Algorithms for the diagnosis and treatment of restless legs syndrome in primary care

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.

A Case Report of Grave's Disease Presenting With an Episode of Restless Legs Syndrome

This case report explores a rare presentation of restless legs syndrome (RLS) in a 59-year-old female with a history of Graves' disease (GD), highlighting the diagnostic challenges and the importance of considering thyroid dysfunctions in RLS. The patient, previously diagnosed and treated for GD, presented with acute nocturnal discomfort in her lower limbs, along with symptoms of fatigue, weight loss, and palpitations. Physical examinations and thyroid function tests indicated a recurrence of GD. Her RLS symptoms notably resolved following the treatment of GD with methimazole, pointing towards secondary RLS induced by GD. This case emphasizes the necessity of a comprehensive diagnostic approach in RLS, particularly in differentiating it from mimicking conditions including leg cramps, arthritis, peripheral neuropathy, and drug-induced akathisia, and identifying underlying etiologies like thyroid dysfunctions. The resolution of RLS symptoms after GD treatment underlines the potential link between thyroid dysfunctions, iron metabolism, and the dopaminergic system in RLS pathophysiology.

Insomnia in Postmenopausal Women: How to Approach and Treat It?

Insomnia is one of the major complaints of menopausal women with advancing age and may be complexly related to a variety of causes. However, there is still a lack of standards on the general approach and treatment for insomnia in menopausal women. The aim of this review is to summarize recent pathogenic theories of sleep disturbance in the menopausal period and discuss the approach and management of insomnia in postmenopausal women. Sleep disturbances in menopausal women may be associated with physical and psychiatric factors and other comorbid diseases. Careful history taking and multidisciplinary physical and psychosocial evaluation are necessary and, in particular, comorbidities related to sleep disorders, such as obstructive sleep apnea, must be taken into consideration. A unique aspect of insomnia in postmenopausal women is that menopausal symptoms due to hormonal decline can be closely related to sleep disturbances. Therefore, menopausal hormone therapy (MHT) should be considered as the treatment of choice among pharmacological treatments following cognitive behavioral therapy, which is suggested as the first-line treatment in the general population insomnia treatment guidelines. Additionally, melatonin and 5HT-based drugs, which have fewer side effects, along with MHT should be preferentially recommended in menopausal women.

Modification and Validation of a Diagnostic Questionnaire for Restless Legs Syndrome: Modified-Restless Legs Syndrome Diagnostic Questionnaire (m-RLS-DQ)

Background

Diagnostic questionnaire that are available for restless legs syndrome does not include items related to RLS mimics and, hence, increases chances of false positive cases. This study aimed at modification and validation of RLS-diagnostic Questionnaire.

Methods

During modification, additional items were identified, developed, and subjected to evaluation by experts. Experts were requested to validate the content of each item. Based on their responses, content validity indices (average and universal agreement) were calculated. It was then translated to Hindi and validated in a clinical population that included patients with RLS, somatic symptoms disorder, anxiety, other RLS mimics, and osteoarthritis. In addition, a group of healthy controls was also included. Face, concurrent, and discriminant validities were calculated.

Results

Among 209 subjects, nearly 40 subjects had clinical diagnosis of RLS, osteoarthritis, somatic-symptoms-disorder, and anxiety disorder, each. In addition, 16 patients had other RLS mimics (akathisia, varicose veins, BFS, leg-cramps, chronic insomnia) and 30 were healthy controls. After multiple revisions, content validity indices achieved a score of 1 for m-RLS-DQ. Sensitivity and specificity of m-RLS-DQ v. 1.4 for the diagnosis of RLS were 94.9% and 94.1%, respectively. For the diagnosis of RLS, PPV was 78.7%, and NPV was 98.7% with an accuracy of 94.3%. Less than one fourth of participants having chronic insomnia, somatic symptoms disorder, anxiety disorder, and knee osteoarthritis were found to be false positive on m-RLS-DQ; however, none of the healthy controls were found positive on m-RLS-DQ. Concurrent validity with clinical diagnosis of RLS was 0.83 (P < 0.001). Discriminant validity with somatic symptoms disorder was -0.14 (P = 0.03) and with osteoarthritis -0.24 (P < 0.001).

