Achievements, challenges, and future perspectives of epidemiologic research in restless legs syndrome (RLS)

Epidemiology of Pediatric Restless Leg Syndrome

Pediatric Restless Legs Syndrome (RLS)/Willis Ekbom Disease is prevalent at around 2% with onset around the end of first decade. There is a strong genetic predisposition and no gender preference till late adolescence, with a female preponderance beyond that. Insomnia-like symptoms, periodic limb movement disorder (PLMD), and excessive daytime sleepiness are significantly associated causing impaired cognition and behavior. RLS can be associated with chronic kidney disease, celiac disease, migraine, and pediatric-onset multiple sclerosis. A close clinical differential is growing pains. Case definitions need to be refined and prospective studies with relevant serum and radiologic biomarkers need planning.

The impact of neuropsychiatric burden on Restless Legs Syndrome (RLS) disease severity

OBJECTIVE

In patients with Restless Legs Syndrome (RLS), neuropsychiatric comorbidities like anxiety, depression, and somatization are common, yet the precise connection between somatization and RLS severity remains unclear. This study aims to elucidate the influence of neuropsychiatric comorbidities on RLS severity, focusing particularly on the role of somatization.

METHODS

This cross-sectional analytical study was conducted at a tertiary hospital. All 113 RLS patients who followed in neurology clinic for at least a year were invited, and 87 participated. Data collection included sociodemographic details, the International Restless Legs Syndrome Study Group rating scale (IRLS), the Beck Depression Inventory, Beck Anxiety Scale, and Somatization Scale. Elastic-net regularized path analysis was used as the statistical method.

RESULTS

Among the 87 participants (70.1 % female, mean age 52.5 ± 13.2 years), the mean duration of RLS diagnosis was 4.95 ± 4.53 years. Univariate statistics revealed positive correlations among RLS severity, anxiety, depression, and somatization. Path analysis showed that somatization was associated with RLS severity (p = 0.014). Anxiety had no direct effect on RLS severity but influenced it indirectly through its positive association with somatization (p < 0.001). Depression was found to have no effect on RLS severity, either directly or through somatization.

CONCLUSIONS

The relationship between anxiety and RLS severity is mediated by somatization. Furthermore, the association between RLS severity and somatization appears to be more significant than previously recognized, highlighting the importance of considering somatization in addressing the neuropsychiatric burden of RLS patients.

Prevalence of restless legs and association with patient-reported outcome measures in myasthenia gravis

STUDY OBJECTIVES

Inflammatory and immune mechanisms are considered in restless legs syndrome (RLS) pathophysiology with several autoimmune diseases associated with RLS. There is a paucity of studies examining RLS prevalence in myasthenia gravis (MG), an autoimmune neuromuscular disease. This study investigated RLS prevalence and association with patient-reported measures in a large registry of participants with MG using a validated RLS diagnostic questionnaire.

METHODS

The Myasthenia Gravis Foundation of America MG Patient Registry is used on a semiannual basis to survey participants with MG. Patients aged ≥ 18 years, living in the United States, and answering "yes" to physician diagnosed MG were invited by email to enroll in an RLS-customized web-based survey. Collection of data included demographics, disease variables, patient-reported measures with a simple depression scale, MG-quality of life-15 revised, MG-activities of daily living instruments, and 13-item short-form Cambridge-Hopkins diagnostic questionnaire for RLS. Multivariable logistic regression models explored the association between RLS and MG variables of interest.

RESULTS

A total of 630 eligible participants with MG (age: 62.8 ± 13.2; 54.9% female; 91.6% White) completed the survey. The overall prevalence of RLS was 14.8%. The prevalence of clinically significant RLS was 8.4%. The odds of having RLS were increased with higher (worse) MG-activities of daily living, MG-quality of life-15 revised, and depression scores. History of "thymic tumor with thymectomy" and "continuous positive airway pressure therapy" were also independent predictors of RLS.

CONCLUSIONS

RLS is common in patients with MG and is associated with worse functional status, quality of life, and depression. The thymus could play a key role in an autoimmune process associating MG with RLS.

CITATION

AlGaeed M, McPherson T, Lee I, et al. Prevalence of restless legs and association with patient-reported outcome measures in myasthenia gravis. J Clin Sleep Med. 2025;21(2):269-276.

Prevalence of depression or depressive state in patients with restless legs syndrome: A systematic review and meta-analysis

Restless legs syndrome (RLS) is a common sleep-related disorder characterized by limb discomfort and the urge to move them when at rest, especially in the evening or at night. Although depression is often linked to various conditions, no systematic review has assessed depression prevalence in patients with RLS after the latest diagnostic criteria revision. This systematic review and meta-analysis aimed to investigate the depression and depressive state prevalence among patients with RLS. We systematically searched databases up to November 2022 and performed meta-analyses of the depression prevalence using a random-effects model and a meta-regression analysis to explore the relationship between the prevalence and severity of depression and factors such as age and RLS severity. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we analyzed 24 studies with 2039 patients. The pooled depression or depressive state prevalence, mostly defined by questionnaire scores, was 30.39 %. Nine studies reported the proportion of patients taking antidepressants (pooled rate: 3.41 %). No specific factors related to the prevalence or severity of depression were identified in patients with RLS. These findings highlight the significant prevalence of depression and underscore the need for future research with standardized diagnostic interviews and consistent methodologies across multi-site studies.

Medication refractory restless legs syndrome: Real-world experience

BACKGROUND

Restless Legs Syndrome (RLS), impacting 5-13% of the population, poses challenges in long-term management. A knowledge gap exists in predicting resistance to first-line therapies.

OBJECTIVE

To identify demographic and clinical factors predictive of refractory cases.

