Efficacy of an eight-week yoga intervention on symptoms of restless legs syndrome (RLS): a pilot study

Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the treatment of restless legs syndrome and periodic limb movement disorder.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of pharmacological or nonpharmacological treatment to no treatment to improve patient-important outcomes. Statistical analyses were performed to determine the clinical significance of using various interventions to treat restless legs syndrome and periodic limb movement disorder in adults and children. The Grading of Recommendations Assessment, Development, and Evaluation process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 3,631 studies out of which 148 studies provided data suitable for statistical analyses. The task force provided a detailed summary of the evidence along with the certainty of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

CITATION

Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2025;21(1):153-199.

Unfolding the role of exercise in the management of sleep disorders

Sleep disorders are prevalent among the general population and even more in individuals suffering from chronic diseases. Recent data reveal promising effects of physical exercise as a non-pharmacological approach for improving sleep and managing various sleep disorders. However, more studies with proper design and methodology should be conducted in the future to obtain a clearer understanding of the subject. The role of exercise in preventing and improving sleep disorders is probably much higher than what is currently exploited. To fully exploit the potential benefit of physical activity on sleep disorders in the future, it is necessary to identify the relevant tools to assess sleep-wake disorders and establish specific exercise protocols tailored to different sleep disorders. The present manuscript aims to review the literature on the use of exercise in managing selected sleep disorders. Regular exercise, including short-term aerobic activity, resistance training, and mind-body exercises, can effectively improve sleep quality, particularly in cases of insomnia and sleep-disordered breathing. Additionally, increasing evidence supports the effectiveness of aerobic and strength training, and body-mind exercises such as yoga in managing sleep-related movement disorders. Exercise can be a safe, affordable, and efficient tool in enhancing sleep quality and improving sleep disorders. Per se, regular exercise could play an adjuvant role alongside with established therapies, or a valid alternative when the pharmacological approach is limited by side effects, interactions, or inefficacy. More research is needed to define how exercise affects the physiology of sleep, and consequently how to use exercise in patients with sleep disorders.

The effect of progressive muscle relaxation exercise on the intensity of symptoms and quality of sleep and quality of life in pregnant women with restless leg syndrome

OBJECTIVE

This study, accordingly, was conducted with the purpose of investigating the effect of progressive muscle relaxation exercise on the intensity of restless leg syndrome (RLS) and RLS-related quality of life and sleep in pregnant women with RLS.

METHODS

This one-centered, parallel randomized controlled study was conducted with 52 pregnant women. 27-28th of pregnancy, progressive muscle relaxation exercises training was shown and they were asked to practice them 3 times a week for 8 weeks.

RESULTS

It was found that the RLS Intensity Scale and PSQI posttest mean scores of the women in experiment group are lower on a statically significant level than the mean scores of the women in control group (p = 0.000 and p = 0.001). It was detected that the RLS-Qol posttest mean scores of the women in the experiment group are higher than the mean scores in the control group on a statistically significant level (p = 0.000).

CONCLUSIONS

It was seen that progressive muscle relaxation exercises alleviate RLS intensity and symptoms and improve RLS-related quality of life and sleep in pregnant women.

PRACTICE IMPLICATION

Progressive muscle relaxation exercises are beneficial for pregnant women and can be easily integrated into practice.

Circadian rhythm in restless legs syndrome

Restless legs syndrome (RLS) is a sensorimotor disorder with a obvious circadian rhythm, as its symptoms often occur or worsen only in the evening or at night. The mechanisms behind the rhythms of RLS have not yet been fully elucidated. This review explores possible causes for the circadian fluctuations of the symptomatology, including the levels of iron, dopamine, melatonin, melanocortin, and thyroid-stimulating hormone in the brain, as well as conditions such as peripheral hypoxia and microvascular function disorders. The metabolic disturbances of the substances above can create a pathological imbalance, which is further aggravated by physiological fluctuations of circadian rhythms, and results in the worsening of RLS symptoms at night. The review concludes with the suggestions for RLS treatment and research directions in the future.

