TOKYO, Apr 27 (News On Japan) - What does it feel like to have Restless Legs Syndrome? To me, it’s like being buried in sand, with a deep heavy ache, and trying to resisting the urge to move making it even more unbearable.
There’s a sense of panic, a kind of claustrophobia, that can only be relieved by moving the legs, or by constant massage, right at a time when all you want to do is sleep. It’s exhausting, and can last all night and into the early morning hours, sometimes beyond. It can destroy your will to survive, yet it’s little talked about, probably because no one has any real idea what causes it or how to treat it, safely.
However, over the last few years, I’ve been working on a theory that seems to unlock the mysteries surrounded this horrible condition. Traditional theories have pointed to iron deficiency, nerve dysfunction, diet, or genetics, but none have provided a complete explanation. This new hypothesis is comprehensive, and centers on nitric oxide—a critical molecule for oxygen delivery, cell signalling, and brain regulation—and how sinus function, facial muscle tension, and brain activity may work together to trigger this overwhelming urge to move the legs which is the main symptom of RLS.
One of the mysteries about RLS is why it characteristically happens at night. Nitric oxide plays a major role in facilitating oxygen delivery to the limbs. When the body reaches a deep level of relaxation, it’s a signal for the muscles to start the repair process in earnest, as muscle fibers are best repaired while they are inactive. Satellite cells that surround the muscles are called into action, spreading across damaged areas in sticky layers. Because the legs and feet have been critical for human survival, the body prioritizes their repair, automatically scheduling this process through the circadian rhythm, the body's built-in daily cycle.
A key ingredient in the muscle repair process is the availability of oxygen, which is supplied through the bloodstream. However, if nitric oxide is lacking, the oxygen molecules are unable to jump off the red blood cells, which creates a feeling of hypoxia. This causes panic as the brain perceives the limbs as being “choked.” A signal is sent to move the muscles in order to increase the supply of oxygen, or alternately, decrease the build-up of bicarbonate, which rises when oxygen delivery is impaired.
Nitric oxide (NO) is transported to the lower limbs via the bloodstream, along with oxygen and other vital materials. NO is first collected from the air we breathe in the paranasal sinuses, which are located within the bones of your skull and face, above the nasal cavity, behind your eyes. Nitric oxide is released through small pipes called ostia into the nasal cavity where it follows the airflow into the lungs. Only about 1/1000 of the air we breathe enters these well-protected sinuses. If these ostia are blocked or the sinuses aren’t functioning properly, this could cause a lack of nitric oxide distribution. While there have been many theories about the function of the paranasal sinuses, which are found in most mammals except a few species such as whales, researchers are gravitating towards their role in sythesizing nitric oxide. Considering that the paranasal sinuses occupy some of the most valuable real estate in the body, this highlights their importance in biological functions, including nitric oxide’s role as a signaling molecule which was discovered in the 1990s and earned three scientists a Nobel Prize in 1998.
It’s well-known that nitric oxide production declines with age, down by 75% or more by the time you reach your 60s or 70s. At the same time, RLS becomes more common and severe in older adults. In the USA alone, it is estimated that around 10% of adults suffer some form of RLS, translating to roughly 30 million people. Studies suggesting that up to 20% of adults over 60 experience moderate to severe symptoms.
Most cells in the body can produce nitric oxide, typically in response to signals such as inflammation, changes in blood flow, oxygen levels, or other physiological stresses. Nitric oxide is also generated in the mouth through the action of beneficial bacteria in the saliva, which is why some doctors now advise against the regular use of mouthwash, as it can interfere with this natural production pathway. Additionally, nitrates found in foods—especially leafy green vegetables—can be converted by the body into nitric oxide, further supporting systemic NO levels.
While all these pathways are important, nitric oxide by itself has a lifespan of only about two seconds, and given that it takes approximately one second for blood to travel from the nasal passages to the lower limbs, it seems reasonable to assume that the extremities rely heavily on continuous nitric oxide contributions from the airways to meet their oxygen delivery needs.
Interestingly, dopamine boosts nitric oxide production, which may explain why medications such as dopamine agonists work well against RLS, although this treatment is no longer recommended as it can lead to augmentation, where the symptoms get worse and can wear out dopamine receptors in the brain. I took pramipexole (a dopamine agonist) for many years until I read on RLS forums to stop because it is dangerous over long periods. It is super addictive and it took me a long time to get off it, until finally I succeeded. Now I am drug free, and feel like myself again.
Another factor to consider is the possible role of nitric oxide in helping to cool the brain. Some researchers believe that NO is involved in thermoregulation, reducing brain temperature, particularly during periods of heightened mental activity. If the brain is overstimulated—whether due to stress, anxiety, or racing thoughts—it could divert nitric oxide toward cooling and regulating brain function. This would leave less nitric oxide available for use in muscle repair and oxygen delivery to the extremities. Although the brain accounts for only about 2% of total body weight, it consumes approximately 20% of the body's energy. Since brain activity generates heat, this "all-mighty" organ may requisition nitric oxide from elsewhere in the body to help regulate its own temperature.
Muscle tension in the face may be one reason the paranasal sinuses are deprived of optimal airflow, hence, reducing the delivery of nitric oxide into the lungs. When facial muscles are tight, they can exert subtle pressure on the tissues surrounding the sinus openings, potentially restricting airflow. Relaxing the facial muscles may therefore serve as an important strategy to enhance nitric oxide delivery throughout the body, particularly to the limbs, helping reduce the likelihood or severity of RLS.
Taken together, this theory suggests that the true origins of Restless Legs Syndrome may lie in a combination of sinus function, facial muscle tension, nitric oxide production, and the body's internal priorities during sleep. Since discovering this connection, and developing exercises and strategies to counter its negative effects, my RLS has significantly decreased, although it’s still a day-to-day proposition. These days I can often sleep peacefully — something that once felt like a miracle — and with lifestyle changes, my RLS has not only become manageable but has also unexpectedly improved my life in many other ways.
I will be giving further updates to this hypothesis and some exercises I’ve developed to naturally boost nitric oxide, so if you’d like to stay in touch, please enter your email address below and I’ll send you periodic updates. P.S. I will not share your email address with anyone, and only send you relevant information.
I also welcome feedback and discussion as this theory continues to evolve. Feel free to contact me directly at brian@vitaltoolboxes.com.
* Brian Dentry has been an independent researcher and journalist for over 25 years, and worked extensively for organizations such as the Asian Development Bank Institute and the Mainichi Shimbun.