METHODS

This retrospective study, conducted at the Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas (January 2018 to September 2023) identified all patients with RLS evaluated during the pre-specified period and compared clinical and demographic data between medication-refractory ("malignant") group and "benign" cohort.

RESULTS

Among 132 patients with RLS, 23 (17.4%) were categorized as medication-refractory. This cohort was characterized by a significantly lower mean age at onset (39.3 vs. 53.5 years, p = 0.0005), longer disease duration (26.7 vs. 14.0 years), and a higher prevalence of a positive family history of RLS among first-degree relatives compared to the "benign" group (56.5% vs. 15.5%, p = 0.003). Furthermore, compared to the "benign" group, in the refractory group dopamine agonists were initiated as the primary medication at a significantly higher rate (p = 0.006).

CONCLUSION

Our study found that a younger age at disease onset, prolonged disease duration, initial use of dopamine agonists, and a positive family history increased the likelihood of refractory RLS. We caution against the use of dopamine agonists, especially in young patients with RLS. Additionally, botulinum toxin might be considered a viable second-line treatment, especially for patients with otherwise medically-refractory RLS.

Risk of Suicidal Ideation and Behavior Following Early-Onset Idiopathic Restless Legs Syndrome Treatment

PURPOSE

To estimate incidence rates of suicidal ideation and behavior following treatment initiation with gabapentinoids or dopamine agonists (DAs) in patients with newly diagnosed early-onset idiopathic restless legs syndrome (RLS) and to examine suicidal behavior risk, comparing between those receiving gabapentinoids and DAs.

METHODS

A new user retrospective cohort study using MarketScan claims data from 2012 to 2019 was conducted. Exposures were monotherapy gabapentinoids or DAs initiated within 60 days of new RLS diagnosis. Three varying outcome measures of suicidality were examined and incidence rates were calculated for each. A log-binomial regression model the estimated relative risk (RR) of the outcomes with gabapentinoids. Propensity score weighting adjusted for baseline covariates, including age, substance use disorders, hyperlipidemia, antipsychotic use, hypnotic/sedative use, and mood stabilizer use, which were most imbalanced before weighting.

RESULTS

The cohort included 6672 patients, with 4986 (74.7%) initiating a DA and 1686 (25.3%) initiating a gabapentinoid. Incidence rates for all outcome measures were higher in the gabapentinoid group (suicidality: 21.6 vs. 10.7 per 1000 person-years; suicidality with self-harm: 23.0 vs. 11.1 per 1000 person-years; overdose- and suicide-related events: 30.0 vs. 15.5 person-years). Associated risk of suicidality (adjusted RR, 1.27 [95% CI, 0.86-1.88]); suicidality with self-harm (adjusted RR, 1.30 [95% CI, 0.89-1.90]); or overdose- and suicide-related events (adjusted RR, 1.30 [95% CI, 0.93-1.80]) was not significant with gabapentinoids.

CONCLUSIONS

Incidence rates for suicidal ideation and behavior were higher among the gabapentinoid group, although increased risk was not detected after adjustment. A possible signal cannot be ruled out given limitations of the data and rarity of the outcome.

A survey-based approach on restless legs syndrome: practices and perspectives among Italian neurologists

INTRODUCTION

Restless Legs Syndrome (RLS) is a widely prevalent and complex neurological disorder. Despite notable advancements in managing RLS, the disorder continues to face challenges related to its recognition and management.

OBJECTIVE

This study seeks to gain comprehensive insights into the knowledge and clinical practices among Italian neurologists regarding RLS diagnosis, management, and treatment, comparing approaches among general neurologists, movement disorder specialists, and sleep experts.

METHODS

Members of the Italian Society of Neurology, the Italian Society of Parkinson and Movement Disorders, and the Italian Association of Sleep Medicine were invited to participate in a 19-question online survey.

RESULTS

Among the 343 surveyed neurologists, 60% categorized RLS as a "sleep-related movement disorder." Forty% indicated managing 5-15 RLS patients annually, with sleep specialists handling the highest patient volume. Of note, only 34% adhered strictly to all five essential diagnostic criteria. The majority (69%) favored low-dosage dopamine agonists as their first-line treatment, with movement disorder specialists predominantly endorsing this approach, while sleep experts preferred iron supplementation. Regular screening for iron levels was widespread (91%), with supplementation typically guided by serum iron alterations. In cases of ineffective initial treatments, escalating dopamine agonist dosage was the preferred strategy (40%).

CONCLUSIONS

These findings underscore a lack of a clear conceptualization of RLS, with a widespread misconception of the disorder as solely a movement disorder significantly influencing treatment approaches. Disparities in RLS understanding across neurology subspecialties underscore the necessity for improved diagnostic accuracy, targeted educational initiatives, and management guidelines to ensure consistent and effective RLS management.

The global and regional prevalence of restless legs syndrome among adults: A systematic review and modelling analysis

Background

Restless legs syndrome (RLS) is a prevalent neuro-sensory disorder that impairs quality of life. In this systematic review and modelling study, we estimated the global and regional prevalence of RLS and its associated factors.

Methods

We searched PubMed, Embase, and Medline for population-based studies on RLS prevalence published up to 12 November 2023. The included studies reported prevalence using the International Restless Leg Syndrome Study Group's (IRLSSG) minimal diagnostic criteria without limitations on frequency, duration, or severity. We applied a multilevel multivariable mixed-effects meta-regression to generate the age-specific and sex-specific prevalence of RLS for high socio-demographic index (H-SDI) and low and middle socio-demographic index (LM-SDI) regions. We pooled odds ratios (ORs) for RLS associated factors using random-effects models. Finally, we derived the regional prevalence and cases of RLS based on an associated factor-based model.