Conclusion

m-RLS-DQ is a valid instrument with acceptable psychometric properties, which can be used for the screening as well as diagnosis of RLS in clinical practice and research studies.

Humans have a basic physical and psychological need to move the body: Physical activity as a primary drive

Physical activity, while less necessary for survival in modern times, is still essential for thriving in life, and low levels of movement are related to numerous physical and mental health problems. However, we poorly understand why people move on a day-to-day basis and how to promote greater energy expenditure. Recently, there has been a turn to understand automatic processes with close examination of older theories of behavior. This has co-occurred with new developments in the study of non-exercise activity thermogenesis (NEAT). In this narrative review, it is hypothesized that psycho-physiological drive is important to understand movement in general and NEAT, specifically. Drive, in short, is a motivation state, characterized by arousal and felt tension, energizing the organism to acquire a basic need. Movement is a biological necessity, like food, water, and sleep, but varies across the lifespan and having the greatest impact before adolescence. Movement meets various criteria for a primary drive: (a) deprivation of it produces feelings of tension, such as an urge or craving, known as affectively-charged motivation states, and particularly the feelings of being antsy, restless, hyper or cooped up, (b) provision of the need quickly reduces tension - one can be satiated, and may even over-consume, (c) it can be provoked by qualities of the environment, (d) it is under homeostatic control, (e) there is an appetite (i.e., appetence) for movement but also aversion, and (f) it has a developmental time course. Evidence for drive has mainly come from children and populations with hyperkinetic disorders, such as those with anorexia nervosa, restless legs syndrome, and akathisia. It is also stimulated in conditions of deprivation, such as bed rest, quarantine, long flights, and physical restraint. It seems to be lacking in the hypokinetic disorders, such as depression and Parkinson's. Thus, drive is associated with displeasure and negative reinforcement, subsuming it within the theory of hedonic drive, but it may fit better within new paradigms, such as the WANT model (Wants and Aversions for Neuromuscular Tasks). Recently developed measurement tools, such as the CRAVE scale, may permit the earnest investigation of movement drive, satiation, and motivation states in humans.

The prevalence and associated factors of seasonal exacerbation of subjective symptoms in Japanese patients with restless legs syndrome

OBJECTIVES

To elucidate the prevalence of seasonal exacerbation in patients with restless legs syndrome (RLS) and identify its associated factors.

METHODS

We investigated the presence/absence of seasonal exacerbation of RLS by distributing self-administered questionnaires with an interval of three years. Patients who reported having seasonal exacerbation in both surveys were defined as having seasonal exacerbation. RLS severity was determined using the International Restless Legs Syndrome Rating Scale (IRLS).

RESULTS

Among 180 patients, 89 reported having seasonal exacerbation in the first survey. Among them, only two reported not having seasonal exacerbation in the second survey; thus, 87 (48.3%) patients were considered to have a seasonal exacerbation. Although many of them (68 out of 87, 78.2%) experienced exacerbation in spring or summer, 19 out of 87 (21.8%) reported that their symptoms worsened in fall or winter. All the patients in this study had mild to moderate degrees of RLS severity according to the IRLS score. Multiple logistic regression analyses revealed that having a family history of RLS (p < 0.05) and moderate RLS (p < 0.001) were significantly associated with the presence of seasonal exacerbation.

CONCLUSIONS

This study revealed that approximately half of all RLS patients had seasonal exacerbation of the symptoms and that about 80% of the exacerbation was observed during the spring/summer season. Moreover, seasonal exacerbation is likely to be present even in patients whose symptoms had been improved to moderate severity with pharmacological treatment.

Assessing Cognitive Behavioral Therapy for Insomnia to Improve Sleep Outcomes in Individuals With a Concussion: Protocol for a Delayed Randomized Controlled Trial

BACKGROUND

Sleep disturbances post concussion have been associated with more frequent and severe concussion symptoms and may contribute to poorer recovery. Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment for insomnia; however, it remains unclear if this treatment method is effective in improving sleep outcomes and reducing concomitant postconcussion symptoms.

OBJECTIVE

The hypotheses for this study are that (1) CBT-I will improve sleep outcomes and (2) CBT-I will improve concomitant postconcussion symptoms.

