Restless legs syndrome: A community-based study of prevalence, severity, and risk factors

Sex and Sleep Disruption as Contributing Factors in Alzheimer's Disease

Alzheimer's disease (AD) affects more women than men, with women throughout the menopausal transition potentially being the most under researched and at-risk group. Sleep disruptions, which are an established risk factor for AD, increase in prevalence with normal aging and are exacerbated in women during menopause. Sex differences showing more disrupted sleep patterns and increased AD pathology in women and female animal models have been established in literature, with much emphasis placed on loss of circulating gonadal hormones with age. Interestingly, increases in gonadotropins such as follicle stimulating hormone are emerging to be a major contributor to AD pathogenesis and may also play a role in sleep disruption, perhaps in combination with other lesser studied hormones. Several sleep influencing regions of the brain appear to be affected early in AD progression and some may exhibit sexual dimorphisms that may contribute to increased sleep disruptions in women with age. Additionally, some of the most common sleep disorders, as well as multiple health conditions that impair sleep quality, are more prevalent and more severe in women. These conditions are often comorbid with AD and have bi-directional relationships that contribute synergistically to cognitive decline and neuropathology. The association during aging of increased sleep disruption and sleep disorders, dramatic hormonal changes during and after menopause, and increased AD pathology may be interacting and contributing factors that lead to the increased number of women living with AD.

Effects of Different Exercise Programs on Symptoms, Sleep, and Quality of Life in Patients with Primary Restless Legs Syndrome

Background

Restless legs syndrome (RLS) is a sensorimotor disorder that can have a significant detrimental impact on the quality of life and sleep.

Objectives

Our aim was to examine the effects of aerobic exercise and stretching exercise programs on symptom severity, sleep, and quality of life in patients with primary RLS.

Methods

A total of 18 patients between the ages of 22 and 61 were randomly divided into 3 groups as aerobic exercise, stretching exercises, and control. All exercise programs were applied 3 times a week for 8 weeks. Evaluations were performed before and after treatment. Symptom severity of the patients was evaluated by the International Restless Legs Syndrome Study Group Rating Scale, sleep was evaluated with the Pittsburgh Sleep Quality Index and actigraphy, and quality of life was evaluated with the John Hopkins Restless Legs Syndrome Quality of Life Questionnaire. Recovery status of the patients was determined using the post treatment global change scale.

Results

Aerobic exercise and the stretching exercise program were found to be effective in decreasing RLS symptoms (P = 0.025, P = 0.034) and improving subjective sleep quality (P = 0.034, P = 0.025), overall sleep quality (P < 0.001, P = 0.034), and quality of life (P = 0.009, P = 0016). Aerobic exercises were found to be more effective in reducing wake after sleep onset of sleep (P = 0.048), whereas stretching exercises reduced sleep disorders (P = 0.025).

Conclusion

Both exercise approaches have been identified as highly effective approaches in patients with RLS. The treatment can be planned according to the choice of the available facilities, patient and clinician preference, and the advantages of the 2 exercise approaches.

Effects of iron-deficient diet on sleep onset and spinal reflexes in a rodent model of Restless Legs Syndrome

Restless Legs Syndrome (RLS) is a common sensorimotor and a sleep disorder that affects 2.5-10% of the European and North American populations. RLS is also often associated with periodic leg movements during sleep (PLMS). Despite ample evidence of genetic contributions, the underlying mechanisms that elicit the sensory and motor symptoms remain unidentified. Clinically, RLS has been correlated with an altered central iron metabolism, particularly in the brain. While several animal models have been developed to determine the outcome of an altered iron homeostasis on brain function, the potential role of an altered iron homeostasis on sleep and sensorimotor circuits has not yet been investigated. Here, we utilize a mouse model to assess the effects of an iron-deficient (ID) but non-anemic state on sleep time and episodes, and sensorimotor reflexes in male and female mice. We found that animals on the ID diet displayed an increased expression of the transferrin receptor in the spinal cord, confirming the results of previous studies that focused only on the impact of ID in the brain. We also demonstrate that the ID diet reduced hematocrit levels compared to controls but not into the anemic range, and that animals on the ID diet exhibited RLS-like symptoms with regard to sleep onset and spinal cord reflex excitability. Interestingly, the effects on the spinal cord were stronger in females than in males, and the ID diet-induced behaviors were rescued by the return of the animals to the control diet. Taken together, these results demonstrate that diet-induced ID changes to CNS function are both inducible and reversible, and that they mimic the sleep and sensorimotor RLS symptoms experienced in the clinic. We therefore propose replacing the commonly used phrase "brain iron deficiency" (BID) hypothesis in the RLS research field with the term "iron deficiency in the central nervous system" (ID-CNS), to include possible effects of altered iron levels on spinal cord function.

Worldwide estimation of restless legs syndrome: a systematic review and meta-analysis of prevalence in the general adult population

This systematic review, meta-analysis and meta-regression assessed the prevalence of restless legs syndrome (RLS) in the general adult population. Studies identified in Scopus, PubMed, Web of Science, and PsycInfo between January 2000 and February 2022 were included if they used a case-control or cross-sectional design and reported data regarding the prevalence of RLS. The protocol was pre-registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022300709). A total of 97 studies including 483,079 participants from 33 different countries met the eligibility criteria. The Newcastle Ottawa Scale was used to evaluate the methodological quality, and the fill-and-trim method was used to correct probable publication bias, while the jack-knife method was performed to assess small study effect. The corrected overall pooled prevalence of RLS was 3% (95% confidence interval [CI] 1.4%-3.8%). The pooled prevalence of RLS syndrome was affected by methodological quality (no data from non-respondents in the included studies), gender (higher among women), study design (lower prevalence in case-control versus cohort and cross-sectional studies). The figures for corrected pooled prevalence among men, women, alcohol consumers and smokers were 2.8% (95% CI 2%-3.7%); 4.7% (95% CI 3.2%-6.3%); 1.4% (95% CI 0%-4.2%); and 2.7% (95% CI 0%-5.3%), respectively. The prevalence among male and female participants was lower in community-based versus non-community-based studies. Moreover, the prevalence was higher in developed versus developing countries and among elders versus adults. In conclusion, RLS is a common disorder in the general adult population, with a higher prevalence in women; however, prevalence data are affected by study design and quality.