Results

From 52 articles across 23 countries, the global RLS prevalence in 2019 was estimated to be 7.12% (95% confidence interval (CI) = 5.15-9.76) among adults 20-79 years of age, equating to 356.07 million (95% CI = 257.61-488.09) affected individuals. Prevalence was similar in H-SDI (7.29%; 95% CI = 5.04-10.41) and LM-SDI (7.10%; 95% CI = 5.16-9.70) regions, with the majority of cases in LM-SDI countries (323.06 million; 90.73%). Europe had the highest (7.60%; 95% CI = 5.44-10.52) and Africa the lowest regional prevalence (6.48%; 95% CI = 4.70-8.87). The Western Pacific Region, meanwhile, had the most cases (111.91 million; 95% CI = 80.93-153.42). Factors positively associated with RLS included advanced age (OR = 1.13; 95% CI = 1.04-1.24), smoking (OR = 1.46; 95% CI = 1.29-1.64), depression (OR = 1.71; 95% CI = 1.26-2.32), and diabetes (OR = 1.54; 95% CI = 1.19-1.97).

Conclusions

A considerable global burden of RLS exists. Effective strategies are needed to increase awareness and optimise resource allocation to address this often-overlooked condition. High-quality epidemiological investigations employing standardised and rigorous criteria for RLS are essential for addressing RLS burden more effectively.

Registration

PROSPERO: CRD42020161860.

Clinical features, polysomnography, and genetics association study of restless legs syndrome in clinic based Chinese patients: A multicenter observational study

STUDY OBJECTIVES

To systemically describe the clinical features, polysomnography (PSG) finding, laboratory tests and single-nucleotide polymorphisms (SNPs) in a clinic based Chinese primary restless legs syndrome (RLS) population.

METHODS

This observational study, conducted from January 2020 to October 2021 across 22 sleep labs in China, recruited 771 patients diagnosed with RLS following the 2014 RLSSG criteria. Clinical data, PSG testing, and laboratory examination and SNPs of patients with RLS were collected. A total of 32 SNPs in 24 loci were replicated using the Asian Screening Array chip, employing data from the Han Chinese Genomes Initiative as controls.

RESULTS

In this study with 771 RLS patients, 645 had primary RLS, and 617 has DNA available for SNP study. Among the 645 primary RLS, 59.7% were women. 33% had a family history of RLS, with stronger familial influence in early-onset cases. Clinical evaluations showed 10.4% had discomfort in body parts other than legs. PSG showed that 57.1% of RLS patients had periodic leg movement index (PLMI) of >5/h and 39.1% had PLMI >15/h, respectively; 73.8% of RLS patients had an Apnea-Hypopnea Index (AHI) > 5/h, and 45.3% had an AHI >15/h. The laboratory examinations revealed serum ferritin levels <75 ng/ml in 31.6%, and transferrin saturation (TSAT) of <45% in 88.7% of RLS patients. Seven new SNPs in 5 genes showed a significant allelic association with Chinese primary RLS, with one previously reported (BTBD9) and four new findings (TOX3, PRMT6, DCDC2C, NOS1).

CONCLUSIONS

Chinese RLS patients has specific characters in many aspects. A high family history with RLS not only indicates strong genetic influence, but also reminds us to consider the familial effect in the epidemiological study. Newly developed sequencing technique with large samples remains to be done.

The multifaceted aspects of sleep and sleep-wake disorders following stroke

Sleep-wake disorders (SWD) are acknowledged risk factors for both ischemic stroke and poor cardiovascular and functional outcome after stroke. SWD are frequent following stroke, with sleep apnea (SA) being the most frequent SWD affecting more than half of stroke survivors. While sleep disturbances and SWD are frequently reported in the acute phase, they may persist in the chronic phase after an ischemic stroke. Despite the frequency and risk associated with SWD following stroke, screening for SWD remains rare in the clinical setting, due to challenges in the assessment of post-stroke SWD, uncertainty regarding the optimal timing for their diagnosis, and a lack of clear treatment guidelines (i.e., when to treat and the optimal treatment strategy). However, little evidence support the feasibility of SWD treatment even in the acute phase of stroke and its favorable effect on long-term cardiovascular and functional outcomes. Thus, sleep health recommendations and SWD treatment should be systematically embedded in secondary stroke prevention strategy. We therefore propose that the management of SWD associated with stroke should rely on a multidisciplinary approach, with an integrated diagnostic, treatment, and follow-up strategy. The challenges in the field are to improve post-stroke SWD diagnosis, prognosis and treatment, through a better appraisal of their pathophysiology and temporal evolution.

Incident mental health episodes after initiation of gabapentinoids vs. dopamine agonists for early-onset idiopathic restless legs syndrome

Limited long-term safety information exists for gabapentinoid treatment of idiopathic restless legs syndrome (RLS). We estimated incident mental health-related emergency department visits and hospitalizations with a primary mental health diagnosis (primary outcome) among early-onset idiopathic RLS patients following first-line treatment initiation and examined outcome risk with gabapentinoids compared with dopamine agonists (DAs). A retrospective cohort study was conducted using administrative claims data from 2012 to 2019. Adults with early-onset (18-44 years) idiopathic RLS initiating either gabapentinoids or DAs within 60 days of new diagnosis were followed up to two years. Incidence rates were calculated and a log-binomial regression model with propensity score weighting estimated relative risk of the outcome and of substance use disorders (SUDs) as a secondary analysis with gabapentinoids. Among a cohort of 6,672 patients, 4,986 (74.7%) initiated DAs and 1,686 (25.3%) gabapentinoids. Incidence of the primary outcome (49.8 [95% CI 40.8-69.3] per 1,000 person-years) and SUDs (49.5 [95% CI 40.6-59.9] per 1,000 person-years) were higher in the gabapentinoid group compared with the DA group. A statistically significant risk of mental health diagnoses with gabapentinoids was not detected, but SUD risk was significant after covariate adjustment. High-risk mental health comorbidities (i.e., SUDs) should be considered when initiating RLS treatments.

