Abstract

The primary focus in treating restless legs syndrome (RLS) is medical interventions. Although the benefits of physical activity are becoming increasingly evident, studies on the impact of exercise in people with both multiple sclerosis (MS) and RLS are limited. In this case report, we explored the effects of aerobic activity on RLS severity and related symptoms in a woman with RLS and MS. The RLS diagnostic criteria guided the diagnosis. Given the extensive impact of RLS symptoms, comprehensive assessment tools were utilized. Over 24 sessions, the patient performed aerobic exercise using a reclined exercise bike under the supervision of a physical therapist. Initially, each session lasted 20 min and consisted of 2-3 min of warm-up, 15 min of activity, and 2-3 min of cool-down. The duration of each session gradually increased to 30 min over 12 weeks. The study findings indicate that aerobic exercise may alleviate RLS severity, enhance sleep quality, reduce daytime sleepiness, improve gait, and enhance the quality of life in people with RLS and MS.

Introduction

Multiple sclerosis (MS) is a chronic inflammatory condition that affects the central nervous system and causes diverse symptoms (1). Restless legs syndrome (RLS) commonly occurs in patients with MS (pwMS), affecting 13.3% and 65.1% of these patients (2). Despite its prevalence, RLS often goes unnoticed during neurological examinations, making its diagnosis and treatment challenging. Although medical interventions are traditionally preferred in the management of RLS, the increasing recognition of the benefits of exercise has prompted studies into the various forms of physical activity for patients with RLS. However, studies on exercise and its impact on RLS in pwMS are limited. In this case report, we aimed to explore the effects of aerobic exercise on RLS severity and related symptoms in a female patient diagnosed with both RLS and MS.

Case Report

A 42-year-old female initially presented to our MS center in 2013 with complaints of weakness. The patient was confirmed to have MS and treated with interferon beta-1b. In 2019, due to treatment inefficacy, fingolimod was discontinued and ocrelizumab was initiated. The severity of RLS symptoms was assessed using the RLS Rating Scale (RLSRS) (3). At the last routine visit, the patient scored 32 out of 40 on the RLS, indicating very severe symptoms despite ongoing medical treatment. Considering the limited efficacy of medical interventions, a collaborative decision was made by the physical therapist and neurologist to incorporate aerobic exercise in the patient’s treatment regimen. With worsening RLS symptoms, even with medical treatment, aerobic exercise training was first introduced in August 2022. The first assessments were performed before initiating the 12-week personalized aerobic exercise program.

Aerobic exercise was chosen as the therapeutic intervention on the basis of a protocol from previous RLS study. The exercise program involved a recumbent exercise bike and was conducted twice a week for 12 weeks under the supervision of a physical therapist. The exercise intensity was gradually increased from 60% to 75%. Each session initially lasted 20 min, consisting of 2-3 min of warm-up, 15 min of exercise, and 2-3 min of cool-down. The duration of each session was gradually increased until each session lasted 30 min at the end of 12 weeks. The patient’s heart rate was monitored using a heart rate sensor (Polar H10). The patient completed all 24 sessions with high motivation and no adverse events.

RLS is diagnosed on the basis of five criteria outlined by the International RLS Working Group in 2014. The patient met all the criteria, and the RLS diagnosis was confirmed on June 29, 2019 (4). Comprehensive assessments were employed to evaluate various aspects affected by RLS symptoms before and after the 12-week aerobic exercise program. The assessments included the RLS severity (RLSRS score) (3), daytime sleeplessness (Epworth Sleepiness Scale) (5), sleep quality (Pittsburgh Sleep Quality Index) (6), walking speed (timed 25-foot walk test) (7), functional mobility (timed up and go test) (8), walking capacity (6-minute walk test) (7), quality of life (Multiple Sclerosis International Quality of Life) (9), and aerobic capacity (estimated VO_2max) (10). The results of these tests are presented in Table 1, and they demonstrate a 25% improvement in RLSRS scores and positive changes in all outcome measures. The patient signed a consent form for the publication of this report and the use their medical data.

Discussion

Managing RLS in pwMS includes diverse non-pharmacological methods such as infrared therapy, compression devices, exercise, and traditional acupuncture. However, the efficacy of these approaches remains debatable due to methodological shortcomings in current research (2). Evidence-based studies are urgently required to develop customized rehabilitation programs for such patients and identify their efficacy and optimal treatment duration. Despite the absence of robust evidence, numerous studies have suggested a potential reduction in RLS severity following aerobic exercise programs (11-13). Thus, we chose to implement aerobic exercises in our patient with both MS and RLS. The outcomes in our study suggest that aerobic exercises may alleviate RLS severity, improve daytime sleepiness and sleep quality, enhance gait, and elevate the quality of life.

Cederberg and Motl (14) explored the feasibility and effectiveness of physical activity modification in enhancing sleep outcomes and reducing RLS severity in pwMS. The 15 pwMS who had developed RLS and were included in the study were further divided into two groups: behavioral intervention (n=8) and control (n=7). The behavioral intervention method consisted of watching videos on a special website and attending 12 synchronous treatment sessions with a behavioral coach for 16 weeks. The participants were given a pedometer and asked to report their weekly step count on the special website. They reported enhancements in RLS severity, time in bed, sleep satisfaction, and sleep duration. They theorized that MS and RLS’s shared pathways could benefit from the exercise-induced increase in dopaminergic signaling (14). The results in our patient support this idea. Our patient demonstrated a reduction in RLS severity and improvement in sleep symptoms and physical functions such as gait and estimated VO_2max. However, this mechanism should externally validated via randomized control trials with large sample sizes.

In conclusion, our case report demonstrates the impact of a 12-week aerobic exercise program on a woman with MS and RLS and highlights it’s potential for enhancing overall health. The results indicate the need to consider RLS symptoms alongside MS symptoms and understand how MS symptoms may affect the assessment and intervention of such patients. The favorable study results suggest the need for thorough randomized controlled trials on aerobic exercise in pwMS and RLS, which could offer valuable insights and validate its benefits. Although this case report demonstrates that aerobic exercise can improve RLS symptoms, the findings cannot be generalized to pwMS or other neurological conditions.