Putative Animal Models of Restless Legs Syndrome: A Systematic Review and Evaluation of Their Face and Construct Validity

Restless legs syndrome (RLS) is a sensorimotor disorder that severely affects sleep. It is characterized by an urge to move the legs, which is often accompanied by periodic limb movements during sleep. RLS has a high prevalence in the population and is usually a life-long condition. While its origins remain unclear, RLS is initially highly responsive to treatment with dopaminergic agonists that target D2-like receptors, in particular D2 and D3, but the long-term response is often unsatisfactory. Over the years, several putative animal models for RLS have been developed, mainly based on the epidemiological and neurochemical link with iron deficiency, treatment efficacy of D2-like dopaminergic agonists, or genome-wide association studies that identified risk factors in the patient population. Here, we present the first systematic review of putative animal models of RLS, provide information about their face and construct validity, and report their role in deciphering the underlying pathophysiological mechanisms that may cause or contribute to RLS. We propose that identifying the causal links between genetic risk factors, altered organ functions, and changes to molecular pathways in neural circuitry will eventually lead to more effective new treatment options that bypass the side effects of the currently used therapeutics in RLS, especially for long-term therapy.

Myoclonus and other jerky movement disorders

Myoclonus and other jerky movements form a large heterogeneous group of disorders. Clinical neurophysiology studies can have an important contribution to support diagnosis but also to gain insight in the pathophysiology of different kind of jerks. This review focuses on myoclonus, tics, startle disorders, restless legs syndrome, and periodic leg movements during sleep. Myoclonus is defined as brief, shock-like movements, and subtypes can be classified based the anatomical origin. Both the clinical phenotype and the neurophysiological tests support this classification: cortical, cortical-subcortical, subcortical/non-segmental, segmental, peripheral, and functional jerks. The most important techniques used are polymyography and the combination of electromyography-electroencephalography focused on jerk-locked back-averaging, cortico-muscular coherence, and the Bereitschaftspotential. Clinically, the differential diagnosis of myoclonus includes tics, and this diagnosis is mainly based on the history with premonitory urges and the ability to suppress the tic. Electrophysiological tests are mainly applied in a research setting and include the Bereitschaftspotential, local field potentials, transcranial magnetic stimulation, and pre-pulse inhibition. Jerks due to a startling stimulus form the group of startle syndromes. This group includes disorders with an exaggerated startle reflex, such as hyperekplexia and stiff person syndrome, but also neuropsychiatric and stimulus-induced disorders. For these disorders polymyography combined with a startling stimulus can be useful to determine the pattern of muscle activation and thus the diagnosis. Assessment of symptoms in restless legs syndrome and periodic leg movements during sleep can be performed with different validated scoring criteria with the help of electromyography.

Restless legs syndrome: Over 50 years of European contribution

Restless legs syndrome (RLS) is a sensorimotor neurological disorder characterised by an urge to move the limbs with a circadian pattern (occurring in the evening/at night), more prominent at rest, and relieved with movements. RLS is one of the most prevalent sleep disorders, occurring in 5%-10% of the European population. Thomas Willis first described RLS clinical cases already in the 17th century, and Karl-Axel Ekbom described the disease as a modern clinical entity in the 20th century. Despite variable severity, RLS can markedly affect sleep (partly through the presence of periodic leg movements) and quality of life, with a relevant socio-economic impact. Thus, its recognition and treatment are essential. However, screening methods present limitations and should be improved. Moreover, available RLS treatment options albeit providing sustained relief to many patients are limited in number. Additionally, the development of augmentation with dopamine agonists represents a major treatment problem. A better understanding of RLS pathomechanisms can bring to light novel treatment possibilities. With emerging new avenues of research in pharmacology, imaging, genetics, and animal models of RLS, this is an interesting and constantly growing field of research. This review will update the reader on the current state of RLS clinical practice and research, with a special focus on the contribution of European researchers.

Huzursuz bacak sendromunun kan parametreleri ile olan ilişkisi

sağlıklı kontrol grubu ile bazı laboratuvar parametreleri açısından karşılaştırarak etyopatogenezi etkileyen faktörleri araştırmak amaçlanmıştır. Gereç ve Yöntem: Huzursuz bacak sendromu tanısı konulan hastalar çalışmaya dahil edildi. Yaş ve cinsiyet açısından benzer kontrol grubu oluşturuldu. Her iki grup demir, ferritin, demir bağlama kapasitesi, folat, vitamin B12, vitamin D, kalsiyum, magnezyum, ALT, AST, hemogram, kreatinin, açlık kan şekeri, tiroid hormon seviyeleri açısından karşılaştırıldı. Bulgular: Çalışmaya 37 huzursuz bacak sendromu hastası, 41 tane de kontrol dahil edildi. Huzursuz bacak sendromu grubunda hemoglobin, ferritin, demir, açlık kan şekeri, D vitamini ve fT4 değerleri sırasıyla 12.7 (10.3-16.0) g/dL, 37.3 (3.7-89.4) mg/L, 62 (21-195) μg/dL, 96 (65-250) mg/L, 11.26 (4.20-41.57) ug/L ve 1.24 (0.73-2.14) µg/dL iken kontrol grubunda sırasıyla 14.8 (12.3-16.1) g/dL, 56 (9-189) mg/L, 90 (30-245) µg/dL, 91 (70-107) mg/L, 17.31 (5.73-32.90) µg/L ve 1.08 (0.63-2.04) µg/dL idi. Hemoglobin, ferritin, demir, açlık kan şekeri, vitamin D ve T4 seviyeleri açısından gruplar arasında istatistiksel olarak anlamlı farklılıklar saptandı. Sonuç: Huzursuz bacak sendromlu hastalarda hemoglobin ve demir parametreleri, vitamin D düzeyleri, açlık kan şekeri ve T4 seviyeleri eksiklikleri açısından mutlaka değerlendirilmeli, gereklilik halinde mutalaka replase edilmelidir. Eksikliklerin düzeltilmesi hastaların klinikleri açısından yararlı olabilir.

Prevalence of restless legs syndrome in pregnant women in Oman and its effect on pregnancy and neonatal outcomes

BACKGROUND:

Restless legs syndrome (RLS) is a common sensorimotor disorder during pregnancy. The purpose of this study was to assess the prevalence of RLS and explore the associated risk factors and outcomes in Omani women in the first and third trimester and at 2-week postpartum.

MATERIALS AND METHODS:

This cross-sectional study included 305 pregnant women visiting four health centers in Muscat between May 2018 and October 2020. A structured questionnaire was used and data were collected through review of electronic records and face-to-face interviews. The International RLS Study Group criteria were used to diagnose RLS. Participants were interviewed during their first trimester, their third trimester, and at their 2-week postpartum visit. Results were presented as means and standard deviations or percentages, as appropriate. To assess the association between RLS and various variables, unpaired t-test or McNemar's test were used, as appropriate.

RESULTS:

The mean age at baseline was 29.8 ± 5.28 years. The prevalence of RLS was significantly higher in the third trimester (41.0%) than in the first trimester (15.7%) and postpartum period (15.1%) (P < 0.001), although there was no significant difference in severity. Family history and personal history of RLS were the only independent correlates of RLS (P < 0.001 and 0.002, respectively). No associations were noted with pregnancy and neonatal outcomes or other comorbidities, including anemia. However, there was a significant relationship between the development of RLS and weight gain during pregnancy (P = 0.023).