Sleep-related motor disorders

Sleep-related motor disorders include non-rapid-eye movement (NREM) sleep parasomnias, rapid-eye movement (REM), sleep parasomnias including REM sleep behavior disorder (RBD), isolated motor phenomena in sleep, and periodic limb movement disorder. Restless legs syndrome (RLS) occurs while awake but is closely related to sleep and has a circadian pattern. The pontine sublaterodorsal tegmental nucleus has an important role in aligning motor control with sleep states, and dysfunction in this region can explain motor activities including cataplexy and loss of REM atonia seen in REM sleep behavior disorder. This chapter begins with a review of motor control in sleep. The rest of the chapter summarizes the clinical presentation, epidemiology, differential and treatment of NREM, REM, and isolated sleep-related motor disorders as well as restless legs syndrome.

Sleep medicine: Practice, challenges and new frontiers

Sleep medicine is an ambitious cross-disciplinary challenge, requiring the mutual integration between complementary specialists in order to build a solid framework. Although knowledge in the sleep field is growing impressively thanks to technical and brain imaging support and through detailed clinic-epidemiologic observations, several topics are still dominated by outdated paradigms. In this review we explore the main novelties and gaps in the field of sleep medicine, assess the commonest sleep disturbances, provide advices for routine clinical practice and offer alternative insights and perspectives on the future of sleep research.

Behavioral sleep medicine-The need for harmonization of clinical best practice outcome measures in children and adolescents with intellectual or developmental disabilities and restless sleep

In behavioral medicine, sleep disorders, insomnia in particular, may be considered comorbidities and precipitating factors to intellectual or developmental disabilities (IDD). Nevertheless, sleep alterations have often been neglected in favor of daytime features and symptoms, albeit simple behavioral nighttime observations may disclose hypermotor features that characterize restless sleep. The root of most hypermotor restlessness is linked to central iron deficiency. The latter is often exacerbated by vitamin D deficiency (VDD), which interferes with both dopaminergic and serotonergic mechanisms. In this way, an imbalance affecting daytime behavior and mood is created. Several sleep-related motor disorders such as bruxism, periodic and aperiodic leg movements, Restless Legs Syndrome (RLS), and Restless Sleep Disorder (RSD) are commonly seen in Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorders (ASD). However, they are rarely diagnosed and often overlooked in affected children and adolescents. As a result, not only are these disorders not adequately addressed therapeutically, but their symptoms may be worsened by the side-effects of drugs used to contain disruptive daytime behavior, such as antipsychotics and antidepressants. In children with IDDs, obesity, inactivity and metabolic effects of antipsychotics often lead to Sleep Disordered Breathing (SDB), which is currently understood as an inflammatory state leading to "hyperactive" lethargy and further alterations of the hypoxic chain and vitamin D levels. Endorsing simple routine blood tests, including inflammatory markers such as C-reactive protein, ferritin, transferrin, and vitamin D levels, may favorably complement caregiver observations and ambulatory sleep recordings, leading to a sleep disorder diagnosis and consequent therapy. In fact, the treatment of SDB, RLS, and RSD has been copiously demonstrated to favorably impact vigilance, behavior, social competence, and academic skills in healthy and, to a greater extent, in IDD children. Thus, consulting and deliberating the root causes of functional and categorical diagnoses within a clinical framework may engender a more precise diagnosis and further benefit pediatric daytime and nighttime management of hyperactive behaviors.

Treatment initiation and utilization patterns of pharmacotherapies for early-onset idiopathic restless legs syndrome

OBJECTIVE/BACKGROUND

Restless legs syndrome (RLS) is a complex condition associated with circadian rhythm that disrupts sleep and can cause multisystemic consequences. This study assesses pharmacotherapy treatment initiation, estimates annual treatment prevalence, and assesses treatment patterns for early-onset idiopathic RLS.

METHODS

We used the MarketScan Commercial Claims Database from 2012 to 2019 to conduct a new user retrospective cohort study. Annual treatment prevalence was calculated from a cross-sectional sample. Newly diagnosed adults with early-onset (18-44 years) idiopathic RLS who initiated on and off-label gabapentinoids, dopamine agonists, or levodopa/carbidopa were included. Among monotherapy users who had one year of insurance enrollment, treatment patterns (single fill, continuous use of initiated therapy, switching, and add-on therapy) were examined and mean time on the initial treatment (as a measure of persistence) was calculated.

RESULTS

In total, 6, 828 patients were initiated on monotherapy treatment for early-onset idiopathic RLS in which 4,638 met all inclusion criteria. In 2019, annual prevalence of monotherapy treatment of diagnosed patients for ropinirole was 171.3/1,000 patients; 85.0/1,000 patients for pramipexole; and 132.1/1,000 patients for gabapentin. Overall, 22.3% (n = 1,033) of patients maintained their initiated pharmacotherapy for the entire year. Rotigotine had the longest persistence (mean 185.4 [161.4 SD] days) but this user group was the smallest (n = 29). Gabapentin enacarbil, pregabalin, and rotigotine use was low (2.8% total).

CONCLUSION

Ropinirole, pramipexole, and gabapentin were initiated most often for early-onset idiopathic RLS. FDA-approved agents for RLS, including gabapentin enacarbil and rotigotine, were used less frequently. In general, persistence was low for all RLS study drugs examined.

