times a day, which helps our nervous system, digestive system, muscles, immune system, and cardiovascular health.
Each time we exhale we push toxins out of our body and rid our lungs of carbon dioxide. But by not breathing correctly, we are keeping these toxins and excess carbon dioxide in our body.
Signs of not breathing correctly
Signs that you are not breathing correctly include…
Grinding your teeth in your sleep
Feeling tired and exhausted all of the time
Having a tight neck and shoulders is also a sign of incorrect breathing, as it means that you are shallow breathing. This causes the neck, shoulders, and back to overcompensate. In short, it means you are breathing through your upper chest, so your lungs aren’t reaching their total breathing capacity.
A great way to tell if you are breathing incorrectly is to pay attention to where you are breathing from. If you are breathing out of your mouth, then you are not breathing correctly. Breathing should always be done through the nose.
By not doing this, you could be altering your heart rate and blood pressure, and increasing your responses to stress.
Also check what your stomach is doing. When most people inhale, their stomach deflates, while inflating on the exhale. When breathing correctly the opposite should happen.
How to breathe
As mentioned above, the best way to breathe and increase your oxygen intake is to breathe through your nose. This will also increase your Total Breathing Capacity and allow toxins and carbon dioxide to be released from your body.
This is the action of breathing through your chest. You draw air into your chest using your intercostal muscles. Breathing into the chest allows your lungs to be fully inflated, freeing the joints in your neck, upper back, and ribs.
With thoracic breathing, you are not breathing through the diaphragm and filling up your lungs, everything stays within the chest. The rib cage and chest widen and lift up on the inhale, and go back down on the exhale.
Place the palms of your hands on your back or on your rib cage and try breathing through the back and sides of the rib cage through your nose. Feel your rib cage expand and lift up as you inhale, and close and go down as you exhale.
As the name suggests, abdominal breathing is breathing through the stomach, using the muscles of the abdominal wall. This is also known as diaphragmatic breathing, and is done by contracting the diaphragm.
As air enters the lungs the belly expands and then goes back down on the exhale. It massages the internal organs, can help relieve lower back pain and is great for the immune system and digestive system. It also helps with stress, anxiety, and high blood pressure. Doctors are now using it to help patients as a relaxation technique.
When you practice abdominal breathing, as you inhale your stomach inflates like a balloon and deflates as you exhale. It can be practiced while sitting or can be done laying down on your back.
This is the combination of both thoracic and abdominal breathing. It is how everyone should be breathing on a regular basis to ensure maximum health and Total Breathing Capacity. It is the correct way to breathe to release as many toxins and as much carbon dioxide as possible out of the body. This is the way that your body wants to breathe for maximum health and stamina.
It takes time to teach your body to breathe this way, especially after not breathing like this for so many years. The more you practice, the more your body will adjust and get used to it. Eventually, this is how you will always breathe automatically.