Sent: Tuesday, December 07, 2004 5:34 AM
Subject: RE: Combining Mirapex and Neurontin
Don't laugh too hard but the answer is much similar than that. The answer is
that my legs would normally start getting jumpy around 5:30 - 6:00PM, except
that I'm usually working outside. And, as long as I'm moving my legs, they
don't get jumpy. Well, since the time change and weather change, I'm now
inside sitting down at 5:30 - 6:00, so my legs would start getting restless at
that time whether I took my medicine at 5:30 - 6:00, or if I didn't.
As you are aware, none of the medicines kick in right away, so if I take any
of it at 5:00 and sit down, my legs will start jerking, until the medicine has
kicked in, which for Mirapex is about an hour and half. And, for Neurontin
it's longer. So, it appears as if the Mirapex is causing the jerky, but in
reality, it's the lack of Mirapex for that time of the day, that's causing the
jerky legs.
So, what I probably need to do is to take 0.5mg of Mirapex right as I leave
work, around 4:00 and take the other 0.5mg at 5:30. Then, the Mirapex I took
at 4:00 should kick in around 5:30 and prevent my legs from kicking, until the
other 0.5 mg kicks in. In any case, my neurologist finally gave me a call and
he says there's some newer RLS drugs he'd like for me to try. At least, I know
that Mirapex works pretty good for me, once it gets going. Thanks for worrying
about me.
Rich
Sent: Wednesday, December 08, 2004 4:34 AM
Subject: Problems with Neurontin?
I am a 41 year old female recently diagnosed with RLS, PLMD and PLMW. All
of my symptoms started very suddenly last March. I tried Mirapex with poor
results. Initially I had some relief, but it was short lived, and as I
increased my dosage the PLMD and PLMW got much worse. I am now taking
Neurontin 300 mg before bed and it works unbelievably well. Nary a twitch or
jerk in sight. I am experiencing some dizziness, so I am
sort of concerned
about taking it during the day and at this point have opted to twitch and
try and deal with the sensations in my hands and legs.
I have only been taking the Neurontin for about 1
week, does the dizziness pass in time? Are their any long term issues
with taking Neurontin?
Elaine
Medical Reply
There do not appear to be any long term issues with taking
Neurontin. Often, the initial symptoms of dizziness and sleepiness tend to
diminish with time.
Sent: Thursday, December 09, 2004 8:23 PM
Subject: Mirapex side effects?
I discovered your website during one of my all-nighters in front of the
computer looking for anything that could help me find a cure or at least
relief from my RLS. I recently got a prescription for Mirapex and Ambien, I
find the Mirapex makes me drowsy which is a good thing, but I seem to be
having an allergic reaction, mostly itching.
My initial RLS problem was greatly intensified when I
began taking Allegra 2.5 years ago, but when I don't take antihistamines I
have insane itch attacks that nearly drive me to the brink of suicide.
I have finally discovered some of the things I'm allergic to and have found
some relief from that problem by avoiding the things that trigger my
allergies, but I still have RLS.
The last 2 days I have noticed my muscles feel so sore
and stiff, and occasionally I have pain shooting up my legs, I never had this
before taking Mirapex, could this be a side effect? I don't like taking
medication for anything and only do so when there is no other option.....I
tend to be very sensitive to many kinds of medicines, the one constant thing
seems to be RLS even with taking Tylenol. I am at my wits end.
Anything you can suggest would be greatly appreciated.
Thank you.
Barbara M.
Medical Reply
It is certainly possible that Mirapex could be causing your
leg pains however, it would be more likely for Mirapex to cause this soon
after taking rather than later. It could be that you are developing the
neuropathy pain that affect some RLS patients.
Allegra and all antihistamines can worsen RLS as you have
already found out. You may want to try Requip instead of Mirapex as they are
very similar but may have different side effects. Another choice would be
Neurontin which can help RLS and neuropathic pain.
Sent: Tuesday, November 30, 2004 4:50 PM
Subject: Sublingual Mirapex
Is it possible to absorb Mirapex under the tongue?
If I forget to take my Mirapex on time I let it dissolve in my mouth.
Seems logical....Mary Lou
Medical Reply
Mirapex is not formulated to work by dissolving under
the tongue so this method of taking it will not be helpful.
I
Sent: Thursday, December 16, 2004 10:55 AM
Subject: RLS and Insomnia?
Has anyone ever mentioned that their RLS
symptoms get worse around the time that their period is supposed to
start? I just turned 47 and have had problems with RLS off and on for
years. I started working midnights and sometimes the RLS would start at
about 4:00- 5:00 am, but would not occur every morning/night.
After awhile,
I started documenting when the RLS was worse and it was always within a week
before and week after my period. It was almost unbearable. I feel like a
zombie because I cant sleep. My bedroom has become the living room because I
twist and turn all night keeping my husband up.
My doctor put me on Sinemet and after I complained about the RLS being worse around my period he
raised the dose to 25-100. I have read that Sinemet has a lot of side
effects, including insomnia. any suggestions on what else I can take for
the RLS and insomnia?
Medical Reply
It is well known that female hormones influence RLS with
many patients worsening around the time of their menses.
Sinemet works well at first for RLS but can cause worsening
of RLS symptoms after a while (in most patients). Mirapex or Requip are much
better choices for your RLS symptoms and Ambien (if you still need something
for sleep once RLS symptoms are gone) would be reasonable for sleep.
Sent: Tuesday, November 23, 2004 7:42 AM
Subject: Need some feedback
Originally a sleep study doctor (had
trouble sleeping) put me on Clonazepam .5 mg He took me up to 2.5 which was really a
drugged state for me. Another sleep doctor said to go off that
(fun) and put me on Mirapex 2 a night of .25 mg
Did not help RLS and leg pains so current
general Practitioner put me back on Clonazepam. which I take 1 mg at night
along with the Mirapex. Does not seem to help much and sleep is
getting worse. plus very tired and feeling drugged when I
get up in the morning.
Have a new
doctor who says he has no experience with Mirapex and has no idea if there
is an interaction but says to give it a try. been on both now for 2
months and sleep not great and no help with RLS. Comments? Is there
interaction? Should I be talking both? Up level of one and eliminate the
other?
I need
medication for RLS and something to assist sleep as I can't sleep
without the Clonazepam and then not great if the RLS kicks in before I get
to sleep.
Appreciate your comments as you obviously
have a lot of experience in this after reviewing the web site,
Kingsley B.