CONCLUSION:

One in six pregnant Omani women may be at risk of RLS during the first trimester, while one in 2–3 may be at risk in the third trimester, particularly those with a personal or family history of RLS and those who gain >12 kg during pregnancy.

Prevalence of restless legs syndrome in people with diabetes mellitus: A pooling analysis of observational studies

BACKGROUND

Diabetes mellitus (DM) is associated with different clinical complications. The aim of this study was to explore the prevalence of RLS in people with diabetes mellitus and compare the risk of restless leg syndrome (RLS) between diabetic and non-diabetic population.

METHODS

We searched for studies of RLS prevalence in DM through PubMed, Embase, and Web of Science. Two authors independently completed the literature screening, data extraction, and bias risk assessment of eligible studies. All observational studies that assessed the prevalence or risk of RLS in DM were included, where the diagnosis of RLS was based on the International Restless Legs Syndrome Study Group (IRLSSG). Percentages, odds ratio (OR) with 95% confidence intervals (CI) were used to assess pooled estimates of RLS prevalence and risk based on random-effects models. Newcastle-Ottawa-scale (NOS) or a modified NOS were used to evaluate the quality of studies.

FINDINGS

A total of 42 studies, including 835,986 participants, met the eligibility criteria for the meta-analysis. Among them, 30 studies were included in meta-analysis to analyze the prevalence of RLS. A second meta-analysis was conducted using 31 studies to determine RLS risk between diabetes and non-diabetes. The results indicate that between 25% (95% confidence interval 21%-29%) of people with diabetes showed signs of RLS, and people with diabetes had an increased risk of developing RLS compare to people without diabetes (OR 1.98, 95%CI 1.66- 2.34, p < 0.001). However, the available evidence was limited due to potential risk of bias and variability between studies (I² >75%), all of observational design.

INTERPRETATION

Our study suggests that the prevalence and risk of RLS might be higher in DM patients than in non-diabetes population. However, given limitations in the analysis and study design, the findings need to be corroborated in future studies.

FUNDING

This work was supported by the Basic Conditions Platform Construction Project of Sichuan Science and Technology Department (2019JDPT0015), and the "1・3・5 project for disciplines of excellence, West China Hospital, Sichuan University" (ZYJC18003).

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.

Autism and chronic ill health: an observational study of symptoms and diagnoses of central sensitivity syndromes in autistic adults

BACKGROUND

Autistic adults, particularly women, are more likely to experience chronic ill health than the general population. Central sensitivity syndromes (CSS) are a group of related conditions that are thought to include an underlying sensitisation of the central nervous system; heightened sensory sensitivity is a common feature. Anecdotal evidence suggests autistic adults may be more prone to developing a CSS. This study aimed to investigate the occurrence of CSS diagnoses and symptoms in autistic adults, and to explore whether CSS symptoms were related to autistic traits, mental health, sensory sensitivity, or gender.

METHODS

The full sample of participants included 973 autistic adults (410 men, 563 women, mean age = 44.6) registered at the Netherlands Autism Register, who completed questionnaires assessing autistic traits, sensory sensitivity, CSS, physical and mental health symptoms. The reliability and validity of the Central Sensitization Inventory (CSI) in an autistic sample was established using exploratory and confirmatory factor analyses. Chi2 analyses, independent t-tests, hierarchical regression and path analysis were used to analyse relationships between CSS symptoms, autistic traits, measures of mental health and wellbeing, sensory sensitivity, age and gender.

RESULTS

21% of participants reported one or more CSS diagnosis, and 60% scored at or above the clinical cut-off for a CSS. Autistic women were more likely to report a CSS diagnosis and experienced more CSS symptoms than men. Sensory sensitivity, anxiety, age and gender were significant predictors of CSS symptoms, with sensory sensitivity and anxiety fully mediating the relationship between autistic traits and CSS symptoms.

LIMITATIONS

Although this study included a large sample of autistic adults, we did not have a control group or a CSS only group. We also could not include a non-binary group due to lack of statistical power.

CONCLUSIONS

CSS diagnoses and symptoms appear to be very common in the autistic population. Increased awareness of an association between autism and central sensitisation should inform clinicians and guide diagnostic practice, particularly for women where CSS are common and autism under recognised.

Successful treatment of restless leg syndrome with the traditional herbal medicines Dangguijakyak-san and Shihogyeji-tang: A case report (CARE-compliant)

RATIONALE

Dopamine replacement is currently the standard treatment for restless leg syndrome (RLS); however, various adverse effects are associated with long-term therapy, and the benefits disappear upon discontinuation. To overcome these limitations, interest in traditional East Asian medicine has increased.

PATIENT CONCERNS

A 72-year-old Asian woman originally admitted for an intracerebral hemorrhage presented with complaints of an unpleasant sensation throughout the body that appeared at night.

DIAGNOSES

The patient was diagnosed with chronic persistent RLS based on the 2012 Revised International Restless Leg Syndrome Study Group Diagnostic Criteria.

INTERVENTIONS

The patient was treated with extracts of the traditional herbal medicines Dangguijakyak-san (DS) and Shihogyeji-tang (ST). After 47 days of therapy, all herbal medicines were discontinued, and symptoms had not returned by the last follow-up 244 days after the initial treatment.

OUTCOMES

One week after initiating herbal treatment with DS and ST, the RLS symptoms began to improve, and the total hours of sleep had increased from 2 to 9 hours by day 21, with a Korean version of the international restless legs scale score of 11 points. On day 36, ST was discontinued, given the continued improvement of symptoms. On day 47, symptoms had disappeared (Korean version of the international restless legs scale score: 0), and sleep disturbances caused by RLS had completely resolved. After day 47, DS was also discontinued. There were no adverse effects associated with the administration of DS and ST, and the symptoms had not recurred by the last follow-up on day 244.

LESSONS

In this case, RLS related symptoms, which had been present for approximately 60 years, were improved using only the traditional herbal medicines DS and ST (without dopamine replacement), and no symptoms recurred for 244 days. This case suggests that if replacement therapy is difficult or not desired, herbal medicinal therapies may be an effective alternative. This also suggests that the effect of herbal medicine on RLS might be semi-permanent. Further investigations, including clinical trials, are needed to confirm these effects.

Language analysis of spontaneous descriptions of restless legs syndrome: Gender differences?