Genetic evidence for a potential causal relationship between insomnia symptoms and suicidal behavior: a Mendelian randomization study

Insomnia and restless leg syndrome (RLS) are associated with increased risk for suicidal behavior (SB), which is often comorbid with mood or thought disorders; however, it is unclear whether these relationships are causal. We performed a two-sample Mendelian randomization study using summary-level genetic associations with insomnia symptoms and RLS against the outcomes of risk of major depressive disorder (MDD), bipolar disorder (BP), schizophrenia (SCZ), and SB. The inverse-variance weighted method was used in the main analysis. We performed replication and sensitivity analyses to examine the robustness of the results. We identified outcome cohorts for MDD (n = 170,756 cases/329,443 controls), BP (n = 20,352/31,358), SCZ (n = 69,369/236,642), SB-Cohort-2019 (n = 6569/14,996 all with MDD, BP or SCZ; and SB within individual disease categories), and SB-Cohort-2020 (n = 29,782/519,961). Genetically proxied liability to insomnia symptoms significantly associated with increased risk of MDD (odds ratio (OR) = 1.23, 95% confidence interval (CI) = 1.2-1.26, P = 1.37 × 10-61), BP (OR = 1.15, 95% CI = 1.07-1.23, P = 5.11 × 10-5), SB-Cohort-2019 (OR = 1.17, 95% CI = 1.07-1.27, P = 2.30 × 10-4), SB-Cohort-2019 in depressed patients (OR = 1.34, 95% CI = 1.16-1.54, P = 5.97 × 10-5), and SB-Cohort-2020 (OR = 1.24, 95% CI = 1.18-1.3, P = 1.47 × 10-18). Genetically proxied liability to RLS did not significantly influence the risk of any of the outcomes (all corrected P > 0.05). Results were replicated for insomnia with MDD and SB in Mass General Brigham Biobank and were consistent in multiple lines of sensitivity analyses. In conclusion, human genetic evidence supports for the first time a potentially independent and causal effect of insomnia on SB and encourages further clinical investigation of treatment of insomnia for prevention or treatment of SB.

Overlapping features of restless legs syndrome and growing pains in Turkish children and adolescents

BACKGROUND

Restless legs syndrome (RLS) and growing pains (GPs) share many common features and are sometimes overlapping diagnoses. The present study aims to investigate the shared features of patients with RLS, classified based on the 2013 diagnostic criteria of International Restless Legs Syndrome Study group and of patients with GPs, diagnosed based on the combined criteria proposed in 2013.

METHODS

A cross-sectional population study was conducted in 7 Istanbul schools, which were selected randomly. A total of 4565 (56.1% female) children aged 9 to 18 years were included. In the first stage, candidates of RLS and GPs were identified based on 2 separate questionnaires, whose diagnoses were confirmed by a second survey applied to them under parental supervision.

RESULTS

Out of 192 children (65.6% female) diagnosed as definite RLS (yearly prevalence: 4.2%), 30 (15.6%) reported bilateral leg muscle pain localized typical regions for GPs, which started <13 years of age in 17 children. An urge to move the legs to relieve unpleasant sensations or pain was present in 39.3% of 140 children (64.3% female) classified as GPs (yearly prevalence: 3.1%). Occurrence of symptoms at rest or when lying down was present in 36.4% of GPs children and relief by gross movements was in 21.4% children. Only 12 patients (9 with definite RLS and 3 with GPs) (0.03% of total cohort) were eligible for overlapping diagnosis of GPs and RLS.

CONCLUSION

Although a considerable number of patients with RLS and GPs share some clinical features, a combined phenotype is very rare.

Restless Legs Syndrome Prevalence and Clinical Correlates Among Psychiatric Inpatients: A Multicenter Study

Background

There are only limited reports on the prevalence of restless legs syndrome (RLS) in patients with psychiatric disorders. The present study aimed to evaluate the prevalence and clinical correlates in psychiatric inpatients in Germany and Switzerland.

Methods

This is a multicenter cross-sectional study of psychiatric inpatients with an age above 18 years that were diagnosed and evaluated face-to-face using the International RLS Study Group criteria (IRLSSG) and the International RLS severity scale (IRLS). In addition to sociodemographic and biometric data, sleep quality and mood were assessed using the Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), the Epworth Sleepiness Scale (ESS), and the Patient Health Questionnaire (PHQ-9). In addition to univariate statistics used to describe and statistically analyze differences in variables of interest between patients with and without RLS, a logistic model was employed to identify predictors for the occurrence of RLS.

Results

The prevalence of RLS in a sample of 317 psychiatric inpatients was 16.4%, and 76.9% of these were diagnosed with RLS for the first time. RLS severity was moderate to severe (IRLS ± SD: 20.3 ± 8.4). The prevalences in women (p = 0.0036) and in first-degree relatives with RLS (p = 0.0108) as well as the body mass index (BMI, p = 0.0161) were significantly higher among patients with RLS, while alcohol consumption was significantly lower in the RLS group. With the exception of atypical antipsychotics, treatment with psychotropic drugs was not associated with RLS symptoms. Regarding subjective sleep quality and mood, scores of the PSQI (p = 0.0007), ISI (p = 0.0003), and ESS (p = 0.0005) were higher in patients with RLS, while PHQ-9 scores were not different. A logistic regression analysis identified gender (OR 2.67; 95% CI [1.25; 5.72]), first-degree relatives with RLS (OR 3.29; 95% CI [1.11; 9.73], ESS score (OR 1.09; 95% CI [1.01; 1.17]), and rare alcohol consumption (OR 0.45; 95% CI [0.22; 0.94] as predictors for RLS.

