Cognitive-behavioral techniques are helpful for retraining healthy sleep patterns, which can occur in people who have developed patterns of sleeplessness from RLS. Such techniques combine sleep hygiene (see Table), relaxation techniques, and changing the habits and thought patterns that might cause wakefulness. Combinations may work best. A 1993 study reported that after only ten weeks, people with insomnia who used sleep restriction therapy, sleep hygiene, and relaxation techniques achieved a 75% reduction in the time taken to fall asleep (an average of 19 minutes). Such behavioral methods are also effective in elderly patients and, in fact, work better than drugs in this population as well as other age groups. If treating underlying problems and establishing proper sleep hygiene do not relieve sleeplessness, the patient may need to experiment with different behavioral approaches.

Sleep Hygiene. The term sleep hygiene is used to describe a holistic approach to sleeping that encompasses many behaviors. Everyone should practice good sleep hygiene to prevent or relieve insomnia, or simply to safeguard sleep, making it more restful and pleasurable (see Table, Sleep Hygiene).

1. Establish a regular time for going to bed and getting up in the morning and stick to it even on weekends and during vacations.

2. Use the bed for sleep and sexual relations only, not for reading, watching television, or working; excessive time in bed seems to fragment sleep.

3. Avoid naps, especially in the evening.

4. Exercise before dinner. A low point in energy occurs a few hours after exercise; sleep will then come more easily. Exercising close to bedtime, however, may increase alertness.

5. Take a hot bath about an hour and a half before bedtime. The body temperature then begins dropping rapidly, which may help sleep after that time. (Taking a bath shortly before bed increases alertness.)

6. Do something relaxing in the half-hour before bedtime. Reading, meditation, and a leisurely walk are all appropriate activities.

7. Keep the bedroom relatively cool and well ventilated.

8. Do not look at the clock. Obsessing over time will just make it more difficult to sleep.

9. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.

10. Avoid fluids just before bedtime so that sleep is not disturbed by the need to urinate.

11. Avoid caffeine in the hours before sleep.

12. Quitting smoking not only brings many health benefits to any smoker, it eliminates the effects of nicotine that contribute to sleep loss.

13. Patients who cannot sleep after 15 or 20 minutes should get up and go into another room, read or do a quiet activity using dim lighting until they are sleepy again. (Don't watch television, which emits too bright a light.)

14. One study showed that sleeping alone is more restful than sleeping with another person. If a person with insomnia is distracted by a sleeping bed partner, moving to the couch for a couple of nights might be useful.

Sleep Restriction Therapy. Sleep restriction therapy is one systematic behavioral method for achieving sleep. After keeping a sleep diary for two weeks, the patient calculates a sleep efficiency number by dividing actual average nightly sleep time by time in bed. (For example, if a patient sleeps five hours out of seven hours in bed, the sleep efficiency percentage is about 71%.) The patient's goal is to be sleeping 85% of the time in bed. To reach this, the patient begins by going to bed fifteen minutes later the first week; if 85% isn't reached by the end of the week, another fifteen minutes is cut from bedtime. The patient must limit time in bed even when tired. Once efficiency reaches 90% or more, the time allowed in bed is increased by 15 minutes per week. Other parts of the program include eating light meals and scheduling dinner four to five hours before bedtime, spending a half hour in the sun each day, and exercising. Sleeping pills should be stopped. People using this treatment have reported lasting improvements after just eight weeks.

In one study comparing those who used sleep restriction therapy and those who used relaxation techniques, the improvement for sleep restriction subjects was approximately twice that of those who used relaxation methods alone.

Relaxation Therapies and Methods. Relaxation may be beneficial for breaking the cycle of self-perpetuating insomnia occurring in some people; the less they sleep the more anxious they become about losing sleep, and the anxiety then keeps them awake. Sometimes a fear of sleeplessness dates back to childhood when parents used various threats to force their children into sleep for which they may not have been ready. Many methods are available, including muscle relaxation techniques, meditation, biofeedback, hypnosis, massage therapy, acupuncture, and guided imagery. No studies have proven one technique to be more effective than others. Infusing the air with the scent of lavender, which has been shown to have a sedative effect in animals, was, in one study, as effective as tranquilizers in helping elderly patients achieve a complete night's sleep. Self-help groups and relaxation practitioners are now found in many towns and cities.