METHODS

In total, 40 individuals who are within ≥4 weeks of postconcussion injury and have insomnia symptoms will be enrolled in this randomized controlled trial. Participants will be randomized into either a group that starts a 6-week CBT-I program immediately after baseline or a waitlist control group that starts CBT-I following a 6-week waiting period. All participants will be reassessed 6, 12, and 18 weeks after baseline. Standardized assessments measuring sleep outcomes, postconcussion symptoms, and mood will be used. Linear regression and t tests will be used for statistical analyses.

RESULTS

Enrollment of 40 participants was completed July 2022, data collection will be completed in November 2022, and publication of main findings is anticipated in May 2023. It is anticipated that participants experience reduced insomnia symptoms and postconcussion symptoms following CBT-I and these improvements will be retained for at least 12 weeks. Additionally, we expect to observe a positive correlation between sleep and postconcussion symptom improvement.

CONCLUSIONS

Successful completion of this pilot study will allow for a better understanding of the treatment of insomnia and postconcussion symptoms in individuals following a concussion.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04885205; https://clinicaltrials.gov/ct2/show/NCT04885205.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38608.

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.

An Exploratory Randomized Controlled Trial of a 12-Week Yoga Versus Educational Film Program for the Management of Restless Legs Syndrome: Feasibility and Acceptability

Objectives: The primary objectives of this pilot trial were to assess the study feasibility and acceptability of the 12-week yoga and educational film programs for the management of restless legs syndrome (RLS) in preparation for a future randomized controlled trial (RCT). Materials and Methods: This pilot, parallel-arm, randomized feasibility trial was conducted at two sites, Morgantown, WV and Columbus, OH. Yoga group participants attended 75-min Iyengar yoga classes, twice weekly for 4 weeks, then once a week for 8 weeks (16 total classes), and completed a 30-min homework routine on nonclass days. Educational film group participants attended once weekly, 75-min classes (12 total classes), which included information on RLS and other sleep disorders, RLS management including sleep hygiene practices, and complementary therapies. Feasibility and acceptability outcomes included program satisfaction and recruitment, retention, and adherence rates. In addition, participants were asked their preferences regarding three yoga class schedule scenarios for a future study. Attendance, yoga, and treatment logs were collected weekly. Program evaluation and yoga scheduling questionnaires were collected at week 12. Results: Forty-one adults with moderate to severe RLS were randomized to a 12-week yoga (n = 19) or educational film (n = 22) program. Thirty participants (73%) completed the program. Yoga and education group participants attended an average of 13.0 ± 0.84 (81%) and 10.3 ± 0.3 classes (85%), respectively. Participants from both groups indicated satisfaction with the study. All yoga group respondents to the program evaluation reported they would likely (n = 6) or very likely (n = 7) continue yoga practice; 86.7% of education group respondents (13 of 15) indicated that they were likely (n = 7) or very likely (n = 6) to make lasting changes based on what they had learned. The preferred schedule for a future study was a 16-week study with once-weekly yoga classes. Conclusions: The findings of this study suggest that a larger RCT comparing yoga with an educational film group for the management of RLS is feasible. Trial registration: Clinicaltrials.gov: NCT03570515; 02/01/2017.

Telehealth-Delivered Cognitive Behavioral Therapy for Insomnia in Individuals with Multiple Sclerosis: A Pilot Study

Background

Over 50% of individuals with multiple sclerosis (MS) have moderate or severe sleep disturbances, insomnia being the most common. In-person cognitive behavioral therapy for insomnia (F2F-CBTi) is currently the first-line treatment for insomnia. However, given potential limitations to access including mobility difficulty, fatigue, or living in a rural area, telehealth-delivered CBT-I (tele-CBTi) has been considered as an alternative treatment. The purpose of this study was to assess the feasibility and treatment effect of tele-CBTi in people with MS and compare it to outcomes from a F2F-CBTi study in individuals with MS.

Methods

11 individuals with MS and symptoms of insomnia participated in 6 weekly CBT-I sessions with a trained CBT-I provider via live video. Insomnia severity (ISI), sleep quality (PSQI), and fatigue severity (FSS and MFIS) were assessed pre- and posttreatment as primary outcomes. Sleep onset latency (SOL), sleep efficiency (SE) and total sleep time (TST) from the PSQI, depression (PHQ-9), anxiety (GAD-7), sleep self-efficacy (SSES), and quality of life (MSIS-29) were also assessed pre- and posttreatment as secondary outcomes.