Toronto, Canada
Medical Reply
Mirapex helps most but not all RLS patients. You might
need a higher dose and can discuss increasing the dose slowly to about 1 mg.
If there is no improvement at that dose then there is no reason to take the
drug. It might be worthwhile to try Requip which is similar to Mirapex but
may work when Mirapex does not help. Make sure that you take either of these
medications at least 1-2 hours before bedtime to give them adequate time to
kick in. There are no interactions between Mirapex and clonazepam.
Clonazepam has a very long half-life and very often causes
daytime sleepiness as a side effect. Shorter acting sleeping pills such as
Halcion are even better. Here in the USA, Ambien is currently the best
sleeping pill but is not available in Canada. Imovane is somewhat similar and
would probably be a better choice than the benzodiazepines (clonazepam or
Halcion).
A pain killer, such as a narcotic or tramadol before
bedtime may also be very helpful and help resolve your RLS symptoms and let
you sleep.
Sent: Friday, December 17, 2004 1:58 PM
Subject: Dopa Bean supplement
Your website is so helpful for RLS patients; thanks very much for the all
the information.
I am wondering whether you've heard of anyone successfully using a OTC
supplement made from Macuna Pruriens (the one I'm looking at lists the
ingredient as
catecholamines 66 mg 20%, L-dopa 50
mg 15%, Velvet Bean (mucuna pruriens) (seed extract) 333 mg ) to treat
mild-to-moderate RLS. I am one of those women who mostly has trouble with
RLS in the week before my period.
It seems to have gotten a bit worse in the
last few years (it's now in my hands as well) and my doctor had me start on
Wellbutrin, but then I developed a high blood pressure problem and to make
sure it wasn't the Wellbutrin (it wasn't), she took me off it and I haven't
gone back on it. It would be nice to avoid having to try it again or to have
to go to the more serious Parkinson's drugs, so I was thinking of giving
this OTC product a shot.
MJD
Medical Reply
I know nothing about this OTC product except for what you
have written. If it contains L-dopa then it may have some benefit for RLS but
then this would be no different than taking a Parkinson's disease drug (as
L-dopa is the original Parkinson's disease drug).
A Reply from MJD
Sent: Monday, December 20, 2004 12:00 AM
Subject: Re: Dopa Bean supplement
Thanks, that makes sense. It might be even worse than taking Mirapex
or Requip since RLS patients seem to take these drugs only when they know
they are going to have trouble, but with this supplement you would take it
twice a day every day.
On another front, I've never had my ferritin level tested and am going to
ask my PCP to do a draw and am wondering if it makes sense to try to
schedule the draw to happen sometime in the week before my period when I am
experiencing the symptoms the most or would that not matter?
MJD
Medical Reply
It makes no difference when you have your blood taken for
your ferritin levels as they change slowly and reflect iron stores.
Mirapex and Requip also have to be taken on a regular basis
before symptoms occur. They do not work well after symptoms are present.
Sent: Monday, December 20, 2004 3:40 PM
Subject: Ultram effectiveness
I take pain meds for severe RLS. I've taken
100mg Ultram in the morning and 100mg in the afternoon. I've taken it for 7
years now. The past year is the first that I started taking drug holidays
using Vicodin. (I only take Mirapex and Neurontin at night because they
knock me out. ). Lately I've noticed that the Ultram is not working as well
as it used to.
I'm afraid its starting to loose its effectiveness. I've
tried Klonopin and it doesn't do anything for me. What could you suggest for
me?
Thank you,
Mary.
Medical Reply
You may want to switch off Ultram. Vicodin is a reasonable
choice although methadone (if you can get your doctor to prescribe it) works
better and has no acetaminophen (Tylenol) in it.
A Reply from Mary
Sent: Tuesday, December 21, 2004 3:13 AM
Subject: Re: Ultram effectiveness
How long could I take methadone or Vicodin without
risking addiction. Or would it work to alternate the 2 drugs?
Thank you,
Mary
Medical Reply
There is no known time limit to developing addiction or
not. I do have many patients who alternate Ultram and the narcotics but
alternating narcotics (methadone and Vicodin) would be of no benefit.
Sent: Tuesday, December 21, 2004 7:56 PM
Subject: Requip and possible weight gain?
I was placed on Requip about 2 months ago. Since then I have gained 15
pounds. Is this possibly a side affect of the Requip? I am 37 years old
and 66 inches tall and have always maintained my wt. at 120 -
125 lbs. I have not weighed 140 since I was 20
weeks pregnant with twins which was 12 yrs. ago. The only other change that
took place is that he also lowered my Wellbutrin from 300 mg to 150 mg.
Please, what are your thoughts?
Thanks,
Mother of 12 year old twins
Medical Reply
I could find no reference to weight gain with Requip. It
is certainly possible that the drug could be causing this problem but it has
not yet been reported nor have I seen this in my patients on Requip.
Sent: Sunday, December 26, 2004 8:08 AM
Subject: Pain with RLS?
I am a 55 year old female. I usually don't take part in e-mailing strangers
or chat rooms, but I am at my wits end. It is a possibility that I have
RLS, my doctor and I are still investigating. However, for the past 3 days
I have been taking 300mg. before bed of Neurontin. It has helped in a minor
way. I understand it has to "get into my system".
In the readings that I have been doing over the past few days, I have a
basic understanding of RLS, however, I don't often hear about people who
have RLS who are in serious pain. I feel so much pain in my legs - yes they
are restless, but the pain is worst than that. I even feel it in my hips.
I do have a scoliosis and have recently had back x-rays taken.
Any input on the pain part?
Thanks,
J.C.
Medical Reply
About 15-20% of RLS sufferers have pain. This is likely
from an associated neuropathy and is not well understood.
Neurontin often helps this painful neuropathy but higher
doses are usually needed (600-1200 mg per dose and up to 3 times per day). It
does not have to get into your system as it works right away but we do
increase the dose slowly in order to let your body get used to the drug (which
may help prevent side effects).
Sent: Sunday, December 26, 2004 8:59 AM
Subject: RLS with sleep?
I have had RLS for as long as I can remember. I
was once on Lithium and it went away and so did the ringing in my head which
I still have today and choose to live with. The only way I can escape RLS
is to sleep, which seem contrary to everyone else.
Thanks,
Fred H.