The Effect of Mindfulness-Based Stress Reduction on Restless Legs Syndrome in Hemodialysis Patients: A Randomized Clinical Trial

Background: There is currently no definitive cure for restless legs syndrome (RLS), and the common treatments are only used to reduce symptoms. Mindfulness-based stress reduction (MBSR) is an intervention that has shown beneficial effects in many mental and physical disorders.Purpose: This study aimed to determine the effect of MBSR on RLS in hemodialysis patients.Methods: This study was a randomized clinical trial involving 60 hemodialysis patients with RLS recruited by convenience sampling each group. Inclusion criteria were patients with RLS diagnosis, age 18-65, Hb>10, no cognitive disorders, ability to read and write, no vision or hearing problems, and history of hemodialysis ≥6 months. The intervention group received eight sessions of the MBSR program, and the control group received routine care in a government dialysis center. International Restless Legs Syndrome Scale and Restless Legs Syndrome Severity Scale were used to measure RLS. Statistical analyses were conducted using independent and pair t-test and ANCOVA.Results: Significant difference was found in the severity the RLS (Mean(SD) score) between the intervention group (12.90(4.58)) and the control group (22.27(4.19)) (95% CI:-11.66 to -7.08, p<0.0001). The effect size between groups was obtained based on Cohen’s d of 2.13.Conclusion: MBSR showed a significant reduction in the severity of RLS in hemodialysis patients. This preliminary study suggests that MBSR can be a promising treatment option in the management of RLS patients.

Practice recommendations for the role of physiotherapy in the management of sleep disorders: the 2022 Brazilian Sleep Association Guidelines

This clinical guideline supported by the Brazilian Sleep Association comprises a brief history of the development of Brazilian sleep physiotherapy, outlines the role of the physiotherapist as part of a sleep health team, and describes the clinical guidelines in respect of the management of some sleep disorders by the physiotherapist (including sleep breathing disorders, i.e., obstructive sleep apnea, central sleep apnea, upper airway resistance syndrome, hypoventilation syndromes and overlap syndrome, and pediatric sleep breathing disorders; sleep bruxism; circadian rhythms disturbances; insomnia; and Willis-Ekbom disease/periodic limb movement disorder. This clinical practice guideline reflects the state of the art at the time of publication and will be reviewed and updated as new information becomes available.

Pharmacologic and Nonpharmacologic Treatment of Restless Legs Syndrome

Restless legs syndrome (RLS) is a sleep-related disorder defined by an urgency to move the legs, usually combined with uncomfortable or unpleasant sensations, which occurs or worsens during rest, usually in the evening or at night, and disappears with the movement of the legs. RLS can be classified as idiopathic or primary, and secondary to comorbid conditions (eg, renal disease, polyneuropathy). The pathophysiology of RLS is still unclear. This article provides an updated practical guide for the treatment of primary RLS in adults.

An Exploratory Randomized Controlled Trial of a 12-Week Yoga Versus Educational Film Program for the Management of Restless Legs Syndrome: Feasibility and Acceptability

Objectives: The primary objectives of this pilot trial were to assess the study feasibility and acceptability of the 12-week yoga and educational film programs for the management of restless legs syndrome (RLS) in preparation for a future randomized controlled trial (RCT). Materials and Methods: This pilot, parallel-arm, randomized feasibility trial was conducted at two sites, Morgantown, WV and Columbus, OH. Yoga group participants attended 75-min Iyengar yoga classes, twice weekly for 4 weeks, then once a week for 8 weeks (16 total classes), and completed a 30-min homework routine on nonclass days. Educational film group participants attended once weekly, 75-min classes (12 total classes), which included information on RLS and other sleep disorders, RLS management including sleep hygiene practices, and complementary therapies. Feasibility and acceptability outcomes included program satisfaction and recruitment, retention, and adherence rates. In addition, participants were asked their preferences regarding three yoga class schedule scenarios for a future study. Attendance, yoga, and treatment logs were collected weekly. Program evaluation and yoga scheduling questionnaires were collected at week 12. Results: Forty-one adults with moderate to severe RLS were randomized to a 12-week yoga (n = 19) or educational film (n = 22) program. Thirty participants (73%) completed the program. Yoga and education group participants attended an average of 13.0 ± 0.84 (81%) and 10.3 ± 0.3 classes (85%), respectively. Participants from both groups indicated satisfaction with the study. All yoga group respondents to the program evaluation reported they would likely (n = 6) or very likely (n = 7) continue yoga practice; 86.7% of education group respondents (13 of 15) indicated that they were likely (n = 7) or very likely (n = 6) to make lasting changes based on what they had learned. The preferred schedule for a future study was a 16-week study with once-weekly yoga classes. Conclusions: The findings of this study suggest that a larger RCT comparing yoga with an educational film group for the management of RLS is feasible. Trial registration: Clinicaltrials.gov: NCT03570515; 02/01/2017.