Conclusions

Clinically significant RLS had a high prevalence in psychiatric patients. RLS was associated with higher BMI, impaired sleep quality, and lower alcohol consumption. A systematic assessment of restless legs symptoms might contribute to improve the treatment of psychiatric patients.

Restless legs syndrome

Restless legs syndrome (RLS) is a common sensorimotor disorder characterized by an urge to move that appears during rest or is exacerbated by rest, that occurs in the evening or night and that disappears during movement or is improved by movement. Symptoms vary considerably in age at onset, frequency and severity, with severe forms affecting sleep, quality of life and mood. Patients with RLS often display periodic leg movements during sleep or resting wakefulness. RLS is considered to be a complex condition in which predisposing genetic factors, environmental factors and comorbidities contribute to the expression of the disorder. RLS occurs alone or with comorbidities, for example, iron deficiency and kidney disease, but also with cardiovascular diseases, diabetes mellitus and neurological, rheumatological and respiratory disorders. The pathophysiology is still unclear, with the involvement of brain iron deficiency, dysfunction in the dopaminergic and nociceptive systems and altered adenosine and glutamatergic pathways as hypotheses being investigated. RLS is poorly recognized by physicians and it is accordingly often incorrectly diagnosed and managed. Treatment guidelines recommend initiation of therapy with low doses of dopamine agonists or α₂δ ligands in severe forms. Although dopaminergic treatment is initially highly effective, its long-term use can result in a serious worsening of symptoms known as augmentation. Other treatments include opioids and iron preparations.

Natural Cannabinoids as Templates for Sleep Disturbances Treatments

The sleep-wake cycle is a complex composition of specific physiological and behavioral characteristics. In addition, neuroanatomical, neurochemical and molecular systems exerts influences in the modulation of the sleep-wake cycle. Moreover, homeostatic and circadian mechanisms interact to control the waking or sleeping states. As many other behaviors, sleep also develops pathological features that include several signs and symptoms corresponding to medical conditions known as sleep disorders.In addition to the neurobiological mechanisms modulating sleep, external elements also influence the sleep-wake cycle, including the use of Cannabis sativa (C. sativa). In this regard, and over the last decades, the interest of studying the pharmacology of Δ⁹-tetrahydrocannabinol (Δ⁹-THC), the principal psychoactive constituent of C. sativa, has been addressed. Moreover, in recent years, the focus of scientific interest has moved on to studying the second plant constituent with non-psychotropic pharmacological properties: Cannabidiol (CBD).The pharmacological and pharmaceutical interest of CBD has been focus of attention due to the accumulating body of evidence regarding the positive outcomes of using CBD for the treatment of several health issues, such as psychiatric and neurodegenerative disorders, epilepsy, etc. Since the most prominent sleep disruptions include excessive daytime sleepiness (EDS), current treatments include the use of drugs such as stimulants of antidepressants. Notwithstanding, side effects are commonly reported among the patients under prescription of these compounds. Thus, the search of novelty therapeutical approaches aimed to treat ESD may consider the use of cannabinoid-derived compounds, such as CBD. In this chapter, we will show experimental evidence regarding the potential role of CBD as a wake-inducing compound aimed to manage EDS.

New onset of restless legs syndrome in pregnancy in a prospective multiracial cohort: Incidence and risk factors

OBJECTIVE

To determine whether the incidence and risk factors of restless legs syndrome (RLS) in pregnancy differ by race/ethnicity, we estimated relative risks of demographic, socioeconomic, and nutritional factors in association with risk of any incident RLS in pregnancy in a cohort of 2,704 healthy pregnant women without prior RLS.

METHODS

Using data from the multicenter, multiracial National Institute of Child Health and Human Development (NICHD) Fetal Growth Studies-Singletons, we examined the incidence of RLS from early pregnancy to near delivery through up to 6 assessments. Multivariable Poisson models with robust variance were applied to estimate relative risks (RRs).

RESULTS

The cumulative incidence of RLS in pregnancy was 18.1% for all women, 20.3% for White women, 15.4% for Black women, 17.1% for Hispanic women, and 21.1% for Asian women. Among Hispanic women, older age (RR [reference ≤25 years]: 25-35 years, 1.51; 95% confidence interval [CI] 1.05-2.16; ≥35 years, 1.58; 95% CI 0.93-2.68), anemia (RR [reference no]: yes, 2.47; 95% CI 1.31-4.64), and greater total skinfolds of the subscapular and triceps sites, independent of body mass index (RR [reference quartile 1]: quartile 5, 2.54; 95% CI 1.30-4.97; p trend = 0.01) were associated with higher risk of RLS, while multiparity was associated with a lower risk (RR [reference nulliparity]: 0.69; 95% CI 0.50-0.96). In Black women, greater skinfolds and waist circumference were associated with higher risk of pregnancy RLS, although the trends were less clear.

CONCLUSIONS

The incidence of RLS in pregnancy was high and differed by race/ethnicity, which is likely accounted for by differences in other risk factors, such as age, parity, and nutritional factors.

Sleep state instabilities in patients with periodic limb movements in sleep - Detection and quantification with heart rate variability

BACKGROUND

Restless legs syndrome (RLS) has been thought to increase the risk of hypertension, cardiovascular events, and all-cause mortality. Periodic limb movements in sleep (PLMS) can be observed in most patients with RLS. Using non-invasive physiologic measurement and analysis, including heart rate variability (HRV) analysis, we aimed to investigate sleep quality and sleep state stability.