Medical Reply
Actually falling asleep is a common way to relieve RLS. It
is very similar to back pain. If you can fall asleep despite the back pain,
then the pain is gone once you are asleep (of course since you do not perceive
these sensations while asleep). Unlike back pain which can occur 24 hours per
day, most RLS sufferers have the symptoms only at night so by morning time
they are gone.
Sent: Sunday, December 26, 2004 12:05 PM
Subject: Mirapex and Seroquel?
I have PLMD, and Severe anxiety. I am considering starting
Seroquel. I am wondering how this might interact if I took it with Mirapex.
I am also not currently taking my Mirapex, because the doctor wants me to
take 1mg a night, and it severely disturbs my sleep.
Any thoughts?
Thanks,
Jamie
Medical Reply
There is only one case report where Seroquel may have
helped RLS but we do not know too much about this drug and RLS although this
drug does antagonize dopamine so it should worsen RLS. They only way to tell
would be trial and error.
The only interaction between the drugs is that Seroquel can
diminish the effectiveness of Mirapex as it antagonizes the dopamine effects
of Mirapex.
If you need a full one mg of Mirapex and it disturbs your
sleep then you should not take it (maybe Requip may work better). If you can
relieve your RLS symptoms with a lower dose that does not affect your sleep
then that may be another option.
A Reply from Jamie
Sent: Saturday, January 01, 2005 9:25 PM
Subject: Re: Mirapex and Seroquel?
I have been using .25 of Mirapex the last couple
nights, and it has been working well. As far as I can tell. I think I will
give it a few weeks, and move up to .5. As for the Seroquel, I am going to try some
alternatives before I go as far as taking Seroquel.
Thanks,
Jamie
Medical Reply
You can try an even lower dose of Mirapex (.125 mg). It is
always best to take the lowest dose that works. Wellbutrin is currently the best drug for RLS patients with
anxiety as it may even help RLS symptoms in addition to anxiety.
Sent: Sunday, December 26, 2004 5:19 PM
Subject: Ambien addiction?
I have been using ambient
for approximately 3 months with essentially no drug holidays. What do you recommend that
I do to avoid ambien addiction? At this point, will taking
a drug holiday every 2 weeks help?
Do you recommend any other
non-addictive medications to try? I have tried all over the
counter medications such as Benadryl, valerian
root,
and kava
kava with no success.
Thanks for your help,
Shelly
Medical Reply
Ambien is not an addictive drug. I still suggest drug
holidays just to be extra careful. You may have to consider going without anything for about 2
days every few months (if you can).
Sent: Monday, December 27, 2004 10:45 PM
Subject: Drug holidays?
I am a 49 year old female who was diagnosed with
RLS 7 years ago. I've tried various drugs including
amitriptyline, Ultram,
benzodiazepines, Permax, Sinemet, Neurontin, Mirapex and Requip to name
most.
The only drug that truly worked for me was
Mirapex, I started at a low .125 mg twice a day but over the past 6 years
have had to increase that to a total of 1.5 mg per day. I'm increasingly
experiencing bouts of RLS that last for a week to a month that I get no
relief from, not even from Mirapex. I've tried drug holidays, but NOTHING
comes close to Mirapex and now even that seems to be wearing out on me.
I've tried going back to drugs that have worked somewhat satisfactorily for
me in the past, but they don't work at all anymore. Requip is the only one
that comes close, but it doesn't work at night. Also, the symptoms have
moved into my arms and shoulders and NOTHING stops that. I've read that
pain meds can help RLS in arms (Vicodin or Darvocet). I've never
experienced pain with my RLS, just this terrible electricity in my
limbs.
How high a dose can I go with Mirapex? Do I raise the dosage each
time I have one of my 'bad episodes'? I'm afraid someday I'll have tried
every drug out there available for RLS!
Brenda
Medical Reply
My suggestion would be to try the pain medications. They
usually help RLS symptoms with or without pain. This may let you get off (or
reduce the dose) Mirapex for a while and see if it will work again at a lower
dose (perhaps in combination with a pain killer).
Sent: Tuesday, December 28, 2004 11:46 AM
Subject: Medical advice for worsening RLS on Sinemet?
I have been reading material provide on the RLS web site. I've read
many of the e-mails sent to you for advise and feel what I'm presently doing
is incorrect and need advise on what I should be doing.
I was diagnosed
with RLS about three years ago and have been taking Sinemet in increasing
dosage since then. My symptoms are becoming increasing more intense
and at this stage I cannot relax during the day at all. In the
evening, before daylight savings I would taking my medication about 8pm,
then approximately every 3 to 4 hours until early morning. I now have
started taking medication about 4pm then every 3 to 4 hours. Long
trips or enjoying the holidays with my family is becoming increasingly
difficult.
Your help and advise is greatly appreciated.
Thanks,
Chuck G.
Medical Reply
Your problem is extremely common when treating RLS with
Sinemet. You are getting worsening or RLS from Sinemet (called
augmentation). You need to speak to your doctor about switching from Sinemet
to Requip or Mirapex and that should solve your problem.
Sent: Sunday, January 02, 2005 1:16 PM
Subject: RLS worsened with an epidural?
I have been an RLS sufferer for many years. I
believe it became worse after I had an epidural before my oldest child's
birth. I experienced temporary paralysis after delivery and I believe it
has made my RLS worse. My regular doctors tried antidepressants for several
years until I finally went to a neurologist.
The first neurologist I went to put me on Permax and
Klonopin. Since then, my new neurologist has put me on Requip (because
Permax is believed to cause complications with the heart). I started off
with taking two 0.5 mg tablets at night, but he has increased it recently to
three 0.25 mg tablets at night. I'm also taking 1/4 of a 2 mg tablet
of Klonopin in addition to the Requip.
The problem is, I've experienced severe depression since
this increase. I would like to get off of the Klonopin because I feel
that I need to increase the dose on some nights. I feel sleepy during
the day and never feel I get enough sleep at night. Is it the Klonopin or
the Requip causing the depression? Also, do you think the
complications resulting from the epidural during my first pregnancy could
have been the onset of RLS?
Thanks,
C. Wood
Medical Reply
It is difficult to say whether or not the epidural had
anything to with worsening your RLS but I suspect that it may have more to do
with your pregnancy (which tends to worsen RLS).
Klonopin is known to cause daytime sedation as it has a
very long half-life. It is also an addictive drug. It might be better to
discontinue this drug (talk with your doctor about slowly weaning off the
drug) and rather increase the dose of Requip (you are still on a relatively
low dose). Benzodiazepines like Klonopin are also known to increase
depression.