Effects of a 12-week yoga versus a 12-week educational film intervention on symptoms of restless legs syndrome and related outcomes: an exploratory randomized controlled trial

STUDY OBJECTIVES

To assess the effects of a yoga versus educational film (EF) program on restless legs syndrome (RLS) symptoms and related outcomes in adults with RLS.

METHODS

Forty-one community-dwelling, ambulatory nonpregnant adults with moderate to severe RLS were randomized to a 12-week yoga (n = 19) or EF program (n = 22). In addition to attending classes, all participants completed practice/treatment logs. Yoga group participants were asked to practice at home 30 minutes per day on nonclass days; EF participants were instructed to record any RLS treatments used on their daily logs. Core outcomes assessed pretreatment and posttreatment were RLS symptoms and symptom severity (International RLS Study Group Scale (IRLS) and RLS ordinal scale), sleep quality, mood, perceived stress, and quality of life (QOL).

RESULTS

Thirty adults (13 yoga, 17 EF), aged 24 to 73 (mean = 50.4 ± 2.4 years), completed the 12-week study (78% female, 80.5% white). Post-intervention, both groups showed significant improvement in RLS symptoms and severity, perceived stress, mood, and QOL-mental health (P ≤ .04). Relative to the EF group, yoga participants demonstrated significantly greater reductions in RLS symptoms and symptom severity (P ≤ .01), and greater improvements in perceived stress and mood (P ≤ .04), as well as sleep quality (P = .09); RLS symptoms decreased to minimal/mild in 77% of yoga group participants, with none scoring in the severe range by week 12, versus 24% and 12%, respectively, in EF participants. In the yoga group, IRLS and RLS severity scores declined with increasing minutes of homework practice (r = .7, P = .009 and r = .6, P = .03, respectively), suggesting a possible dose-response relationship.

CONCLUSIONS

Findings of this exploratory RCT suggest that yoga may be effective in reducing RLS symptoms and symptom severity, decreasing perceived stress, and improving mood and sleep in adults with RLS.

CLINICAL TRIAL REGISTRATION

Registry: Clinicaltrials.gov; Title: Yoga vs. Education for Restless Legs: a Feasibility Study; Identifier: NCT03570515; URL: https://clinicaltrials.gov/ct2/show/NCT03570515.

Current Evidence on Diagnostic Criteria, Relevant Outcome Measures, and Efficacy of Nonpharmacologic Therapy in the Management of Restless Legs Syndrome (RLS): A Scoping Review

OBJECTIVE

The aim of this scoping review is to outline the current evidence regarding the management of restless legs syndrome (RLS) with nonpharmacologic approaches. To categorize the efficacy of conservative approaches in reducing symptoms of RLS, we have identified and summarized the current data regarding diagnostic criteria and relevant outcome measures, to inform future research and to guide clinical practice.

METHODS

A scoping review was conducted using the National Center for Biotechnology Information; EBSCO; the Manual, Alternative and Natural Therapy Index System; the Cumulative Index to Nursing & Allied Health Literature; and Scopus. All literature related to RLS was extracted, screened, and reviewed based on titles and abstract contents. The authors then extracted data from the 24 admissible studies, that is, the ones about manual therapy, exercises, and alternative treatments for RLS. The Physiotherapy Evidence Database scale was used to rate the methodological quality of the included randomized controlled trials by 2 independent readers.