Patients with restless legs syndrome (RLS) use various terms when describing their symptoms. Whether gender might influence this has not been investigated so far. The aim of this study was to evaluate possible gender differences in spontaneous descriptions of RLS symptoms. This prospective study, conducted in 100 consecutive German‐speaking RLS patients, used a single standardized question. Answers were digitally recorded and transcribed. A content‐related linguistic analysis of the transcripts was performed by two independent blinded raters. The lengths of the answers and content‐related linguistic features were compared between women and men. Ninety‐eight patients were included in the final analysis, 59 women (60.2%) and 39 men (39.8%), with a median age of 62 (23–94) and 63 (31–82) years, respectively (p = 0.602). Demographic and clinical features, including educational level and RLS treatment class, did not differ between genders (p > 0.05). Total word or sentence count showed no gender differences (p = 0.159 and 0.259, respectively), although men used more words per sentence than women (p = 0.018). More men than women described quiescegenic (i.e., triggered by rest or inactivity) symptoms (p = 0.006) and successful attempts at relief (p = 0.039). There was a non‐significant trend toward a more frequent use of the first‐person perspective in men (median times used = 5 [0–10.5] vs. 3.8 [0–17.5], p = 0.068). The more frequent mention of quiescegenic symptoms and successful attempts at relief in men could indicate differences in phenotypic presentation of RLS between genders, a more precise description of RLS symptoms or a higher experience of self‐efficacy in men compared to women.

Signs of sympathetic and endothelial cell activation in the skin of patients with restless legs syndrome

OBJECTIVES

To evaluate skin biopsies of patients with early- and late onset restless legs syndrome (RLS) for concomitant small fiber neuropathy (SFN) and to determine cutaneous sympathetic innervation and microvascularization in comparison to healthy individuals.

METHODS

Density of intraepidermal nerve fibers (IENFD), adrenergic nerve fibers and dermal capillaries was analyzed by immunofluorescence for PGP9.5, tyrosine hydroxylase and endothelial markers CD31 and CD105 in skin biopsies of 11 individuals with RLS and 8 age- and sex-matched controls.

RESULTS

IENFD did not differ between RLS and controls, but two RLS patients with comorbid impaired glucose metabolism fulfilled morphometric criteria of SFN according to published normative values. In contrast, dermal nerve bundles of RLS patients showed an increased density of tyrosine hydroxylase⁺ adrenergic nerve fibers (p < 0.005). Moreover, an increased ratio between immature CD105⁺ and mature CD31⁺ endothelial cells within dermal capillaries was observed in RLS (p < 0.02).

CONCLUSIONS

SFN, as a potential contributing factor for RLS, should be considered in patients with predisposing comorbidities presenting with burning or shooting pain, dysesthesias and impaired sensory and temperature perception. Evidence of an increased adrenergic innervation of the skin in RLS patients is in accordance with sympathetic hyperactivity while signs of endothelial cell activation may reflect an adaptive response to tissue hypoxia.

A potential role for zinc in restless legs syndrome

STUDY OBJECTIVES

Evaluate serum and brain noniron metals in the pathology and genetics of restless legs syndrome (RLS).

METHODS

In two independent studies (cohorts 1 and 2), in which subjects either remained on medications or tapered off medications, we analyzed serum levels of iron, calcium, magnesium, manganese, copper, and zinc both in RLS patients and controls, and assessed the prevalence of the MEIS1 and BTBD9 risk alleles previously established through genome-wide association studies. Human brain sections and a nematode genetic model were also quantified for metal levels using mass spectrometry.

RESULTS

We found a significant enrichment for the BTBD9 risk genotype in the RLS affected group compared to control (p = 0.0252), consistent with previous literature. Serum (p = 0.0458 and p = 0.0139 for study cohorts 1 and 2, respectively) and brain (p = 0.0413) zinc levels were significantly elevated in the RLS patients versus control subjects.

CONCLUSION

We show for the first time that serum and brain levels of zinc are elevated in RLS. Further, we confirm the BTBD9 genetic risk factor in a new population, although the zinc changes were not significantly associated with risk genotypes. Zinc and iron homeostasis are interrelated, and zinc biology impacts neurotransmitter systems previously linked to RLS. Given the modest albeit statistically significant increase in serum zinc of ~20%, and the lack of association with two known genetic risk factors, zinc may not represent a primary etiology for the syndrome. Further investigation into the pathogenetic role that zinc may play in restless legs syndrome is needed.

Birds of a Feather Flock Together: Disadvantageous Decision Making in Augmented Restless Legs Syndrome Patients with and without Impulse Control Disorders

Background: Augmentation (AUG) in patients with restless legs syndrome (RLS) can be associated with impulse control disorder (ICD) symptoms, such as compulsive sexual behavior, gambling disorder or compulsive shopping. In this study, we wanted to assess whether RLS patients with AUG differ in decision making from those patients who have augmentation and in addition ICD symptoms (AUG + ICD) in a post hoc analysis of a patient cohort assessed in a previous study. Methods: In total, 40 RLS patients with augmentation (19 AUG + ICD, 21 AUG without ICDs) were included. RLS diagnosis, severity, and diagnosis of augmentation were made by sleep disorder specialists. ICD symptoms were assessed using semi-structured interviews. All patients performed the beads task, which is an information sampling task where participants must decide from which of the two cups colored beads were drawn. Results were compared to 21 healthy controls (HC). Results: There was no difference in information sampling or irrational decision making between AUG and AUG + ICD patients (p = 0.67 and p = 1.00, respectively). Both patient groups drew less beads and made more irrational decisions than HC (all p-values < 0.03, respectively). Conclusions: Our results suggest that augmentation itself is associated with poorer decision making even in the absence of ICD symptoms. Further studies are necessary to explore whether rapid and hasty decision making are a harbinger of augmentation in RLS.

Restless Legs Syndrome and Periodic Limb Movements in 86 patients with Multiple Sclerosis

STUDY OBJECTIVES

To assess the frequency of restless legs syndrome (RLS), periodic limb movements during sleep (PLMS) and their overlap in a large sample of patients with multiple sclerosis (MS). To compare clinical and paraclinical findings among four sub-groups of patients: RLS-/PLMS- (patients without RLS and PLMS), RLS+/PLMS- (patients with RLS and without PLMS), RLS-/PLMS (patients without RLS and with PLMS), RLS+/PLMS+ (patients with both RLS and PLMS).

METHODS

In this cross-sectional, observational, instrumental study, eighty-six patients (M/F: 27/59; mean age 48.0 ± 10.8 years) with a diagnosis of MS underwent a telephone interview assessing the five standard diagnostic criteria for RLS. Seventy-six participants underwent polysomnography (PSG) and maintenance of wakefulness test. Instrumental and clinical findings were subsequently statistically compared to investigate their association with RLS and PLMS index (PLMSI).

RESULTS

RLS and PLMS (PLMSI ≥15/h) frequency in patients with MS was of 31.4% and 31.6% respectively. Among patients with RLS, 37.5% had a PLMSI ≥15/h. RLS-/PLMS+ group showed higher wake after sleep onset (p = 0.01), stage shifts per hour (p = 0.03), increased stage N1 (p = 0.03) and reduction in stage N3 (p = 0.01) compared to RLS-/PLMS-. RLS had no influence on clinical and PSG parameters (p = 0.45).