Sent: Sunday, January 02, 2005 10:51 PM
Subject: Extreme dry eyes with Mirapex?
I have
been on Mirapex 1.25 mg (4) years and Ativan 2mg (20) years. for RLS. After
being on the Mirapex about one year I developed severe dry eyes and to help
keep any moisture in my eyes at all they had to cauterize shut all 4 tear
ducts. I use ointment in my eyes at night and since then it has been OK.
Last summer I had another sleep study that showed I basically have refractory
RLS with associated pathologic daytime sleepiness. My Mirapex was increased
to 1.50mg and a change in job allows me to achieve more sleep so I have been
feeling better than I had in years.
About 2 weeks ago, I again started to experience the "sandpaper" in the eye
feeling. It is very intense and almost unbearable. My question is what
alternatives if any for medication could I try. My system is really sensitive
to meds. We already tried Requip last summer for a drug holiday from the
Mirapex. It gave me migraine headaches and had to be stopped.
The side effects from the Mirapex have been numerous and yet I am not sure
what else to even try at this point. I have heard you mention Ultram. Could
that be used with the Ativan and decreasing the Mirapex way down? At this
point stopping the Ativan really is not a choice. I was put on it 20 years
ago and did slowly wean myself down off it over a months time and managed a
(3) day drug holiday. The physical effects were horrible and I was almost at
seizure level when it was restarted. I am also on synthroid and Lithium.
Since RLS is worsened by Lithium I was tried on other medications for that
also but again my chemical makeup caused them all to have severe side effects
that required me to return and stay on the Lithium.
You have helped me much with your answers in the past and I am hoping you may
have some suggestions for me now.
Sincerely,
KM
Medical Reply
Ultram, possibly alternating with a narcotic pain killer
(like Vicodin) may be very helpful to eliminate Mirapex. In addition (or
instead), Neurontin can be used and should be helpful.
Sent: Tuesday, January 04, 2005 10:55 AM
Subject: Mirapex not helping?
I have taken Mirapex for a year and a half. It has been a
life saver for me, up to now. My present dosage is Mirapex 0.25MG
,half pill at noon ,half pill at supper and one hole pill at bed time. In
the last three weeks my RLS has returned with a vengeance. Would you suggest
changing to Requip or increasing my dosage of Mirapex? I also take half pill
of oxazepam 30MG at bedtime.
I would appreciate your help
Thank You
Jackie
Medical Reply
Generally I would increase the Mirapex (slowly) and if that
does not help (once a significantly higher dose is reached) or worsens the
problem then a change to Requip may be helpful.
Sent: Tuesday, January 04, 2005 5:01 PM
Subject: Time to take Requip?
I take .50 mg of Requip at night for PLMD. I also take .50 mg of Xanax for
insomnia. How far in advance of bedtime should I take the Requip? Would it
be beneficial to take the Requip and Xanax at the same time?
Thanks.
TJS
Medical Reply
It takes Requip about 1-2 hours to be effective for RLS.
Therefore, it is best to take this drug about 1-2 hours before bed (most RLS
sufferers can tell how long it takes for the drug to work for them). The
Xanax usually becomes effective in about 15-30 minutes so that is the interval
before bedtime that it should be taken.
Sent: Saturday, January 08, 2005 2:31 PM
Subject: Worsening of PLMD
I have the following conditions:
Depression – currently treated with
Wellbutrin XL 150 mg and Prozac 10 mg.
Sleep apnea – currently treated with CPAP.
PLMD – currently treated with .50 mg Requip at bedtime.
Insomnia/Anxiety – currently treated with .50 mg Xanax at bedtime
During the initial sleep study from which the diagnosis of PLMD was made
I had a PLMD index of 37.7. I was initially treated with Mirapex and then
switched to .25 mg of Requip. A second sleep study (related to the sleep
apnea treatment) showed my PLMD index at 18. A third sleep study (for CPAP
titration) showed my PLMD index dropped to 11.2 at .50 mg of Requip.
Within the past month I have begun to experience periodic RLS symptoms
during the evening hours and at bedtime. My wife also reports a significant
increase in leg movements during my sleep.
These symptoms roughly coincide with a decrease in my
dosage of Wellbutrin XL from 300 mg to 150 mg. I am wondering if this change
in the dose of Wellbutrin could have caused the increase in RLS/PLMD
symptoms or if my disorder has worsened necessitating an increase in Requip
and/or the utilization of another medication.
Thomas J. S.
Medical Reply
First of all, the only important PLM finding on sleep
studies is the PLMAI - that is the PLM arousal index. PLM's that do not
cause arousals are not treated and have virtually no medical significance.
So, it is important to know whether or not your PLMD (wrong terminology as
that stands for PLM Disorder) index is a PLM Index or PLM Arousal Index.
Wellbutrin does have dopamine like properties (just like
Requip) so lowering it may worsen RLS or PLMS (PLM's during Sleep).
Medical A Reply from Thomas J. S.
Sent: Sunday, January 09, 2005 8:01 AM
Subject: Re: worsening of PLMD
Thanks for the clarification. This makes me look a
lot differently at my
treatment. On my initial sleep study the PLMAI was 0.6, on the second and
third it was 0. Is an index of 0.6 typically significant enough for
treatment? Even that is the case , it would appear the Requip at .25 mg
eliminated PLM's that caused arousals. If the Requip dosage is lowered or
eliminated does the potential exist for the PLM symptoms to became worse
than they were before treatment?
I would appreciate any additional comments you may have. I will raise this
issue with my doctor.
Medical Reply
Here is the severity information from our website:
The severity of PLMD is measured by the amount of leg
jerks per hour (PLMD index, mild = 5-24/hour, moderate = 25-49/hour, severe =
more than 50/hour).
As a PLMAI of .6 is subclinical and within normal limits,
it does not appear that you have any need for Requip. You should discuss this
with your doctor.
Sent: Sunday, January 09, 2005 3:21 AM
Subject: Arms and legs jerking in bed?
i have recently started sleeping with my girlfriend, but just recently she
has complained, with good reason that during the night i 'kick out' and it
is hurting her.
I am a 27 year old man of good health. During the day i am extremely calm
and caring towards everyone-especially those that i care for. I am rarely
stressed and can not remember the last time i had nightmares.