RESULTS

In the 24 articles fulfilling the selection criteria, there was a consistent trend in the findings showing positive results in lowering RLS symptom severity. Most clinical studies based their diagnosis on the International Restless Legs Syndrome Study Group diagnostic criteria; the International Restless Legs Syndrome Study Group rating scale was the most often used outcome measure. The efficacy of exercise, yoga, massage, acupuncture, traction straight leg raise, cryotherapy, pneumatic compression devices, whole-body vibration, transcranial and transcutaneous stimulation, and near-infrared lights showed different effects on RLS symptom severity, and the level of evidence was evaluated.

CONCLUSION

Our results showed clinically significant effects for exercises, acupuncture, pneumatic compression devices, and near-infrared light. Short-lasting effects were identified with whole-body cryotherapy, repetitive transcranial stimulation, and transcutaneous stimulation. More studies are necessary to investigate efficacy of yoga, massage, traction straight leg raise, and whole-body vibration. No adverse effects were identified for moderate-intensity exercise, yoga, massage, and pneumatic compression devices.

Pharmacologic and Nonpharmacologic Treatment of Restless Legs Syndrome

This article provides an updated practical guide for the treatment of primary restless legs syndrome (RLS). Articles that appeared after the American Academy of Neurology guideline search were reviewed according to the same evidence rating schedule. We found limited evidence for nonpharmacologic treatment options. In moderate to severe primary RLS, pharmacologic options may be considered, including iron suppletion, an α2δ ligand, a dopamine agonist, a combination of an α2δ ligand and a dopamine agonist, or oxycodone/naloxone. This article includes treatment options in case of augmentation.

Acceptability and feasibility of a 12-week yoga vs. educational film program for the management of restless legs syndrome (RLS): study protocol for a randomized controlled trial

Background

Restless legs syndrome (RLS) is a common and burdensome sleep disorder associated with profound impairment of health, well-being, and quality of life. Unfortunately, the medications used for RLS management carry risk of serious side effects, including augmentation of symptoms. Yoga, an ancient mind-body discipline designed to promote physical, emotional, and mental well-being, may offer a viable, low-risk new treatment. The primary objectives of this pilot, parallel-arm, randomized controlled trial (RCT) are to assess the acceptability and feasibility of a 12-week yoga vs. educational film program for the management of RLS.

Methods

Forty-four adults with confirmed moderate to severe RLS will be recruited and randomized to a 12-week yoga (n = 22) or standardized educational film program (N = 22). Yoga group participants will attend two 75-min Iyengar yoga classes per week for the first 4 weeks, then one 75-min class per week for the remaining 8 weeks, and will complete a 30-min homework routine on non-class days. Educational film group participants will attend one 75-min class per week for 12 weeks and complete a daily RLS treatment log; classes will include information on: RLS management, including sleep hygiene practices; other sleep disorders; and complementary therapies likely to be of interest to those participating in a yoga and sleep education study.

Yoga and treatment logs will be collected weekly. Feasibility outcomes will include recruitment, enrollment, and randomization rates, retention, adherence, and program satisfaction. Program evaluation and yoga-dosing questionnaires will be collected at week 12; data on exploratory outcomes (e.g., RLS symptom severity (IRLS), sleep quality (PSQI), mood (POMS, PSS), and health-related quality of life (SF-36)) will be gathered at baseline and week 12.

Discussion

This study will lay the essential groundwork for a planned larger RCT to determine the efficacy of a yoga program for reducing symptoms and associated burden of RLS. If the findings of the current trial and the subsequent larger RCTs are positive, this study will also help support a new approach to clinical treatment of this challenging disorder, help foster improved understanding of RLS etiology, and ultimately contribute to reducing the individual, societal, and economic burden associated with this condition.

Trial registration

ClinicalTrials.gov, ID: NCT03570515. Retrospectively registered on 1 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3217-7) contains supplementary material, which is available to authorized users.