CONCLUSIONS

RLS is highly frequent in patients with MS. The frequency of PLMS is comparable to the general population. The low percentage of patients with RLS having a high PLMSI, together with the absence of correlation between RLS and female gender and older age, support the existence of a distinct symptomatic form of RLS in MS.

The prevalence of restless legs syndrome in patients undergoing coronary angiography and its relationship with the severity of coronary artery stenosis

PURPOSE

Results from studies on the relationship between restless legs syndrome (RLS) and coronary artery disease (CAD) are conflicting. Some studies associate RLS with CAD by heart rate variability, blood pressure variability, and other autonomic, neuronal reasons, while other studies do not support these observations. The aim of this study was to investigate the prevalence of RLS in patients undergoing coronary angiography for CAD and to assess RLS prevalence with severity of CAD.

METHODS

After inclusion and exclusion criteria were applied, enrolled patients with less than 50% coronary artery stenosis by angiography (0-49%) were assigned to group 1, and patients with 50% or more coronary artery stenosis were assigned to group 2. Patients were diagnosed with RLS if they met all five essential criteria of the International RLS study group. RLS prevalence and other comorbidities were compared between the two groups.

RESULTS

Of 126 patients, 74 men (59%), mean age 64.0 ± 8.7 years, mean BMI 29.6 kg/m2, 47 (37%) were assigned to group 1 (no or nonobstructive CAD) and 79 (63%) were assigned to group 2 (obstructive CAD). No significant differences were found between the groups in terms of mean age, BMI, gender, or prevalence of hypertension, hypercholesterolemia, and DM. The prevalence of RLS in group 2 (29%) was significantly higher than in group 1 (15%), p = 0.013.

CONCLUSION

These results suggest that prevalence of RLS is associated with CAD and with CAD severity. We conjecture that RLS may be related to vascular endothelial dysfunction in cardiovascular disease.

The Effect of Parenteral or Oral Iron Supplementation on Fatigue, Sleep, Quality of Life and Restless Legs Syndrome in Iron-Deficient Blood Donors: A Secondary Analysis of the IronWoMan RCT

Background: Besides anemia, iron deficiency may cause more subtle symptoms, including the restless legs syndrome (RLS), the chronic fatigue syndrome (CFS) or sleeping disorders. Objective: The aim of this pre-planned secondary analysis of the IronWoMan randomized controlled trial (RCT) was to compare the frequency and severity of symptoms associated with iron deficiency before and after (intravenous or oral) iron supplementation in iron deficient blood donors. Methods/Design: Prospective, randomized, controlled, single-centre trial. (ClinicalTrials.gov: NCT01787526). Setting: Tertiary care center in Graz, Austria. Participants: 176 (138 female and 38 male) whole-blood and platelet apheresis donors aged ≥ 18 and ≤ 65 years with iron deficiency (ferritin ≤ 30ng/mL at the time of blood donation). Interventions: Intravenous iron (1 g ferric carboxymaltose, n = 86) or oral iron supplementation (10 g iron fumarate, 100 capsules, n = 90). Measurements: Clinical symptoms were evaluated by a survey before iron therapy (visit 0, V0) and after 8–12 weeks (visit 1, V1), including questions about symptoms of restless legs syndrome (RLS), chronic fatigue syndrome (CFS), sleeping disorders, quality of life and symptoms like headaches, dyspnoea, dizziness, palpitations, pica and trophic changes in fingernails or hair. Results: We found a significant improvement in the severity of symptoms for RLS, fatigue and sleep quality (p < 0.001). Furthermore, a significant decrease in headaches, dyspnoea, dizziness and palpitations was reported (p < 0.05). There was no difference between the type of iron supplementation (intravenous versus oral) and clinical outcome data. Conclusion: Iron supplementation in iron-deficient blood donors may be an effective strategy to improve symptoms related to iron deficiency and the wellbeing of blood donors.

Acupuncture and Moxibustion for restless legs syndrome: A systematic review and meta-analysis protocol

INTRODUCTION

Previous reviews indicate that the effect of acupuncture and moxibustion (AM) on restless legs syndrome (RLS) remains uncertainty. The results of trials published in the past 12 years may possibly change this situation, but an updated systematic review is not available. We therefore designed this study to systematically assess the effectiveness and safety of AM for treating RLS.

METHODS AND ANALYSIS

Nine online databases will be searched from inception to October 01 2019; there will be no language restrictions on the included trials. Randomized controlled trials that included patients with RLS receiving AM therapy versus a control group will be included. The selection of studies, risk of bias assessment and data extraction will be conducted by 2 independent researchers. Data synthesis will be performed by using RevMan V.5.2 software with fixed effects model or random effects model, according to the heterogeneity test. The dichotomous data will be presented as risk ratios with 95% confidence intervals (Cis) and the continuous data will be presented as weighted mean differences or standardized mean differences with 95% CIs. Evidence quality will be evaluated by using the grading of recommendations assessment (GRADE), development and evaluation system with low risk, unclear risk, and high risk.

ETHICS AND DISSEMINATION

This systematic review and meta-analysis is literature research which will not refer to private information and not impair one's health, so, ethical approval is not required. The results of this study will be published in a journal or concerned conferences.

PROSPERO REGISTRATION NUMBER

CRD42019148325.

Convergence of psychiatric symptoms and restless legs syndrome: A cross-sectional study in an elderly French population

OBJECTIVE

The objective was to evaluate the association between restless legs syndrome (RLS) with generalized anxiety disorder (GAD), major depression disorder (MDD), dysthymia, and GAD-depression comorbidity. Secondary aims were to examine the association between RLS with the cognitive-affective and somatic-vegetative disturbances experienced as part of depression and GAD.

METHODS

This was a cross-sectional study of 1493 elderly participants (median age 80.6 years, 64% women) from Dijon, France. Probable RLS was assessed using the minimal diagnostic criteria of the International Restless Legs Study Group and RLS symptom frequency and treatment. Participants underwent structured interviews for MDD, dysthymia, and GAD. Participants also completed the Center for Epidemiological Studies-Depression scale (CES-D). The association between RLS and psychiatric disorders, their criterion symptoms, or symptom factors was examined using logistic regression.

RESULTS

The point prevalence of probable RLS in this sample was 8.2%. Probable RLS was associated with isolated GAD (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.01-4.68) and comorbid GAD-any depression disorder (OR 3.26, 95% CI 1.14-9.29), but not MDD or dysthymia. Probable RLS was also associated with the GAD criterion worry most days and feeling tense, and the CES-D factors representing depressed affect, somatic symptoms, and positive affect.

CONCLUSIONS

Probable RLS was associated with GAD-depression comorbidity as well as isolated GAD. The findings challenge previous reports linking RLS solely with MDD, suggesting the association is partly driven by GAD-depression comorbidity.