Exercise may be one of the best ways to achieve healthy sleep. A recent study found that people with minor sleep disturbances improved after four months of brisk walking 30 minutes four times a week. Another recent study also reported that sleep improved in a group of elderly people who exercised regularly. Regular, moderate exercise may help prevent RLS (and is, in any case, healthful). Some patients report that either bursts of excessive energy or long sedentary periods worsen symptoms.

Before taking stronger medications, people should try over-the-counter pain relievers, such as acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Advil, Motrin, Rufen), naproxen (Anaprox, Naprosyn, Aleve), and ketoprofen (Orudis KT, Aktron). Some people report that vitamin E (800 to 1200 IU per day) and calcium supplements may help.

People who have folate deficiencies should take supplements of folic acid (the synthetic form of folate). One study indicated that magnesium supplements may help patients with mild or moderate symptoms.

Severe cases of restless leg syndrome are now commonly treated with the drug levodopa (L-dopa), sometimes in combination with carbidopa (Sinemet) or bromocriptine (Parlodel) All of these drugs are ordinarily used for Parkinson's disease and can have severe side effects. One study reported that a combination therapy of regular-release L-dopa plus sustained release L-dopa was effective in improving sleep. About 25% of patients who take Sinemet report a rebound effect, with increased leg movements, not only in the morning as the dose wears off but in late afternoon as well. Using the lowest dose possible can minimize this effect. Pergolide (Permax), another antiparkinsonism drug, may be as effective as Sinemet with fewer side effects, although in one study nausea and nasal congestion were common. The drug seems to be very effective in improving sleep and may also reduce periodic limb movement. Similar drugs being tested include pramipexole (Mirapex), ropinirole (Requip), and tolpicone (Tasmar). To date, pramipexole is the most potent drug yet used for RLS and has resulted in dramatic improvement in symptoms. Pramipexole also appears to have antidepressant properties. The drug is used at much lower doses than when used for Parkinson's disease. Side effects of all these drugs vary but generally include nausea, constipation, headache, rapid heartbeat, and nasal congestion. In rare cases, they can cause hallucinations.

Benzodiazepines or opiates such as codeine, oxycodone, methadone, or propoxyphene have been prescribed for severe cases. Clonazepam (Klonopin), a benzodiazepine commonly used for anxiety, has also been helpful for some patients. One study reported that it may be helpful for children with periodic limb movement and symptoms of attention-deficit hyperactivity disorder. Some patients have reported relief with the use of the opiate fentanyl (Duragesic), used in skin patch form.

The antiseizure drugs, such as gabapentin (Neurontin), valproic acid (Depakene), and carbamazepine (Tegretol), relax blood vessels and are being tested for RLS. Gabapentin, a newer antiseizure drug, is showing particular promise for mild to moderate RLS. All have potentially severe side effects and should be tried only after non-drug methods have failed.

Clonidine (Catapres), a drug used for high blood pressure, is helpful for some patients. The anti-spasm drug baclofen (Lioresal) appears to reduce intensity but not frequency of movements.

Quinine had been used to prevent leg cramping but was banned by the FDA. Studies indicate it had only a slight benefit and some serious, although rare, side effects had been reported, including bleeding problems and heart irregularities. Other, less serious side effects include headaches, vision problems, and rash. Drinking tonic soda (which contains small amounts of quinine) before bedtime may be helpful. Other drugs tried for leg cramps without much success include vitamin E and potassium chloride. Calcium supplements help relieve leg cramps in pregnant women. Experts advise nightly stretching exercises as the best preventive measures for leg cramps. While in bed, loose covers should be used to prevent pointing the toes, which causes calf muscles to contract and cramp. Propping the feet up higher than the torso may help. Once a cramp begins, the patient should straighten the leg, flex the foot up or grab the toes and pull forward.

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