Pharmacologic and Nonpharmacologic Treatment of Restless Legs Syndrome

This article provides an updated practical guide for the treatment of primary restless legs syndrome (RLS). Articles that appeared after the American Academy of Neurology guideline search were reviewed according to the same evidence rating schedule. We found limited evidence for nonpharmacologic treatment options. In moderate to severe primary RLS, pharmacologic options may be considered, including iron suppletion, an α2δ ligand, a dopamine agonist, a combination of an α2δ ligand and a dopamine agonist, or oxycodone/naloxone. This article includes treatment options in case of augmentation.

Disciplined sleep for healthy living: Role of noradrenaline

Sleep is essential for maintaining normal physiological processes. It has been broadly divided into rapid eye movement sleep (REMS) and non-REMS (NREMS); one spends the least amount of time in REMS. Sleep (both NREMS and REMS) disturbance is associated with most altered states, disorders and pathological conditions. It is affected by factors within the body as well as the environment, which ultimately modulate lifestyle. Noradrenaline (NA) is one of the key molecules whose level increases upon sleep-loss, REMS-loss in particular and it induces several REMS-loss associated effects and symptoms. The locus coeruleus (LC)-NAergic neurons are primarily responsible for providing NA throughout the brain. As those neurons project to and receive inputs from across the brain, they are modulated by lifestyle changes, which include changes within the body as well as in the environment. We have reviewed the literature showing how various inputs from outside and within the body integrate at the LC neuronal level to modulate sleep (NREMS and REMS) and vice versa. We propose that these changes modulate NA levels in the brain, which in turn is responsible for acute as well as chronic psycho-somatic disorders and pathological conditions.

Effects of Yoga on Heart Rate Variability and Depressive Symptoms in Women: A Randomized Controlled Trial

OBJECTIVES

The purpose of the study was to investigate the effects of a 12-week yoga program on heart rate variability (HRV) and depressive symptoms in depressed women.

METHODS

This was a randomized controlled trial. Twenty-six sedentary women scoring ≥14 on the Beck Depression Inventory-II were randomized to either the yoga or the control group. The yoga group completed a 12-week yoga program, which took place twice a week for 60 min per session and consisted of breathing exercises, yoga pose practice, and supine meditation/relaxation. The control group was instructed not to engage in any yoga practice and to maintain their usual level of physical activity during the course of the study. Participants' HRV, depressive symptoms, and perceived stress were assessed at baseline and post-test.

RESULTS

The yoga group had a significant increase in high-frequency HRV and decreases in low-frequency HRV and low frequency/high frequency ratio after the intervention. The yoga group also reported significantly reduced depressive symptoms and perceived stress. No change was found in the control group.

CONCLUSIONS

A 12-week yoga program was effective in increasing parasympathetic tone and reducing depressive symptoms and perceived stress in women with elevated depressive symptoms. Regular yoga practice may be recommended for women to cope with their depressive symptoms and stress and to improve their HRV.

Effects of Meditation versus Music Listening on Perceived Stress, Mood, Sleep, and Quality of Life in Adults with Early Memory Loss: A Pilot Randomized Controlled Trial

BACKGROUND

Older adults with subjective cognitive decline (SCD) are at increased risk not only for Alzheimer's disease, but for poor mental health, impaired sleep, and diminished quality of life (QOL), which in turn, contribute to further cognitive decline, highlighting the need for early intervention.

OBJECTIVE

In this randomized controlled trial, we assessed the effects of two 12-week relaxation programs, Kirtan Kriya Meditation (KK) and music listening (ML), on perceived stress, sleep, mood, and health-related QOL in older adults with SCD.

METHODS

Sixty community-dwelling older adults with SCD were randomized to a KK or ML program and asked to practice 12 minutes daily for 12 weeks, then at their discretion for the following 3 months. At baseline, 12 weeks, and 26 weeks, perceived stress, mood, psychological well-being, sleep quality, and health-related QOL were measured using well-validated instruments.

RESULTS

Fifty-three participants (88%) completed the 6-month study. Participants in both groups showed significant improvement at 12 weeks in psychological well-being and in multiple domains of mood and sleep quality (p's≤0.05). Relative to ML, those assigned to KK showed greater gains in perceived stress, mood, psychological well-being, and QOL-Mental Health (p's≤0.09). Observed gains were sustained or improved at 6 months, with both groups showing marked and significant improvement in all outcomes. Changes were unrelated to treatment expectancies.