Determinants of Nocturnal Cardiovascular Variability and Heart Rate Arousal Response in Restless Legs Syndrome (RLS)/Periodic Limb Movements (PLMS)

Recent studies have suggested that restless legs syndrome is associated with an increased prevalence of cardiovascular diseases mediated by sympathetic activation occurring during periodic limb movements. The aim of this study was to establish which factors affect the degree of sympathetic activation during the basal condition and during periodic limb movements that may contribute to increased vascular risk. Fifty untreated restless legs syndrome patients aged 62.6 ± 11.1 y, free of cardiovascular diseases, were examined. Heart rate variability was calculated during wakefulness and all sleep stages, during periods with and without periodic limb movements. Heart rate changes before and after periodic limb movement onset were analyzed to assess the arousal response to periodic limb movements. Both analyses took into account the effects of age, gender, periodic limb movement duration, periodic limb movement index, periodic limb movement interval and periodicity, and magnitude of muscular activity (electromyogram power). Compared to periods without periodic limb movements, a significant increase in sympathetic activity occurred in periods with periodic limb movements, independent of age, sex and periodic limb movement characteristics. Data obtained from the cardiac arousal response to periodic limb movements showed that electromyogram power is the factor affecting sympathetic tonus. These results suggest that other factors, such as electromyogram power and individual susceptibility, should be considered in the assessment of the vascular risk related to restless legs syndrome.

The experience of living with restless legs syndrome: A qualitative study

Restless legs syndrome is a sensorimotor disorder that significantly affects quality of life. This study explored the experience of people living with restless legs syndrome. Focus groups were analysed thematically resulting in five themes. Participants described disempowerment in managing symptoms, difficulty coping and poor understanding of the condition. Participants tried many therapies with little relief and were unable to monitor treatment effects. Concerns with healthcare services were common. Feeling understood provided validation and empowerment. Healthcare providers can help people with restless legs syndrome by improving restless legs syndrome awareness, providing psychosocial support and education, and assisting people to monitor treatment effects.

Sleep disturbances in patients with amyotrophic lateral sclerosis: current perspectives

Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disease inevitably leading to generalized muscle weakness and premature death. Sleep disturbances are extremely common in patients with ALS and substantially add to the burden of disease for both patients and caregivers. Disruption of sleep can be caused by physical symptoms, such as muscle cramps, pain, reduced mobility, spasticity, mucus retention, and restless legs syndrome. In addition, depression and anxiety may lead to significant insomnia. In a small subset of patients, rapid eye movement (REM) sleep behavioral disorder may be present, reflecting neurodegeneration of central nervous system pathways which are involved in REM sleep regulation. With regard to overall prognosis, sleep-disordered breathing (SDB) and nocturnal hypoventilation (NH) are of utmost importance, particularly because NH precedes respiratory failure. Timely mechanical ventilation is one of the most significant therapeutic measures to prolong life span in ALS, and transcutaneous capnometry is superior to pulse oxymetry to detect NH early. In addition, it has been shown that in patients on home ventilatory support, survival time depends on whether normocapnia, normoxia, and elimination of apneic events during sleep can be reliably achieved. Several studies have investigated sleep patterns and clinical determinants of sleep disruption in ALS, but exact prevalence numbers are unknown. Thus, constant awareness for sleep-related symptoms is appropriate. Since no curative treatment can be offered to affected patients, sleep complaints should be thoroughly investigated in order to identify any treatable etiology and improve or stabilize quality of life as much as possible. The use of hypnotics should be confined to palliation during the terminal phase and refractory insomnia in earlier stages of the disease, taking into account that most compounds potentially aggravate SDB.

Restless legs syndrome, periodic limb movements during sleep and cardiovascular risk

Multiple mechanisms may modulate an association between restless legs syndrome/Willis-Ekbom disease (RLS/WED) and cardiovascular disease (CVD), including chronic sleep deprivation, intermittent, periodic limb movements in sleep (PLMS)-related autonomic fluctuations and possible autonomic dysfunction intrinsically associated with RLS per se. The purpose of this paper is to review the existing RLS/WED literature focusing on the pathophysiologic evidence for possible associations between RLS/WED and PLMS with CVD and events (CVE). Specific intrinsic dysautonomic aspects of the disease, which may contribute to generating CVD, are separately discussed. The association between RLS/WED and both CV risk factors and CVD still remains elusive. Although several shared pathophysiological causes could explain these possible relationships, the emerging body of literature focusing on these disorders remains controversial. Not only longitudinal population-based studies and meta-analyses, but also more animal models and therapeutic interventions are needed in order to build a sufficiently robust body of evidence on this topic.

Gender differences in clinical, laboratory and polysomnographic features of restless legs syndrome

Restless legs syndrome is a common neurological disorder with a clear female predominance. This study aims to evaluate gender differences in clinical, laboratory and polysomnographic features in patients with restless legs syndrome. For this retrospective analysis, 42 women and 42 men from the Innsbruck RLS database matched by age and therapy were included. Demographic data as well as different severity scales (IRLS, RLS‐6 and CGI) were evaluated. Laboratory parameters included several indicators of serum iron status. In all patients, polysomnography was performed according to the AASM guidelines, and periodic leg movements during sleep were scored according to the AASM criteria. IRLS, RLS‐6 and CGI revealed more severe symptoms in women (IRLS median [range]: 17.5 [0–35] versus 13.5 [0–32], p = 0.028; RLS‐6 median [range]: 18 [0–39] versus 12 [1–42], p = 0.014). Women had lower serum ferritin levels than men (median [range] in μg L⁻¹: 74 [9–346] versus 167 [15–389], p < 0.001). Twenty‐two women and eight men (53.7% versus 22.2%, p = 0.003) had ferritin values below 75 μg L⁻¹. Periodic leg movements during sleep indices were significantly lower in women than in men (median [range] in number per hr: 11.4 [0–62.5] versus 40 [0–154], p = 0.004, and 12.6 [0–58.5] versus 40 [0.5–208], p = 0.002, for night I and night II, respectively). Restless legs syndrome severity as measured by validated scales was worse in women, while periodic leg movements during sleep indices were higher in men. These results suggest a possible gender difference in phenotypical presentation of restless legs syndrome, manifesting with predominantly sensory symptoms in women and predominantly motor symptoms in men.

Restless Legs Syndrome in Parkinson's Disease Patients: Clinical Features Including Motor and Nonmotor Symptoms

Background and Purpose

We investigated the frequency and clinical features of restless legs syndrome (RLS) in patients with Parkinson's disease (PD).

Methods

This study included 74 PD patients. RLS was diagnosed in face-to-face assessments of all of the subjects based on diagnostic criteria of the International Restless Legs Syndrome Study Group revised in 2003. We analyzed the clinical features of PD patients with and without RLS and compared the data to idiopathic RLS.