METHOD

A total of 53 healthy controls and 15 patients with RLS and PLMS were recruited. Patients with other sleep-related disorders such as obstructive sleep apnea (OSA) and major depressive disorder (MDD) were excluded. Each subject was evaluated using sleep and mood questionnaires and had to undergo polysomnography (PSG). HRV analysis was applied to assess autonomic function and analyze correlations with the severity of periodic leg movements (PLM). The power of different brainwaves was analyzed using electroencephalogram (EEG). Electromyogram (EMG) was also used to explore the temporal correlation between changes in HRV and leg movement events.

RESULTS

Compared with healthy controls, PLMS group had not only poorer perceived sleep and mood questionnaires scales but also reductions in parasympathetic-related HRV indices and increases in sympathetic-related HRV parameters. The changes were in proportion to the severity of PLM. Brainwaves and sleep stage which indicate "deep sleep" decreased in the PLMS group. There were no significant temporal correlations between changes in HRV and leg movement events.

CONCLUSIONS

Our findings suggest that patients with RLS and PLMS have poorer subjective sleep and mood scales. Besides, objective sleep quality including HRV analysis and brainwaves analysis revealed reduced parasympathetic tone, increased sympathetic tone, and sleep disturbance, which reveal the possibility of a higher risk for secondary disease.

Therapeutic Approaches for the Management of Sleep Disorders in Geriatric Population

OBJECTIVE

Aging is a natural biological phenomenon that occurs in human beings. With increasing of age, there is an appearance of deleterious changes related to progression onto pathological conditions, including hypertension, heart disease, diabetes, hearing and vision impairments, as well as sleep disorders. It is important to recognize that some sleep disturbances reported by aged subjects include insomnia, obstructive sleep apnea, restless legs syndrome, among others. Moreover, accumulating evidence indicates that coexistence of medical issues with sleep disorders constitutes clinical challenges for treatment of comorbidities in elderly. Here, we have attempted to review and summarize the available literature that assesses the sleep disturbances in aging. In addition, we highlight the management of sleep disorders associated with aging. Due to the particular health condition of aged adults, the development of effective pharmacological interventions for sleep disorders treatment in aging is warranted.

METHODS

Review of studies retrieved from the PubMed.

RESULTS

The sleep-wake cycle includes abnormalities classified as sleep disorders. Comorbidity between sleep disturbances and aging-related health issues will represent a public health challenge to be addressed in the near future. Moreover, this scenario will suggest an area that requires further drug investigation and design of new pharmacological and pharmaceutical strategies to treat sleep disorders in the elderly population.

CONCLUSION

The review highlights the sleep disturbances in aging. We focus on current knowledge in medicinal chemistry and further design of new treatments tools for managing sleep disturbances in the aged population.

Genetic and epidemiological characterization of restless legs syndrome in Québec

Currently, a total of 19 genetic loci are associated with the risk for developing RLS. This study aimed to assess these RLS predisposing genetic variants, as well as investigate the epidemiological profile and diagnostic features of individuals with RLS in the Québec population, using an interviewer–administered questionnaire. A total of 18 RLS-associated variants were genotyped in the Québec population-based CARTaGENE cohort. A case–control series consisting of 1,362 RLS cases and 1,379 age-matched unaffected controls was used to conduct a genetic and epidemiological association study that integrated the first four RLS diagnostic features of affected individuals, as well as additional RLS-related questions (e.g. frequency of the symptoms and number of total pregnancies in female). Five RLS-predisposing variants were significantly associated after Bonferroni correction and an additional five variants were nominally associated with RLS (p &lt; 0.05). BTBD9 was the strongest genetic risk factor in our cohort (rs9296249, OR = 1.71, p = 9.57 × 10−10). The patient group that met all four essential diagnostic criteria of RLS provided the most significant genetic findings. These results suggest that employing the questionnaire which included standard diagnostic criteria of RLS could improve the accuracy of the survey-based studies.

Improvement of Restless Legs Syndrome Under Treatment of Cancer Pain With Morphine and Fentanyl

Restless-Legs-Syndrome (RLS), also known as Willis-Ekbom disease, is a sleep- and rest related disorder characterized by the unpleasant urge to move the legs. Pharmacological therapy is mainly based on dopamine-agonists and delta-2-alpha calcium channel ligands. Also, randomized-controlled-trials (RCTs) reported effectiveness of oral oxycodone (in combination with naloxone), and intrathecal opioids have also been administered for this indication. In the case reported here, a patient with advanced pancreatic cancer was referred to an acute palliative care unit for the treatment of cancer-related pain. Yet, in thorough exploration of her symptom burden, the patient reported that she felt her quality of life had been predominantly limited by symptoms other than cancer pain. Her medical history and neurological examination revealed that these symptoms were most obviously caused by severe RLS. In the years before, pharmacological therapies with dopamine-agonists and delta-2-alpha calcium channel ligands were initiated, but failed to relieve the RLS. In the palliative care ward, intravenous morphine was successfully titrated to treat her cancer pain. Concurrently, the patient also experienced almost complete relief from her RLS-symptoms and an increase in quality of life. The amelioration of her RLS-symptoms continued after morphine therapy was switched from intravenous to oral administration. Even after the patient was dismissed to home care and opioid rotation to transdermal fentanyl, symptom control of RLS remained excellent. To our knowledge, this is the first report of successfully treating RLS with intravenous and oral morphine. Since morphine is more easily available worldwide and the cost of morphine therapy is substantially lower compared to oxycodone/naloxone, comparisons to morphine may be an intriguing option for future RCTs.

Elevation of tumor necrosis factor alpha levels is associated with restless legs symptoms in clinically depressed patients

BACKGROUND

Restless legs syndrome is a sensorimotor disorder associated with several mental illnesses particularly depression.

