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Behavioral Interventions with Sleep Disorders
10 CEUs Behavioral Interventions for Night Terrors and other Sleep Disorders

Section 26
Non-Pharmacological Treatments for Restless Legs Syndrome

Question 26 | Test | Table of Contents | Sleep Disorders CEU Courses
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

The initial approach to a patient who complains of sleeplessness and restless legs syndrome is a non-drug one that aims at improving sleep and eliminating possible causes of RLS. A non-drug approach is particularly an important first step in elderly patients: A physician should first try to treat any underlying medical condition that may be causing restless legs.  If medications may be causing RLS, the physician should try to prescribe alternatives, if possible.  If the cause cannot be determined, it is best to try sleep hygiene and relaxation methods described below. Hot baths or cold compresses may help.  Some patients report that symptoms don't occur if they sleep late in the morning, so, if feasible, changing sleep patterns may be helpful.  This approach provides added benefits, even if drug therapy is later required.

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

Behavioral Approaches for Preventing Insomnia: Prevention of sleeplessness is very much dependent upon the patient's ability to relax and learn the art of sleeping well. A number of behavioral methods are aimed at achieving these goals. Behavioral methods are effective and work better than drugs in all age groups, including elderly patients. Studies have reported that between 70% and 80% of those who are treated with non-drug methods experience improved sleep with an average treatment duration of only five hours over a four-week period. Furthermore, studies report that 75% of those who have been taking drugs are able to stop or reduce their use. Experts currently recommend the following methods in order of effectiveness for patients with chronic primary insomnia. Some may be helpful for patients with sleeplessness due to RLS: Stimulus control (standard treatment, which receives a high degree of physician support). It may also be helpful for some patients with secondary insomnia caused by a medical or psychiatric condition.  Progressive muscle relaxation (studies and physician reports reflect a moderate degree of confidence in its effectiveness). It may also be helpful for some patients with secondary insomnia caused by a medical or psychiatric condition.  Paradoxical intention (studies and physician reports reflect a moderate degree of certainty in its effectiveness).  Biofeedback (studies and physician reports reflect a moderate degree of certainty in its effectiveness).  Sleep restriction (evidence inconclusive on its value). Multicomponent cognitive behavioral therapy (evidence is inconclusive on its value, although a 2001 study reported that it was significantly more effective that progressive muscle relaxation and offered persistent benefits).
Sleep hygiene, imagery training, and cognitive training only (experts unable to recommend these approaches as sole therapy).

Stimulus Control. Stimulus control is now considered the standard treatment for primary chronic insomnia and may be helpful for some patients with secondary insomnia as well. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following: Go to bed only when ready to sleep or for sex.  If unable to sleep within fifteen to twenty minutes, get up and go into another room. (People who find it physically difficult to get out of bed may stay in bed, but they should do something relatively arousing, such as reading.)  Maintain a regular wake-up time no matter how few hours are spent sleeping.  Avoid naps.

Progressive Muscle Relaxation. Progressive muscle relaxation is another effective technique for inducing sleep and may help reduce legs symptoms in some patients. It takes about 10 minutes a day and involves the following: Focus on a specific muscle group (for example the muscle in the right foot). Inhale and tense the muscle group for about eight seconds until the muscles start to shake and there is some mild muscle pain. (Do this gently. It is not intended to cause any severe muscles contraction pain.) Release the muscles quickly and let them become loose and limp. Stay relaxed for 15 seconds and then repeat the same muscle group. Focus on the next muscle group and repeat the sequence. (Typically start with the muscles in one foot and move progressively from each foot and leg up through the abdomen, chest, then to each hand and arm and then to the neck and shoulders and face.)

Paradoxical Intention. Paradoxical intention is a psychological approach that is based on doing the opposite of what one wants or fears and take it to extreme. The first step is to make a plan to take such a paradoxical approach to RLS.
Instead of going through activities leading to sleep, the patient prepares for staying awake and doing something energetic.
In some cases, people may take specific psychological barriers to sleep to an extreme limit. For example, if worry is a factor in RLS, the patient intensifies the worries.

Biofeedback. Biofeedback is also effective but requires being monitored with an electroencephalogram (EEG), a device that measures brain waves. Patients are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily.

Sleep Restriction Therapy. Sleep restriction therapy may be effective, although evidence is inconclusive. In one 2001 study, patients practiced sleep hygiene and sleep restriction. Sleep hygiene was very helpful during the first two months while sleep restriction led to sustained benefits and deeper sleep. The approach is a systematic method for achieving sleep and restricting the time spent in bed. The first step is to calculate a person's sleep efficiency number : Keep a sleep diary for two weeks. Dividing actual average nightly sleep time by hours in bed. The answer, given as a percentage, is the sleep efficiency number. (For example, if a patient sleeps five hours out of seven hours in bed the calculation result is .714 and the sleep efficiency percentage is 71%.) The patient's goal is to achieve a sleep efficiency percentage of between 85% and 90%, which means only 10% to 15% of the time is spent staying awake in bed. (Sleep efficiency in older people may fall somewhere between 75% to 85%.) To achieve this goal, the patient takes the following actions: Begin by going to bed fifteen minutes later than usual the first week.  If 85% sleep efficiency isn't reached by the end of the week, another fifteen minutes is added to staying up until bedtime. The patient must limit time in bed even when tired. (The time in bed should not be reduced below five hours, however.) Once efficiency reaches 90% or more, the time allowed in bed is increased by 15 minutes per week. Other parts of the program include stopping any sleep medications and following good sleep hygiene. 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.

Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts (such as, "I'll never fall asleep"). It also employs actions intended to change behavior. Studies have been mixed on its effectiveness. One reported that it helped people with insomnia, even when it was caused by pain disorders, which are commonly thought to require sleeping medications and be resistant to therapeutic maneuvers.
Sleep Hygiene. The term sleep hygiene is used to describe simple behaviors that may help everyone improve their sleep.
- Leg Disorders (Restless Legs Syndrome and Nocturnal Leg Cramps). Leg Disorders Annual Report (Restless Legs Syndrome, Intermittent Claudication, & Nocturnal Leg Cramps), 2002, p1, 11p

Personal Reflection Exercise #12
The preceding section contained information about non-pharmacological treatments for Restless Legs Syndrome.  Write three case study examples regarding how you might use the content of this section in your practice.

What are six behavioral approaches that may be useful in treating Restless Leg Syndrome? Record the letter of the correct answer the Test.

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