Results

The frequency of RLS in the cohort was 21.6% (n=16). Two (12.5%) of the patients with RLS were not treated with dopaminergic drugs, while 14 (24.1%) of the 58 patients without RLS received treatment with dopaminergic drugs. Anxiety, depression, and quality of life (QoL) were significantly worst in patients with RLS. PD patients with RLS had significantly worse sleep quality (p=0.003) and worse scores on the cardiovascular subscale of the Scales for Outcomes in Parkinson's Disease for Autonomic Symptoms (p=0.031) compared to those without RLS. In the group of PD patients with RLS, RLS preceding PD onset was related to a lower Hoehn and Yahr stage.

Conclusions

We found that the frequency of RLS in the present patients with PD was higher than that in our previous study of a general population of RLS subjects. Compared to the PD patients without RLS, the present PD patients with RLS suffered from worse sleep quality and QoL, depression, anxiety, and autonomic disturbances, especially those with cardiovascular problems.

Paediatric neurodisability and sleep disorders: clinical pathways and management strategies

Sleep disorders are common in children with neurodisability. Their presentation is often complex. This complexity of presentation can make sleep disorders in children with neurodisability daunting to diagnose and manage. Both parents and healthcare professionals have identified sleep disorders as a healthcare outcome that they prioritise in children with neurodisability. We aim to explore the challenges of diagnosing sleep problems, discuss common difficulties with sleep in children with neurodisability and will touch on how to set up a service to support and manage sleep, working through case examples.

Acute-onset Restless legs syndrome in acute neurological conditions-a prospective study on patients with the Guillain-Barre syndrome and acute stroke

OBJECTIVES

While the Restless legs syndrome (RLS) is usually recognized as a chronic condition, it has often been diagnosed among patients with acute neurological illnesses, in which limb discomfort is reported. This study was conducted to determine how many among these, actually have acute-onset RLS, and also to evaluate characteristics of this subgroup of patients with Guillain-Barre syndrome (GBS) and stroke developing acute-onset RLS.

METHODS

Consecutive patients diagnosed with GBS and eligible stroke patients, admitted to our Neurology services over a 1-year period, were enrolled. They were evaluated for symptoms of RLS based on IRLSSG consensus criteria and the AIIMS RLS Questionnaire for Indian patients (ARQIP).

RESULTS

Forty adults with GBS and 58 with stroke were included. A total of 10 of the 40 (25%) patients with GBS developed definite acute RLS, which was mostly monophasic. Seven (70%) of these had demyelinating type of GBS, a significant association with acute RLS (P = .024). Six of the 58 stroke patients (10%) developed definite acute-onset, often persistent RLS. Subcortical location showed significant association with increased risk of developing acute RLS (P < .001). All patients diagnosed with acute-onset RLS had an immediate and good response to dopamine agonists.

CONCLUSION

This is the first study showing that acute-onset RLS is common, affecting nearly 25% of patients with GBS and 10% patients with acute stroke. Recognizing and treating it can majorly contribute toward symptom relief and early improvement in the quality of life for this population.

Involvement of the central somatosensory system in restless legs syndrome

Objective

To investigate morphologic changes in the somatosensory cortex and the thickness of the corpus callosum subdivisions that provide interhemispheric connections between the 2 somatosensory cortical areas.

Methods

Twenty-eight patients with severe restless legs syndrome (RLS) symptoms and 51 age-matched healthy controls were examined with high-resolution MRI at 3.0 tesla. The vertex-wise analysis in conjunction with a novel cortical surface classification method was performed to assess the cortical thickness across the whole-brain structures. In addition, the thickness of the midbody of the corpus callosum that links postcentral gyri in the 2 hemispheres was measured.

Results

We demonstrated that a morphologic change occurred in the brain somatosensory system in patients with RLS compared to controls. Patients with RLS exhibited a 7.5% decrease in average cortical thickness in the bilateral postcentral gyrus (p < 0.0001). Accordingly, there was a substantial decrease in the corpus callosum posterior midbody (p < 0.008) wherein the callosal fibers are connected to the postcentral gyrus, suggesting altered white matter properties in the somatosensory pathway.

Conclusion

Our results provide in vivo evidence of morphologic changes in the primary somatosensory system, which could be responsible for the sensory functional symptoms of RLS. These results provide a better understanding of the pathophysiology underlying the RLS sensory symptoms and could lead to a potential imaging marker for RLS.

Non-pharmacological interventions for restless legs syndrome: a systematic review of randomised controlled trials

Introduction: Restless legs syndrome (RLS) is a sensorimotor disorder characterised by an uncomfortable urge to move the legs. Management is primarily pharmacological. Effects for non-pharmacological, non-surgical options are published but lack systematic examination. Objectives: To synthesise results of non-pharmacological/non-surgical treatment compared to no-treatment controls or alternative treatment for RLS on any relevant outcome. Methods: Databases and reference lists of reviews were searched for randomised controlled trials (RCTs) comparing non-pharmacological treatment to alternative or no treatment controls for idiopathic RLS. Search results were independently screened for inclusion by two researchers; disagreements regarding eligibility were resolved with discussion. Outcomes were summarised, and pooled where possible in meta-analysis. Results: The search yielded 442 articles. Eleven trials met inclusion criteria. Repetitive transcranial magnetic stimulation, exercise, compression devices, counterstrain manipulation, infrared therapy, and standard acupuncture were significantly more effective for RLS severity than control conditions. Vibration pads, cryotherapy, and transcranial direct current stimulation were ineffective in reducing RLS severity. Vibration pads, cryotherapy, yoga, compression devices, and acupuncture significantly improved some sleep-related outcomes. Conclusions: Few studies were identified and quality of evidence was not high. Some non-pharmacological interventions may be beneficial for reducing RLS severity and enhancing sleep. Implications for Rehabilitation The current management of restless leg syndrome is primarily pharmacological, and medications can have unwanted side effects. Repetitive transcranial magnetic stimulation, exercise, compression devices, counterstrain manipulation, infrared therapy, and standard acupuncture may reduce restless leg syndrome severity. Vibration pads, cryotherapy, yoga, compression devices, and acupuncture may improve some sleep-related outcomes in restless leg syndrome. Non-pharmacological interventions for RLS may cause placebo effects and rehabilitation professionals should control for this possibility in future investigations.

Association between serum hepcidin level and restless legs syndrome

BACKGROUND

To better understand the role of iron homeostasis dysregulation in restless legs syndrome, we compared serum hepcidin and ferritin levels in drug-free patients with primary restless legs syndrome and healthy controls and studied the relationship between hepcidin level and restless legs syndrome severity.

METHODS

One hundred and eight drug-free patients with primary restless legs syndrome (65 women; median age, 61.5 years) and 45 controls (28 women; median age, 53.9 years) were enrolled. Inclusion criteria were: normal ferritin level (>50 ng/mL) and absence of iron disorders, chronic renal or liver failure, and inflammatory or neurological diseases. Each subject underwent a thorough clinical examination and a polysomnography assessment. Serum hepcidin-25 was quantified using a validated mass spectrometry method. Restless legs syndrome severity was evaluated according to the International Restless Legs Syndrome Study Group.