CONCLUSIONS

Findings suggest that practice of a simple meditation or ML program may improve stress, mood, well-being, sleep, and QOL in adults with SCD, with benefits sustained at 6 months and gains that were particularly pronounced in the KK group.

Yoga for Adults with Type 2 Diabetes: A Systematic Review of Controlled Trials

A growing body of evidence suggests yogic practices may benefit adults with type 2 diabetes (DM2). In this systematic review, we evaluate available evidence from prospective controlled trials regarding the effects of yoga-based programs on specific health outcomes pertinent to DM2 management. To identify qualifying studies, we searched nine databases and scanned bibliographies of relevant review papers and all identified articles. Controlled trials that did not target adults with diabetes, included only adults with type 1 diabetes, were under two-week duration, or did not include quantitative outcome data were excluded. Study quality was evaluated using the PEDro scale. Thirty-three papers reporting findings from 25 controlled trials (13 nonrandomized, 12 randomized) met our inclusion criteria (N = 2170 participants). Collectively, findings suggest that yogic practices may promote significant improvements in several indices of importance in DM2 management, including glycemic control, lipid levels, and body composition. More limited data suggest that yoga may also lower oxidative stress and blood pressure; enhance pulmonary and autonomic function, mood, sleep, and quality of life; and reduce medication use in adults with DM2. However, given the methodological limitations of existing studies, additional high-quality investigations are required to confirm and further elucidate the potential benefits of yoga programs in populations with DM2.

Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis-Ekbom disease during pregnancy and lactation

Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is common during pregnancy, affecting approximately one in five pregnant women in Western countries. Many report moderate or severe symptoms and negative impact on sleep. There is very little information in the medical literature for practitioners on the management of this condition during pregnancy. Accordingly, a task force was chosen by the International RLS Study Group (IRLSSG) to develop guidelines for the diagnosis and treatment of RLS/WED during pregnancy and lactation. A committee of nine experts in RLS/WED and/or obstetrics developed a set of 12 consensus questions, conducted a literature search, and extensively discussed potential guidelines. Recommendations were approved by the IRLSSG executive committee, reviewed by IRLSSG membership, and approved by the WED Foundation Medical Advisory Board. These guidelines address diagnosis, differential diagnosis, clinical course, and severity assessment of RLS/WED during pregnancy and lactation. Nonpharmacologic approaches, including reassurance, exercise and avoidance of exacerbating factors, are outlined. A rationale for iron supplementation is presented. Medications for RLS/WED are risk/benefit rated for use during pregnancy and lactation. A few are rated "may be considered" when RLS/WED is refractory to more conservative approaches. An algorithm summarizes the recommendations. These guidelines are intended to improve clinical practice and promote further research.

Treatment of restless legs syndrome

Restless legs syndrome (RLS) is a common disorder diagnosed by the clinical characteristics of restlessness in the legs associated often with abnormal sensations that start at rest and are improved by activity, occurring with a diurnal pattern of worsened symptoms at night and improvement in the morning. RLS is the cause of impaired quality of life in those more severely afflicted. Treatment of RLS has undergone considerable change over the last few years. Several classes of medications have demonstrated efficacy, including the dopaminergic agents and the alpha-2-delta ligands. Levodopa was the first dopaminergic agent found to be successful. However, chronic use of levodopa is frequently associated with augmentation that is defined as an earlier occurrence of symptoms frequently associated with worsening severity and sometimes spread to other body areas. The direct dopamine agonists, including ropinirole, pramipexole, and rotigotine patch, are also effective, although side effects, including daytime sleepiness, impulse control disorders, and augmentation, may limit usefulness. The alpha-2-delta ligands, including gabapentin, gabapentin enacarbil, and pregabalin, are effective for RLS without known occurrence of augmentation or impulse control disorders, although sedation and dizziness can occur. Other agents, including the opioids and clonazepam do not have sufficient evidence to recommend them as treatment for RLS, although in an individual patient, they may provide benefit.