My girlfriend says that during the night, i will all of sudden either kick
out or swing my arm in her direction. Last night i caught her in the face
and also in the back causing her much pain. Neither of us wish to sleep
together at the moment until this has been resolved.
Bert
Medical Reply
You may be having PLMS (Periodic Limb Movement Disorder). This
can cause your arms or legs to kick or jerk but if it is not causing arousals
(sleep stage changes from deeper to lighter sleep which you would not notice
as you do not wake up from these jerks) resulting in daytime sleepiness on
your part, then we do not treat them.
A sleep study (only if necessary to decide on treating daytime
sleepiness) would confirm this diagnosis. If you do not have any daytime
sleepiness then the only treatment necessary is to get twin beds and separate
them by a few inches when you actually go to sleep with your bed partner.
Sent: Monday, January 10, 2005 9:58 PM
Subject: Restless leg syndrome and ferritin levels?
After 15 years of being awake and 8 doctors I
finally found one who said my iron level should be between 20 and 200 to be
normal. Mine was 26. He said that was to low. He says if a person's was
below between 50 and 75 he conceded that low in a person with RLS. So he
had me take Nu-Iron . I had a hard time finding them but he insisted on
Nu-Iron only. Well after 6 months no restless legs. I did have my liver
checked and all is well.
E R
Medical Reply
Usually we try to get the ferritin level as close to 45 as
we can. It is usually quite difficult to do that with oral iron supplements
and not everyone who is able to raise their serum ferritin to 45 or higher
will benefit from doing so.
Any iron supplement that is tolerated and brings the
ferritin level up is fine.
Sent: Tuesday, January 11, 2005 9:45 PM
Subject: Would like feedback on condition
I don't have the typical RLS symptoms of
having creepy crawling sensations in my legs. I have no problem going to
sleep, but as soon as I go to sleep my legs will jerk and move
periodically. A sleep study measured PLM at 90/hour with frequent
arousals from sleep. I usually wake during the night and have varying
degrees of success in falling back asleep. I don't remember my leg
movements even though I am told that within seconds of falling my right
leg will typically jerk.
I recently had a blood test where ferritin was
measured at 21 NG/ML with the normal level being from 20 to 380. Doctor
said this was good. My question is this really a good level?
I am in good health, except for sleeping.
Doctor gave me Sinemet but it did not help.
Any comments.
Jim
Medical Reply
For RLS and PLMS (leg jerks during sleep) a serum ferritin
level of about 45 is much better (despite what the normal levels are in your
lab - that is for non-RLS patients). Getting the serum ferritin level up
(often hard to do) will often help the RLS/PLMS symptoms.
Mirapex or Requip are much better choices than Sinemet for
RLS or PLMS.
Sent: Wednesday, January 12, 2005 11:04 AM
Subject: Mirapex side effects
I have found your site to be very informative and you
have been most helpful in answering my previous questions. I also
can't tell you how fortunate it is to have finally found relief from RLS by
taking Mirapex. I have been on Mirapex for about a year.
While I suffer various side effects from the medication, I believe the cure
is worth the aggravation.
But I still have concerns with one side effect, even
though I am taking an extremely low dose. I take .25 mg about two hours
before bed time, but invariably I will get this most uncomfortable feeling
in my chest each night as I lie down to sleep. It goes away after
about ten minutes but it is somewhat frightening.
The best way to describe it is that I think my heart
begins to race and/or I have a sort of panic attack. That may not even
be the best description of how I feel...I just know that it is a most
unusual and scary feeling. I guess it doesn't help to hear all this
news about these other drugs that are said to be safe and all of a sudden
the FDA issues warnings saying the drugs can be harmful to your heart.
Am I worried about nothing or should I consider
asking my doctor to change me to another medication?
JD
Medical Reply
It is impossible to say whether or not your symptoms from
Mirapex are benign or medically dangerous as they are somewhat unusual.
It might be worth a change to Requip which is a similar dopamine agonist but
has a different side effect profile
Sent: Wednesday, January 12, 2005 9:43 PM
Subject: Found something that made my Restless Legs disappear
I have just discovered a miracle drug for my RLS. I have had RLS for 40
years, with it being severe for the last 10 years. I take Mirapex (3 years),
have previously taken Permax ( 4 years) and also have tried everything
including iron, magnesium, calcium, B12, acupuncture, avoiding wheat and
sugar, etc. I also have been under the study and care of Drs. Early and Allen
of Johns Hopkins. Mirapex allows me to sleep most nights, but I still go
through much pain getting to sleep, pace on airplanes, and dread for night to
come.
In December I had bronchitis, a sinus infection, and a severe cough. My Dr.
prescribed 4 medications. While on them my RLS disappeared. I flew from VA
to Hawaii and sat peacefully all the way and even went one night without
taking my Mirapex. I was sleeping like a baby. Immediately when the
medications were over, the RLS came back.
I went back to my doctor and asked him
to work with me to prescribe each for a week to see which one helped the RLS.
The miracle drug turned out to be Profen Forte which is made of 90mg of
Pseudoephedrine (a decongestant) and 800 mg of Guaifenesin (an expectorant) .
I have a Physicians Desk Reference (PDR) and the ingredients in Profen Forte
(prescription) are the same as in Sudafed non-drying sinus liquid caps (non-prescription) except 1 Profen is 3 times the strength of 1 Sudafed.
I
have not tried using Sudafed to see if it has the same results. I take two
800mg capsules of Profen Forte a day. The RLS went away within a day of
starting the Profen and has remained gone for 10 days now. I notice no side
effects. I am still taking my Mirapex.
I have no explanation for the result but I am praising the Lord. I am feeling
wonderful with a peace in my legs that I had totally forgotten could exist. I
went to a movie tonight and sat through it without standing up in back for the
first time in at least 20 years. I pass it on hoping it will work for you too
and hoping the doctors can experiment with this to discover a cure for RLS.
Terry C.
Medical Reply
I have absolutely no explanation as to why the Profen Forte
has helped you. The two ingredients should have no positive effects on RLS.
Guaifenesin is a mucous thinner that has no effects (good or bad) on RLS.
Sudafed (pseudoephedrine) sometimes worsens RLS so that is even more difficult
to explain.
It is not uncommon for RLS patients to get better or worse
with drugs that should do the opposite. There is much more that we cannot
explain (than is understood) with RLS.