RESULTS

Despite no group difference between normal ferritin levels and demographic features, serum hepcidin level and hepcidin/ferritin ratio were higher in patients than in controls. Hepcidin level and hepcidin/ferritin ratio, but not ferritin level, were positively correlated with periodic leg movements during sleep and wakefulness in the whole sample. Hepcidin level seem to be associated with restless legs syndrome severity in a complex U-shaped relationship, without relationship with age at restless legs syndrome onset, positive family history, sleep and depressive symptoms, genetic background, and polysomnographic measurements. No relationship was found between ferritin level and restless legs syndrome severity.

CONCLUSION

In drug-free patients with primary restless legs syndrome, hepcidin level is higher than in controls and may be associated with restless legs syndrome clinical severity. This result emphasizes the complex peripheral iron metabolism deregulation in restless legs syndrome, opening potential perspectives for a personalized approach with a hepcidin antagonist. © 2018 International Parkinson and Movement Disorder Society.

Association Between Restless Legs Syndrome and Adult ADHD in a German Community-Based Sample

OBJECTIVE

Previous research in clinical samples indicated a significant association between ADHD and restless legs syndrome (RLS). The present study examined the association between adult ADHD and RLS in the German population.

METHOD

Self-rating instruments to assess RLS, childhood ADHD, and adult ADHD were administered to a community-based sample ( N = 1,632). In addition, current depression and anxiety, sleep disturbances, weight, and height were assessed by self-report.

RESULTS

Adult ADHD was associated with statistically significant increases in the odds of meeting diagnostic criteria for RLS even when adjusting for potential confounding variables such as weight (odds ratio [OR] = 3.18, 95% confidence interval [CI] = [1.29, 7.63], p< .001). However, the association did not hold true after adjusting for the presence of sleep disturbances (OR = 2.02, 95% CI = [0.82, 4.96], p = .13).

CONCLUSION

The findings suggest a strong link between RLS and adult ADHD symptoms. Clinicians should be aware of RLS among adult ADHD patients, especially as there might be a negative interactive effect.

Restless Legs Syndrome: From Pathophysiology to Clinical Diagnosis and Management

Restless legs syndrome (RLS), a common neurological sensorimotor disorder in western countries, has gained more and more attention in Asian countries. The prevalence of RLS is higher in older people and females. RLS is most commonly related to iron deficiency, pregnancy and uremia. The RLS symptoms show a significant circadian rhythm and a close relationship to periodic limb movements (PLMs) in clinical observations, while the pathophysiological pathways are still unknown. The diagnostic criteria have been revised in 2012 to improve the validity of RLS diagnosis. Recent studies have suggested an important role of iron decrease of brain in RLS pathophysiology. Dopaminergic (DA) system dysfunction in A11 cell groups has been recognized long ago from clinical treatment and autopsy. Nowadays, it is believed that iron dysfunction can affect DA system from different pathways and opioids have a protective effect on DA system. Several susceptible single nucleotide polymorphisms such as BTBD9 and MEIS1, which are thought to be involved in embryonic neuronal development, have been reported to be associated with RLS. Several pharmacological and non-pharmacological treatment are discussed in this review. First-line treatments of RLS include DA agents and α2δ agonists. Augmentation is very common in long-term treatment of RLS which makes prevention and management of augmentation very important for RLS patients. A combination of different types of medication is effective in preventing and treating augmentation. The knowledge on RLS is still limited, the pathophysiology and better management of RLS remain to be discovered.

Prevalence of Restless Legs Syndrome in Patients with Inflammatory Bowel Disease

BACKGROUND AND AIM

There has been increased interest in sleep disorders in patients with inflammatory bowel disease (IBD). Studies in North America and Europe reported that the prevalence of restless legs syndrome (RLS) is much higher in patients with Crohn's disease (CD) than in the general population. The aim of this study was to reveal the prevalence and clinical features of RLS in Japanese patients with IBD and investigate the influence of RLS on sleep quality and quality of life (QOL).

METHODS

The study included 80 outpatients with IBD who visited Nagasaki University Hospital between December 2012 and July 2014. All patients completed the international RLS study group rating scale, a validated measure of the presence of RLS. Sleep quality was assessed using the Japanese version of the Pittsburgh Sleep Quality Index (PSQI), and health-related QOL was assessed using the Japanese version of the 36-item short form healthy profile (SF-36) version 2.

RESULTS

The prevalence of RLS in patients with IBD was 20%, including rates of 21.7% in patients with ulcerative colitis (UC) and 17.6% in patients with CD. Among patients with CD, the proportion of women and serum level of CRP were higher in the RLS group than in the non-RLS group. Among those with UC, there were no differences in clinical characteristics between the RLS and non-RLS groups. Patients in the RLS group slept significantly less well than those in the non-RLS group (PSQI > 5; 62.5 vs. 34.4%, P < 0.05). No significant relationships were observed between QOL indices and the presence of RLS (SF-36 physical score, 46.8 vs. 50.1; mental score, 43.8 vs. 45.7; role/social score, 48.1 vs. 49.2).

CONCLUSIONS

RLS occurs frequently in Japanese patients with UC as well as CD. RLS affects sleep quality but not QOL, and it should be considered one of the causes of sleep disturbance in patients with IBD.

Lifestyle Factors and Risk of Restless Legs Syndrome: Prospective Cohort Study

STUDY OBJECTIVES

To examine the association between modifiable lifestyle factors, and the risk of developing restless legs syndrome (RLS).

METHODS

This is a Prospective Cohort study of population including 12,812 men participating in Health Professionals Follow-up Study and 42,728 women participating in the Nurses' Health study II. The participants were free of RLS at baseline (2002 for the HPFS and 2005 for the NHS II) and free of diabetes and arthritis through follow-up. RLS was assessed via a set of questions recommended by International Restless Legs Syndrome Study group. The Information was collected on height, weight, level of physical activity, dietary intake, and smoking status via questionnaires.

RESULTS

During 4-6 years of follow-up, we identified 1,538 incident RLS cases. Participants with normal weight, and who were physically active, non-smoker, and had some alcohol consumption had a lower risk of developing RLS. When we combined the effects of these four factors together, we observed a dose response relationship between the increased number of healthy lifestyle factors and a low risk of RLS: after adjusting for potential confounders the pooled odds ratio was 0.67 (95% CI: 0.47-0.97) for 4 vs.0 healthy factors (p trend < 0.001). In contrast, we did not observe significant associations between caffeine consumption or diet quality as assessed by the Alternate Healthy Eating Index, and altered RLS risk in men and women.

CONCLUSIONS

Several modifiable lifestyle factors may play an important role in RLS risk.