Results

Participants resided in 9 different states. Retention and adherence rates were 100%. There were significant improvements in ISI, PSQI, MFIS, FSS, SOL, SSES, PHQ-9, and MSIS-29, but not SE, TST, or GAD-7. There were no significant differences between the F2F-CBTi group and tele-CBTi group for magnitude of change in the primary outcomes (ISI, PSQI, MFIS, and FSS) or the secondary outcomes (SOL, SE, TST, SSES, PHQ-9, GAD-7, and MSIS-29).

Conclusions

Tele-CBTi is feasible and has outcome measures that are similar to that of in-person CBT-I treatment. Tele-CBTi may increase access to insomnia treatment in individuals with MS.

Prevalence, severity and associated factors of restless leg syndrome in inflammatory bowel disease patients

BACKGROUND

The association between restless leg syndrome (RLS) and inflammatory bowel disease (IBD) has often been an under-investigated and clinically misdiagnosed entity. An emphasis should be made on the severity and associated factors, as the prevalence of both entities is on the rise globally. In this study we aimed to investigate the prevalence, severity and associated risk factors of RLS in patients with IBD.

METHODS

A multi-center, prospective cross-sectional study was conducted with age and gender matched controls in the ratio of 1:3. Cases of IBD were confirmed according to European Crohns and Colitis Organization guidelines. The study recruited 377 cases and 1131 age and gender-matched controls. RLS severity and prevalence was determined using a validated International Restless Legs Syndrome Study Group questionnaire. The anthropometric and blood biochemical measurements were retrieved from the patient's medical records. Associated factors were analyzed by regression analysis.

RESULTS

The prevalence of RLS in patients with IBD and non-IBD control groups was 21.5% and 9.7%, respectively (P = 0.001). The severity index of RLS symptoms in all the three categories of mild, moderate and severe RLS was higher in the IBD group (P = 0.001). Obesity (BMI >30 Kg/m²) was more prevalent in patients with IBD with RLS than without RLS (21.9%: 10.3%, P = 0.009). Ages between 46 and 59 years (OR = 18.7 [2.6-29.4], P = 0.008), obesity (OR = 22 [2.6-29.4], P = 0.005), higher TSH levels (OR = 1.7 [1.0-3.0], P = 0.033), and lower hemoglobin levels (P = 0.028) showed a greater risk associated with RLS.

CONCLUSION

Prevalence and severity of RLS was higher in patients with IBD. The risk factors for RLS in IBD include increasing age, obesity, higher TSH, and lower hemoglobin.

Clinical Decision-Making: Restless Legs Syndrome and Dementia in Older Adults

Restless legs syndrome (RLS), one of the more prevalent sleep disturbances among older adults, impacts quality of life. Patients with dementia are at high risk for developing RLS and may be unable to describe their symptoms. Often underdiagnosed, RLS can contribute to discomfort, pain, nighttime agitation, disturbed sleep, and falls. Clinical assessment is crucial and should include a thorough evaluation with input from the patient and family, deprescribing medication if possible, and consideration of common sleep-disturbing factors. Evidence-based treatment in this population is limited; overall focus should center on relieving discomfort while identifying and treating bothersome sleep symptoms.

Effects of a 12-week yoga versus a 12-week educational film intervention on symptoms of restless legs syndrome and related outcomes: an exploratory randomized controlled trial

STUDY OBJECTIVES

To assess the effects of a yoga versus educational film (EF) program on restless legs syndrome (RLS) symptoms and related outcomes in adults with RLS.

METHODS

Forty-one community-dwelling, ambulatory nonpregnant adults with moderate to severe RLS were randomized to a 12-week yoga (n = 19) or EF program (n = 22). In addition to attending classes, all participants completed practice/treatment logs. Yoga group participants were asked to practice at home 30 minutes per day on nonclass days; EF participants were instructed to record any RLS treatments used on their daily logs. Core outcomes assessed pretreatment and posttreatment were RLS symptoms and symptom severity (International RLS Study Group Scale (IRLS) and RLS ordinal scale), sleep quality, mood, perceived stress, and quality of life (QOL).