Sent: Wednesday, January 12, 2005 11:04 AM
Subject: Mirapex side effects
I have found your site to be very informative and you
have been most helpful in answering my previous questions. I also
can't tell you how fortunate it is to have finally found relief from RLS by
taking Mirapex. I have been on Mirapex for about a year.
While I suffer various side effects from the medication, I believe the cure
is worth the aggravation.
But I still have concerns with one side effect, even
though I am taking an extremely low dose. I take .25 mg about two hours
before bed time, but invariably I will get this most uncomfortable feeling
in my chest each night as I lie down to sleep. It goes away after
about ten minutes but it is somewhat frightening. The best way to
describe it is that I think my heart begins to race and/or I have a sort of
panic attack. That may not even be the best description of how I
feel...I just know that it is a most unusual and scary feeling.
I guess it doesn't help to hear all this news about these
other drugs that are said to be safe and all of a sudden the FDA issues
warnings saying the drugs can be harmful to your heart. Am I worried
about nothing or should I consider asking my doctor to change me to another
medication?
JD
Medical Reply
It is impossible to say whether or not your symptoms from
Mirapex are benign or medically dangerous as they are somewhat unusual. It
might be worth a change to Requip which is a similar dopamine agonist but has
a different side effect profile.
A Reply from JD
Sent: Thursday, January 13, 2005 5:40 AM
Subject: Re: Mirapex side effect
I appreciate your quick reply and will follow up
with my doctor. I really don't want to change the medication since it has
been so helpful, but of course if it is medically dangerous for me to
continue then I will make the change. Are there any tests my doctor can
perform to determine if the symptoms I am experiencing from Mirapex are
benign or medically dangerous?
JD
Medical Reply
There is no way to tell if your symptoms are dangerous or
not. The only major concern would be a heart problem and a stress test should
clear up that concern. It is most likely that the side effect is benign, but
even so, if you can do better with Requip (I use Mirapex and Requip
interchangeably), then why not change and see if you can get rid of that side
effect?
A Reply from JD
Sent: Tuesday, January 25, 2005 4:45 AM
Subject: Mirapex side effect
Thank you for this site. It has proven to be very helpful and informative
and has provided much useful information for RLS. Fortunately I have found
relief with Mirapex but one uncomfortable side effect is severe acid
indigestion at times. Any recommendations on which OTC medications will
provide best relief? I have tried such things as Tums and even the old
standby, baking soda, but they don't do the trick.
JD
Medical Reply
You may want to try Zantac, Pepcid, Tagamet or Prilosec.
Any of those should work well although Prilosec is the most potent (but does
not have greater side effects than the others).
It might be worthwhile to change to Requip, which is
similar to Mirapex in treating RLS but may not have the same side effects.
Sent: Thursday, January 13, 2005 10:35 PM
Subject: RLS and dopamine
I am convinced that RLS is an
effect of insufficient (or inefficiently processed) dopamine, which I find
confirmed in readings on the web and elsewhere. But my own experience
persuaded me long before reading, for the following reason: I have ADD and
for a long time have taken Dexedrine in combination with various other ADD
medications. In order to avoid tolerance to the Dexedrine, I abstain
completely when there is no work-related reason to take it.
The only
exception to this rule is occasionally when I must sit in a car or on a
plane for hours, and (especially when tired) have RLS. It is mild compared
to the symptoms described here, but uncomfortable enough that I must take
Dexedrine only to relieve the symptoms. It goes away immediately with
Dexedrine. Since I know that Dexedrine operates primarily on dopamine, I
conclude that it is a sudden decrease in dopamine that brings on the
symptoms.
My problem is that I want badly
to find a substitute for the Dexedrine, as I live in fear of addiction to
it. For the past year, when I have taken a week or two as "vacation" from
the Dexedrine, I find that I can not sleep well, and my husband complains that
when I do sleep, my movements disturb him.
Could I have RLS as a result of
taking Dexedrine regularly for almost 10 years now? That is, is it possible
that my use of this drug has permanently depleted me of dopamine so that
without Dexedrine I have RLS? And if this is the case, would a regular dose
of the drugs you describe (Requip, Mirapex, etc.) be enough to restore what
is missing?
Thanks for any advice,
Nelie F.
Medical Reply
You are partially right in your first
statement that RLS is a dopamine problem. We are still trying to sort out
exactly what the problem is with dopamine, but this does seem like one of the
key problems with this disorder.
Dexedrine may cause some release of
dopamine and therefore help RLS somewhat (this will vary considerably with RLS
sufferers as many do not get any relief from this drug). Taking Dexedrine
does not cause RLS and cannot deplete dopamine over the long run.
It is likely that RLS is a cause of ADD as
it causes what appears to be hyperactivity, poor concentration and the
inability to sit and pay attention. There have been studies done on ADD
children and up to 25% of them may have RLS which when treated will resolve
the ADD.
Sent: Friday, January 14, 2005 11:59 AM
Subject: RLS worse with back problems?
My mother has suffers from RLS....she has had
this problem for over 30 years. Needless to say she has tried dozens of
remedies without much help. She did damage her back in a snowmobile related
injury many years ago. Could this make her RLS worse and if so should she
have an MRI to determine if this may be a cause of her worsening condition?
Do you recommend Ropinirole? What is its success pattern? We have also
read that diet may play a role. Any recommendations from you will be very
much appreciated.
Terry M.
Medical Reply
Trauma to the body, especially to the back or spine may
precipitate or worsen RLS (we have no idea why), but once that has occurred
there is nothing you can do to reverse the situation (that is by doing
anything to the back).
Requip (ropinirole) or Mirapex (pramipexole) are the two
best drugs for RLS that usually work great to relieve RLS symptoms.
Sent: Wednesday, January 19, 2005 7:26 AM
Subject: Switching meds
I stumbled upon your website
and found it very helpful. I have had RLS since the birth of my child
6 years ago. my symptoms are severe and have required medication
nightly since. I started taking Permax but switched to Mirapex because
the Permax makes me extremely tired and unable to have any kind of social
life. I am now finding that my symptoms are starting to occur earlier
in the day and I am requiring slightly higher doses of the Mirapex to obtain
relief.
If I switch back to the Permax for awhile and then resume
the Mirapex would that help to decrease my daytime symptoms and the dose of
Mirapex required? Do I need to worry about developing any kind of
neurological disorder as a result of taking these drugs long term. I
am somewhat scared about my future health, knowing that I have needed to
take these drugs for so long.
Thank you so much for your advice.
