How Alison Fixed Her Restless Leg Syndrome With Functional Medicine: A Case Study

Restless Leg Syndrome (RLS) is a condition that involves discomfort and an urge to move the body, often becoming more noticeable during periods of rest.

RLS can occur alone or alongside other neurological and systemic conditions, such as Parkinson's disease, multiple sclerosis, fibromyalgia, diabetic neuropathy, kidney disease, and chronic digestive conditions.  

RLS has been reported to occur between 25-30% of the time in patients with IBS compared to an overall 6% occurrence in the general population. Some theories suggest a link between the chronic malabsorption issues of IBS and chronic iron deficiency, as well as inflammation in the nervous system.

[signup]

CC: Celiac Disease, Restless Leg Syndrome, Fatigue

Alison was a 30-year-old female who came to my office with symptoms of restless legs on and off for the last ten years. It had been significantly interrupting her sleep the last year, and her energy level had become so low that she could not get through the workday without a cup of coffee every other hour. The high intake of coffee had begun aggravating her stomach and Celiac disease symptoms, which had previously been asymptomatic for the last three years.

Alison was diagnosed with Celiac as a young child and was well managed through a gluten-free diet with occasional aggravations when heavy gluten exposure occurred. She followed up yearly with her gastroenterologist however had not had basic lab work performed since her last visit ten months ago, when symptoms were not as prevalent.  

Additional History:

Alison was working as a yoga teacher at the time and described her lifestyle as very relaxed and health focused. Her diet consisted of a gluten-free, dairy-free, whole food, plant-heavy diet with occasional homemade gluten-free treats. For the last three years, she has been following the Blue Zone diet, with her weekly diet intake consisting of 80% plant-based food and 20% animal-based food, consuming occasional fish or chicken. She exercised 4-6 times a week and drank 100 oz of Brita filtered water daily while weighing around 110 pounds.

Initial Lab Work:

Comprehensive Stool Test Results:

• Low Commensal Bacteria: Akkermansia spp., Lactobacillus spp., Collinsella spp., Ruminococcus spp., Bifidobacterium spp.
• Digestive Enzyme production: within normal limits
• Elevated Fecal Secretory IgA: 3,185 mcg/mL (<=2,040 mcg/mL)
• Beta-glucuronidase <DL
• Low SCFA overall ‍

Micronutrient Test Results:

• Mild deficiencies: Vitamin C, B2, B9, B12, Omega 3  
• Strongly deficient: B6, Magnesium

Lab Analysis

Alison's lab work suggests multiple factors that may be contributing to her symptoms:

• Her low iron and ferritin were paired with low MCV and MCH found on her CBC, indicating current and past iron deficiency anemia. This may be contributing to her current fatigue and her ongoing Restless Leg Syndrome.
• There was a low level of beneficial commensal bacteria and a high level of gastrointestinal inflammation. The relationship between the commensal microflora and intestinal lining is important for maintaining the proper integrity of the tissue and the protective mucous membrane lining it. When bacterial microflora levels are low and inflammation is high, digestion and absorption may be affected. This can result in nutrient deficiencies, including iron deficiency, due to the challenging nature of their absorption at the brush border of the gut lining.
• Low commensal bacteria also contribute to low SCFA levels, as microflora consume the fiber and complex carbohydrates in our intestines to produce these short chain fatty acids (SCFA).
• B-glucuronidase is an indicator of metabolic activity among the intestinal microbiota that can be affected by diminished abundance and diversity of the intestinal microbiota. This low level is concerning as B-glucuronidase is involved in the detoxification process that inactivates and detoxifies hormones, neurotransmitters, drugs, mold toxins, and other toxins, potentially leading to an accumulation of toxins.
• The patient's specific B Vitamin deficiencies may further hinder her ability to absorb and convert iron since Vitamin B6, B9, and B12 are important for these mechanisms to occur.
• The patient's other nutrient deficiencies (magnesium and omega-3 fatty acids) may contribute to sleep issues and restless legs.

Interventions

• Supporting gut health was the priority for this initial approach as this was likely a contributing factor to many of the patient's issues. We started a high dose of L glutamine powder, 5g 2x daily (away from food), to support gut lining integrity. Fish oil was also started at 2g daily (liquid form) to support nutrient repletion and help manage gastrointestinal inflammation.
• To support microbiome diversity, a powdered prebiotic supplement consisting of plant-based polyphenols was paired with a spore-based probiotic while instructing her to increase her intake of prebiotic and probiotic foods such as chicory root, acacia, and fermented foods.
• A powdered multivitamin and liquid iron supplement were suggested each 2x per day for nutrient restoration. We also reviewed food sources of iron and the correct nutrient pairing for absorption, such as eating leafy greens with a dressing that included lemon (for Vitamin C) and black pepper (for absorption support).
• A gentle liver cleanse was discussed with a slow increase of a liver-supportive supplement containing milk thistle, burdock root, and chicory root to support liver function and detoxification.
• Diet changes included increasing red meat intake to 1x weekly, decreasing water intake to 70 oz with electrolyte support, taking additional magnesium to replenish her low level, and reducing coffee intake to 2 cups daily.

4 Months Follow Up:

One month into the approach at the initial follow up, Alison needed support sticking with the plan as she had cut down on coffee but was still experiencing restless leg induced sleepless nights and high level of fatigue during the day.

Six weeks into the approach, she began noticing improvement.

Four month follow-up for labs: Allison’s labs were showing improvement, so we reduced iron supplement and multivitamin to 1x daily. At this point in the process, Allison was feeling much better. Her energy had improved, and she had replaced coffee entirely with a chicory root based alternative. Her digestion was back to a stable place, and she slept effectively through the night. She was encouraged to continue with the ongoing diet work for optimal iron and probiotic intake.

Summary

This case is unique in how quickly the patient progressed; however, her dedication to healthy living and adherence to the suggested approach helped her see sustainable results quickly. Her low-level commensal microbiota and gastrointestinal inflammation may have contributed to nutrient malabsorption, including iron, which can be associated with RLS. This demonstrates that when considering approaches for individuals with chronic restless leg syndrome, it may be helpful to consider the role of digestion and nutrient absorption as contributing factors.