RESULTS

Thirty adults (13 yoga, 17 EF), aged 24 to 73 (mean = 50.4 ± 2.4 years), completed the 12-week study (78% female, 80.5% white). Post-intervention, both groups showed significant improvement in RLS symptoms and severity, perceived stress, mood, and QOL-mental health (P ≤ .04). Relative to the EF group, yoga participants demonstrated significantly greater reductions in RLS symptoms and symptom severity (P ≤ .01), and greater improvements in perceived stress and mood (P ≤ .04), as well as sleep quality (P = .09); RLS symptoms decreased to minimal/mild in 77% of yoga group participants, with none scoring in the severe range by week 12, versus 24% and 12%, respectively, in EF participants. In the yoga group, IRLS and RLS severity scores declined with increasing minutes of homework practice (r = .7, P = .009 and r = .6, P = .03, respectively), suggesting a possible dose-response relationship.

CONCLUSIONS

Findings of this exploratory RCT suggest that yoga may be effective in reducing RLS symptoms and symptom severity, decreasing perceived stress, and improving mood and sleep in adults with RLS.

CLINICAL TRIAL REGISTRATION

Registry: Clinicaltrials.gov; Title: Yoga vs. Education for Restless Legs: a Feasibility Study; Identifier: NCT03570515; URL: https://clinicaltrials.gov/ct2/show/NCT03570515.

Measurement of Motivation States for Physical Activity and Sedentary Behavior: Development and Validation of the CRAVE Scale

Physical activity, and likely the motivation for it, varies throughout the day. The aim of this investigation was to create a short assessment (CRAVE: Cravings for Rest and Volitional Energy Expenditure) to measure motivation states (wants, desires, urges) for physical activity and sedentary behaviors. Five studies were conducted to develop and evaluate the construct validity and reliability of the scale, with 1,035 participants completing the scale a total of 1,697 times. In Study 1, 402 university students completed a questionnaire inquiring about the want or desire to perform behaviors "at the present moment (right now)." Items related to physical activity (e.g., "move my body") and sedentary behaviors (e.g., "do nothing active"). An exploratory structural equation model (ESEM) revealed that 10 items should be retained, loading onto two factors (5 each for Move and Rest). In Study 2, an independent sample (n = 444) confirmed these results and found that Move and Rest desires were associated with stage-of-change for exercise behavior. In Study 3, 127 community-residing participants completed the CRAVE at 6-month intervals over two years- two times each session. Across-session interclass correlations (ICC) for Move (ICC = 0.72-0.95) and Rest (ICC = 0.69-0.88) were higher than when they were measured across 24-months (Move: ICC = 0.53; Rest: ICC = 0.49), indicating wants/desires have state-like qualities. In Study 4, a maximal treadmill test was completed by 21 university students. The CRAVE was completed immediately pre and post. Move desires decreased 26% and Rest increased 74%. Changes in Move and Rest desires were moderately associated with changes in perceived physical fatigue and energy. In Study 5, 41 university students sat quietly during a 50-min lecture. They completed the CRAVE at 3 time points. Move increased 19.6% and Rest decreased 16.7%. Small correlations were detected between move and both perceived energy and tiredness, but not calmness or tension. In conclusion, the CRAVE scale has good psychometric properties. These data also support tenets of the WANT model of motivation states for movement and rest (Stults-Kolehmainen et al., 2020a). Future studies need to explore how desires to move/rest relate to dynamic changes in physical activity and sedentarism.

Racial disparities in sleep health between Black and White young adults: The role of neighborhood safety in childhood

OBJECTIVES

Black adults in the United States have shorter sleep durations and poorer sleep efficiency relative to White adults, yet reasons for these disparities are not well explicated. The objective of this study was to examine neighborhood safety in childhood as a mediator of subsequent racial disparities in sleep.

METHODS

Data were from Black and White young adults attending a large, predominantly White university in the Southeastern United States (N = 263; 52% Black, 53% female; Mean age = 19.21 years, SD = 1.01). Sleep parameters were assessed from eight nights of wrist actigraphy (time in bed, sleep duration, and efficiency) and an established self-report measure of daytime sleepiness. Residential histories from birth through age 18 were documented, and retrospective self-reports of neighborhood safety in childhood were assessed.