Medical Reply
It is possible that you are getting augmentation
with Mirapex. This means that the symptoms may get worse and occur earlier in
the day due to taking the drug. This may still occur if you change to another
dopamine like drug (Permax or Requip), although it may still be worth a trial
to see if you improve (Requip is better tolerated than Permax and safer).
You may want to consider a change to Neurontin or
other classes of RLS drugs.
Sent: Wednesday, January 19, 2005 11:25 PM
Subject: Does Orgasm " treat" RLS?
I have had RLS since young
childhood. Once married I slept well
and was still. Once sexual fulfillment
declined a bit, I began to feel twitching in my legs and would gently move
and reposition myself in bed… (she’s great and a God send truly – but
pregnancies and babies and all that plus work and life may reduce the level
of sexual fulfillment happening – yes?).
My wife would say “be
still” and when I wasn’t she’d think that I was punishing her for no sex or
being a spaz. If she “gave in” and
“treated me” , after sex I’d be still and sleep great. So does the chemistry of
orgasm treat RLS?
Medical Reply
We do not understand why orgasm helps RLS but this seems to
benefit both male and female RLS sufferers. It is one of the many mysteries
of this disorder.
Sent: Tuesday, January 25, 2005 10:01 PM
Subject: RLS at bad times
I found your website after Googling "restless leg." I don't have RLS often, but
when I do, it usually happens in my right calf muscle and sometimes in my
right arm just below the elbow. I can usually cure it by standing for awhile,
but sometimes it's not convenient to do so, such as in church or traveling
by car and stretching has little if any effect. What can I do to stop RLS in
such situations?
Also, I wonder why RLS only happens when I'm sitting, never when I'm standing
or laying down and why it often happens in the calves. Any ideas?
Medical Reply
I have no idea why your RLS is not worse when lying down
compared to sitting as that is when most RLS sufferers have their worst
symptoms.
To stop RLS symptoms when traveling or sitting in church
you would need to take medication about 1-2 hours before. You can choose from
many, but Requip and Mirapex are the best choices.
Sent: Thursday, January 27, 2005 2:12 AM
Subject: Medication for RLS
I was wondering why you think Requip and
Mirapex are the best choices? I was on Mirapex for about 3 years and
started getting augmentation. The doctor told me that you don’t get
augmentation with Mirapex but I definitely did. I have a severe case
of RLS, and my parents both suffered with RLS. I also suffer with it in my
arms and chest. I start getting RLS a lot of times early in the evening
when I am fixing dinner. There are many times when I can’t even sit to
eat. If it doesn’t start early, it will start about 10 PM.
I am on Neurontin along with Vicodin and
Xanax. I usually take 900 mg of Neurontin around 10 PM and then 1 Vicodin
and 1 mg of Xanax 30 minutes before I go to bed, which is usually around
midnight. I sometimes still have to get up around 4 AM and walk the floor
for about 30 minutes to an hour. I go back to bed and I can usually get
some sleep, but I am kicking and feel miserable and finally have to get up
around 8 AM because my RLS is so bad. I feel exhausted a lot of the time.
I can never lie down and rest during the day because my RLS will usually
start, especially if I am really tired.
Do you have any suggestions for me? I
have been on the Neurontin for 2 years. I am afraid it will stop working.
The only time I really got relief from RLS was when my dentist put me on
Vicodin for a few days for a dental problem. I took it every 4 hours and
it was great. I had no problems at all. My doctor will only give me 30
Vicodin a month. If I could get more I could take it in the night and not
have to suffer the way I do. This problem has really almost ruined my
life. It takes so much energy to try to function normally.
I am 66 years old and
I am seriously thinking about donating my brain to the RLS Foundation. It
scares me to think about it, but I would really like to help others. My
grandchildren are already starting to get RLS.
Thank you so much for
all the help you give. You are truly sent by God.
Medical Reply
Requip and Mirapex are the best drugs for the majority of
RLS patients. Like any disease, not all patients will respond to certain
drugs. Unfortunately, many cases of severe RLS (such as yours) do not respond
to those drugs or can actually get worse due to augmentation. Over the past
few years, we have realized that about 15% of patients may get augmentation
with Mirapex or Requip.
My recommendation for your case is to ask your doctor to
switch the Vicodin to methadone. It lasts longer and works much better for
RLS. You may need to take the methadone 2-3 times per day to get full relief
(which is what you should except from current RLS therapy).
You can take drug holidays from the methadone (2 days off
every few weeks) or try to alternate with Ultram (tramadol) which should
reduce the chance of addiction/tolerance.
Sent: Thursday, January 27, 2005 8:26 AM
Subject: Need Help with Daytime RLS
I am a 58 year old male and have a genetic
predisposition to RLS. Over the last 6 years my symptoms have become more
acute. I now have restless leg day and night. I have taken the usual RLS
drug regimen: quinine, Sinemet, clonazepam, diazepam and monthly B-12
shots for pernicious anemia. None of these treatments seemed to help -
Sinemet resulted in augmentation and rebound, and the benzodiazepines turned
me into a walking zombie. The B-12 has no noticeable effect.
For the last 3 years I have been taking
hydrocodone which has helped. However, for over a year now I have had
daytime symptoms and have been taking the hydrocodone throughout the day to
relieve the symptoms. I am taking 30-35mg. a day but am concerned about
building up a tolerance to the drug. I have tried taking tramadol for a
"drug holiday" but have had problems with urinary retention.
Last week my doctor placed me on a Mirapex, one
.125mg. before bedtime. It works great. I've been sleeping all night and
wake up refreshed. However, upon waking the RLS symptoms return with a
vengeance. I tried taking the Mirapex during the day but end up sleepy and
in a daze all day. Also, the drug wears off within 4-5 hours and it seems
as if the RLS symptoms become even more severe.
Since both hydrocodone and Mirapex make me
groggy, are there any any other drugs available that won't cause daytime
sleepiness? Does a person adjust to the Mirapex over time so that daytime
sleepiness eventually diminishes? Can a low dose of Mirapex (.125 mg) cause
augmentation? Any help you could provide would be much appreciated.
Marvin
Medical Reply
Quinine is not recommended for RLS at all and the other
drugs, Sinemet, diazepam and clonazepam are not very good drugs for this
disorder (they were used in the past but are no longer considered first line
choices for RLS).
