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The readers may be interested to learn about my success in using acupuncture to treat patients with restless legs syndrome and about the reduced responses in patients who have already received dopaminergic drugs.
Restless legs syndrome (RLS) can wreck people's lives by preventing them from sitting down for long to do anything in the afternoons and evenings and disrupting their sleep every night. It is not an insignificant condition, but it is often regarded as something of a Cinderella with many patients not reporting it and many doctors not treating it – often regarding it as minor, trivial or psychological or not realising that treatments are available.
Although there is considerable anecdotal evidence of the benefit of acupuncture in RLS, a Cochrane review in 20081 found only two trials that met their selection criteria and concluded that ‘there is insufficient evidence to support the use of acupuncture for the symptomatic treatment of restless legs syndrome’.
Having practised acupuncture since 1990 (since 1996 with an NHS contract for patients referred), I have noticed a high rate of dramatic improvement in RLS reported by patients. So, I was surprised by the findings of the Cochrane review. as I have had patients report that the only time that they have had any break from as long as 30 years of symptoms is after acupuncture treatment. Even patients' spouses have commented that their own sleep is much better now and they are no longer disturbed.
The treatment I give for RLS is BL57 and LR3 bilaterally, using a Western approach. (Two sets of needles are used: Chinese type and Hwato or Wujiang jia chen, BL57 0.30×40 mm and LR3 0.25×25 mm inserted ¾ of the needle's length). Needles are stimulated with electroacupuncture (AWQ104B or E Electronic Acupuncturescope)to generate a strong sensation controlled by the patient for 20–30 min. Patients have typically had three treatments but some have needed more – where, for example, the benefit has seemed to tail off, subsequent ‘booster’ treatments may be given after one or more years.
Some patients are given drug treatments for RLS, including clonazepam and other benzodiazepines, zopiclone and zolpidem, L-dopa, pergolide and cabergoline, opioids, carbamazepine, gabapentin, baclofen, clonidine and bromocriptine.
Dopaminergic drugs were licensed in the UK for RLS – pramipexole and ropinirole in 2006. I wonder if it is appropriate to use dopaminergic drugs, sometimes from a young age, in people without Parkinsonism. When I discovered that some patients in our practice had been given drug treatment for RLS without trying acupuncture first, I suggested that they be invited to try acupuncture. Six responded to this invitation, suggesting a preference for acupuncture.
More significantly, I gained the impression that the success rate with acupuncture seemed lower for patients previously treated with these dopaminergic drugs. I, therefore, determined to try to quantify the benefit for patients with RLS by means of a retrospective survey.
A search on the practice computer system was performed for patients who had a code both for acupuncture treatment and RLS. The records were checked to ensure that the acupuncture treatment included treatment for RLS and that there was no other current reason making the survey inappropriate. Any history of taking dopaminergic drugs was obtained from their notes.
I wrote to the 24 patients thus identified requesting that they mark their perceived symptom score on a visual analogue scale (with 10 being the worst and 0 the best) when they started acupuncture, after acupuncture, 6 months later and currently.
Nineteen patients replied, with an age range of 31–88 years. Of these, 16 had not received drug treatment for RLS before acupuncture, and three had had either ropinirole or pramipexole. Of the five patients who did not reply, three had previously been treated with ropinirole, pramipexole or co-careldopa. Their mean symptom scores are shown in table 1. Three of the six patients taking dopaminergic drugs reduced or stopped taking these drugs during acupuncture treatment.
These data suggest that acupuncture treatment does indeed help the symptoms of RLS, and support my impression that there was a large reduction in symptom score in both patient groups but a greater reduction (from a higher pre-treatment score to a lower post-treatment score) in those not previously treated with dopaminergic drugs.
Ropinirole and pramipexole have no safety data for the potentially long duration of treatment for which they might be needed in RLS (eg, lifelong from age 31 for one of my patients). Their costs in the UK range from £38.20 to £57.30 for 30 days.2 Therefore, acupuncture appears to be an effective alternative in terms of cost and safety.
The limitations of this study are that it is a retrospective analysis of patients' symptom scoring comparing after treatment with pre-treatment, and relies heavily on patient recall. But the data suggest that it would be worth carrying out controlled trials, ideally one that would meet the selection criteria of the Cochrane review. I plan to do this and would welcome advice from other readers.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
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