METHODS

A cross-sectional study of primary care patients. The prevalence of restless legs symptoms was studied in 706 patients with depressive symptoms and 426 controls without a psychiatric diagnosis by using a structured questionnaire. The depressive symptoms were evaluated with the BDI and the psychiatric diagnosis was confirmed by means of a diagnostic interview (M.I.N.I.). The subjects with elevated depressive symptoms were divided into two groups subjects with depressive symptoms with and without clinical depression.

RESULTS

The prevalence of restless legs symptoms was 24.8% in the controls, 50.0% in the patients with clinical depression and 42.4% in the patients with depressive symptoms. CRP value was significantly higher (p = .003) in the clinically depressed patients than in the other groups. There was a higher concentration of TNF-α in the subjects with restless legs symptoms (7.4 ng/l ± 3.2) compared with the subjects without symptoms (6.7 ng/l ± 2.3)(p < .001). There was a significant difference in the TNF-α levels between the subjects with and without restless legs symptoms in the depression group (p < .001) and among the patients with depressive symptoms but no a depression diagnosis (p = .022). In these groups, restless legs symptoms were associated with elevated levels of TNF-α.

CONCLUSIONS

TNF-α level was associated with restless legs symptoms only among subjects with depressive symptoms whether they had clinical depression or not. We suggest that TNF-α could be an underlying factor between restless legs symptoms and comorbidities.

Restless Legs Syndrome and Other Movement Disorders of Sleep-Treatment Update

PURPOSE OF REVIEW

The purpose of this review article is to summarize and discuss the recent advances in the treatment of restless legs syndrome (RLS), as well as REM sleep behavior disorder (RBD), and periodic leg movement disorder (PLMD).

RECENT FINDINGS

Traditionally, dopaminergic therapy has been considered the sole option for first-line treatment of RLS due to their impressive acute efficacy. Dopamine agonists such as oral pramipexole and ropinirole, as well as transdermal rotigotine are all effective treatment options. However, augmentation of the RLS symptoms is a major limitation of oral dopaminergic therapy. Recently, gabapentinoid agents such as gabapentin enacarbil and pregabalin have shown comparable short-term efficacy to dopaminergics with lower risk of augmentation of the RLS symptoms. Recent evidence on the efficacy of oxycodone-naloxone in treatment-resistant RLS provides an additional therapeutic avenue. The increasing understanding of the role of iron in RLS pathophysiology has led to new options in iron supplementation therapy in RLS, including treatment with ferric carboxymaltose. With emerging evidence of augmentation being a side effect specific to dopaminergic treatment, gabapentinoids are considered a safer option as initial treatment. In severe refractory RLS, oxycodone-naloxone can be used. If iron stores are low, IV iron formulations should be the initial treatment choice. New treatment options are needed to address issues with current therapies.

An Overview of the Clinical Uses, Pharmacology, and Safety of Modafinil

Modafinil (MOD) is a wakefulness-inducing compound prescribed for treatment of excessive daytime sleepiness as a consequence of sleep disturbances such as shift work sleep disorder, obstructive sleep apnea, restless leg syndrome, or narcolepsy. While providing effective results in patients with sleepiness, MOD also produces positive outcomes in the management of fatigue associated with different conditions including depression, cancer, or tiredness in military personnel. Although there is clear evidence of the stimulant effects of MOD, current data also show that administration of this drug apparently induces positive neurobiological effects, such as improvement in memory. However, serious concerns have been raised since some reports have suggested MOD dependence. Taken together, these findings highlight the need to characterize the changes induced by MOD which have been observed in several neurobiological functions. Moreover, further work should follow up on the likely long-term effects of this drug if used for treatment of drowsiness and tiredness. Here, we review and summarize recent findings of the medical uses of MOD in the management of sleepiness and fatigue associated with depression or cancer as well as exhaustion in military personnel. We also discuss the available literature related with the cognitive enhancing properties of this stimulant, as well as what is known and unknown about MOD addiction.

Restless Legs Syndrome/Willis-Ekbom Disease Is Prevalent in Working Nurses, but Seems Not to Be Associated with Shift Work Schedules

Insomnia and excessive sleepiness are among the most commonly reported sleep problems related to shift work. Sleep-related movement disorders have, however, received far less attention in relation to such work schedules. The objective of this study was to investigate the association between different shift work schedules and the prevalence of Restless legs syndrome/Willis–Ekbom disease (RLS/WED) in a large sample of Norwegian nurses. Our hypothesis was that shift working nurses would report higher prevalence of RLS/WED compared to day workers. A total of 1,788 nurses with different work schedules (day work, two-shift rotation, night work, three shift rotation) participated in a cohort study, started in 2008/2009. Four questions about RLS/WED based on the diagnostic criteria were included in wave 4 (2012). RLS/WED prevalence rates across different shift schedules were explored by the Pearson chi-square test. Logistic regression analysis was used to assess the association between RLS/WED and work schedules and shift work disorder (SWD) with adjustment for sex, age, marital status, smoking, and caffeine use. In total, 90.0% of the nurses were females, mean age 36.5 years (SD = 8.6, range 25–67). The overall prevalence of RLS/WED was 26.8%. We found no significant differences between the prevalence of RLS/WED across the different shift schedules, ranging from 23.3% (day work) to 29.4% (night work). There was a significant difference (p < 0.001) in the prevalence of RLS/WED between nurses having SWD (33.5%) compared to nurses not having SWD (23.8%). SWD remained significantly associated with RLS/WED in the adjusted logistic regression analysis (1.56, CI: 1.24–1.97). This study did not support the hypothesis. RLS/WED was associated with SWD, which might indicate that nurses vulnerable to shift work also are sensitive to other complaints related to a misalignment of the biological clock.