Mirapex is a very good drug for RLS but it seems that you
may be getting rebound (worsening of RLS as the drug wears off). It is very
unusual for such a low dose of Mirapex to cause augmentation or rebound. It
might be worth trying a higher dose of Mirapex (check with your own doctor
first) and see if this works better or worse. Requip may also work better,
although it is also a dopamine agonist drug like Mirapex.
Methadone would be a better choice than Vicodin
(hydrocodone) and the methadone does not contain acetaminophen (Tylenol) which
is not needed for RLS.
Sent: Saturday, January 29, 2005 11:03 AM
Subject: Could this be something else?
I have been suffering with what I have considered to be
RLS for 6-8 years. Where in the past it has been more of an annoyance
than a problem, in the last 6+ months this has been escalating to be a real
disturbance in my life. Thankfully I've never had a problem with
sleep disturbance from this -- laying down is the most reliable way that I can
relieve my symptoms.
Originally I only had problems in the evening when I sat
down to relax and watch TV and it seemed to only effect my legs. Now I
often start having trouble early in the day while at work and the symptoms
encompass my whole body. It's characterized by an extreme irritability
-- physical as well as mental/emotional. My arm rubbing on the desk can
drive me crazy or the cat wanting to sit on my lap or cuddle next to me on the
couch.
The smallest things turn into major irritations.
I'll get up from my desk and walk around with my hands, arms and whole upper
body clenched trying to get some relief. I'll go for a couple weeks with
really bad symptoms and then things settle down somewhat.
I've tried Mirapex. My doctor originally prescribed
taking .125 mg 4 times per day. This didn't seem to help and disturbed
my sleep so I stopped. I'm trying again with just taking the pills
earlier in the day and staying away from taking them in the evening.
It's only been a couple days, but I don't see any signs that this is helping.
Before I felt that my symptoms were classic RLS, albeit
more a daytime version. Now I'm not so sure. Is there something
else that this could be? If Mirapex doesn't have any effect, is there
much chance that Requip will?
Thanks for any help you can give,
Janet
Medical Reply
You may need a higher dose of Mirapex. This can be
increased by .125 mg every 3-7 days (under the supervision of your doctor)
until symptoms have improved. If Mirapex does not help, it is possible that
Requip may benefit your problem.
Neurontin may also be helpful if it does not cause problems
with daytime sleepiness. Pain killers (narcotics or tramadol) may be another
option.If you respond to this therapy then you it
is much more likely that you have RLS.
Sent: Saturday, January 29, 2005 12:39 PM
Subject: Ritalin and RLS
I have RLS and I try many meds for that disease and depression. Prozac and
most of the SSRI exacerbate RLS. Wellbutrin does not. I'm now taking Ritalin
for concentration/depression, along with bupropion (Wellbutrin) and I notice
an increase
in RLS in evening.
I don't understand why there is an increase since
Ritalin
does not decrease dopamine concentration. I know that caffeine exacerbate
RLS so maybe Ritalin (similar to caffeine) do the same. Do you have some
information about Ritalin (or Adderall) and RLS and can I mix those
stimulants with Mirapex ?
C.L.
Medical Reply
Most stimulants will make RLS worse. Not much is known
about Ritalin and RLS, but anecdotal reports are similar to yours. Mirapex
There are known interactions between Ritalin and Mirapex so these drugs can be
taken together.
Sent: Saturday, January 29, 2005 8:54 PM
Subject: RLS better with Mirapex.
I sure do know about RLS. I first started
about 20 years ago. My episodes of legs wanting to move were very
infrequent in the beginning. As the years have gone by they have become
worse and worse. It is now a more serious condition. When I first talked to my doctor about the
condition, he had not even heard of it. I took a clipping of the RLS
article to him on an other office visit and asked him to read it and than
suggest a medication for me to take.
My doctor prescribed Neurontin. It did not
always give me relief, but I was able to be RLS free for periods at a
time. This went on for 5 or 6 years until the condition became noticeable
more frequent. My doctor sent me to a Neurologist, who to my
surprise said she did know of RLS. She prescribed Mirapex. That was about
8 years ago. I started by taking one pill a day 0.125mgs. Later as the
condition became more frequent and more intense, the dosage was increased to
2 a day, same strength, and then to three a day.
In the last 2 years the RLS has not just
effected my legs, but at times it also hits my arms. On rare occasions it
seems that it has also made my whole body feel restless. My neurologist
increased my dosage and strength to 0.25mgs, three times a day. I am
lucky that on occasion when the pills lose their effectiveness, although the
agitation takes place in the evening, when I go to bed, it subsides.
Twice in all these years I have had to take a
holiday. The first time that happened, my regular doctor took me completely
off the Mirapex and put me on Requip ( a fairly new medication). That gave
me the jitters and shakes and loss of two nights sleep.
I immediately stopped taking it and went back on
Mirapex. The reprieve was enough to fool my brain into thinking I was drug
free.
The second time was just a short time ago. This
time I instructed my doctor to let me take a lower strength and only 2 pills
a day for one week. I did have mild bouts of RLS during this time, but as
soon as I went back to the higher dose and strength, my body has readjusted
to it.
Mirapex works wonders for me. I am 80 years
old, and still able to work. I have had RLS for over 20 years. Without
Mirapex, I would be a basket case. RLS is one horrible condition.
Sincerely,
Mary
Medical Reply
RLS can vary with good days and bad days. Sometimes
stopping the medication fro a few days does help. If you do have problems
with Mirapex in the future, there are other drugs that will help you.
Sent: Sunday, January 30, 2005 12:02 PM
Subject: PLMD causing leg injuries?
I have severe PLMD and the arousals at night are
sufficiently frequent and violent to cause injuries to one of my legs. I
sleep mainly on my right side and the injuries are to my left knee and outer
thigh. I notice that my leg pain is worst in the morning. I now have
significant fluid swelling in the area around and above my kneecap though
little direct pain in the joint. The thigh pain is in the area of the
iliotibial band and seems to run along this.
Do you have any suggestions as to how I might limit the
damage caused by the leg movements at night? I had considered that the left
leg problems might be caused by the drop towards the mattress after
extending forwards, the leg twisting as it does so, affecting both the hip
and the knee. I have been thinking of sleeping with a cushion between my
legs to see if that helps. Any suggestions welcomed.
David,
Ireland
Medical Reply
You might be able to devise a cushion system with a Velcro
band that may help your leg kicking problem. Mirapex or Requip taken before
bed might also help take care of your leg kicking in general.