RESULTS

Black participants had less time in bed (p < 0.001), shorter sleep duration (p < 0.001), poorer sleep efficiency (p < 0.001), and more daytime sleepiness (p = 0.009) than White participants. Neighborhood safety mediated race differences in time in bed (p = 0.028), sleep duration (p = 0.033), and daytime sleepiness (p = 0.048), but not sleep efficiency. Findings were substantively unchanged after adjustment for family socioeconomic status, BMI, and substance use.

CONCLUSIONS

Findings support the hypothesis that neighborhood safety in childhood may partially account for race differences in subsequent sleep duration and daytime sleepiness. Addressing racial inequities in childhood neighborhood safety may be an important step toward reducing racial disparities in sleep health.

[Restless legs syndrome in Parkinson's disease]

Disturbances in sleep and wakefulness are important symptoms of Parkinson's disease (PD) and are associated with negative effects on patients' quality of life. The analysis of literature on the relationship between RLS and PD revealed three main hypotheses explaining the relatively high incidence of RLS in PD: (1) RLS can be considered as an early (prodromal) manifestation or a predictor of PD that can outpace its main symptoms by several years (by analogy with conduct disorder during sleep with REM); (2) the high incidence of RLS in the advanced stage of PD may be associated with augmentation of previously latent RLS symptoms during prolonged dopaminergic therapy of PD; (3) a significant proportion of RLS cases in PD patients are not «classical» RLS, but represent, for example, manifestations of motor or non-motor fluctuations or a special form of stereotypy in the legs. Further research is needed to determine if any of these statements are true.

Motivation States for Physical Activity and Sedentary Behavior: Desire, Urge, Wanting, and Craving

To better explain daily fluctuations in physical activity and sedentary behavior, investigations of motivation are turning from social cognitive frameworks to those centered on affect, emotion and automaticity, such as the Affect and Health Behavior Framework (AHBF), Integrated Framework and Affective-Reflective Theory (ART). This shift has necessitated: (a) re-examination of older theories and their constructs, such as drives, needs and tensions and (b) an inspection of competing theories from other fields that also attempt to explain dynamic changes in health behaviors. The Dynamical Model of Desire, Elaborated Intrusion Theory and others commonly share with AHBF the idea that human behavior is driven strongly by desires and/or the similar concepts of wants, urges, and cravings. These affectively-charged motivation states (ACMS) change quickly and may better explain physical activity behavior from one moment to the next. Desires for movement predominantly derive from negative but also positive reinforcement. Data from clinical populations with movement dysfunction or psychiatric disorders provides further evidence of these drivers of movement. Those with Restless Legs Syndrome, akathisia, tic disorders and exercise dependence all report strong urges to move and relief when it is accomplished. Motor control research has identified centers of the brain responsible for wants and urges for muscular movement. Models elaborated herein differentiate between wants, desires, urges and cravings. The WANT model (Wants and Aversions for Neuromuscular Tasks) conceptualizes desires for movement and rest as varying by magnitude, approach or avoidance-orientation (wants versus aversions) and as occupying independent dimensions instead of opposite ends of the same axis. For instance, one hypothetically might be in a state of both high desire for movement and rest simultaneously. Variations in motivation states to move and rest may also be associated with various stress states, like freezing or fight and flight. The first validated instrument to measure feelings of desire/want for movement and rest, the CRAVE Scale (Cravings for Rest and Volitional Energy Expenditure) is already shedding light on the nature of these states. With these advances in theory, conceptual modeling and instrumentation, future investigations may explore the effects of desires and urges for movement and sedentary behavior in earnest.

Feasibility and Treatment Effect of a Web-Based Cognitive Behavioral Therapy for Insomnia Program in Individuals with Multiple Sclerosis: A Pilot Randomized Controlled Trial

Background

At least 40% of individuals with multiple sclerosis (MS) experience chronic insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment for insomnia symptoms in individuals with MS. Delivery of CBT-I using Web-based applications has been shown to be effective and may increase access to CBT-I for individuals with MS who have mobility difficulties, experience fatigue, or live in rural areas. Therefore, the purpose of this study was to assess the feasibility and treatment effect of CBT-I delivered using a Web-based application with or without biweekly telephone calls to improve sleep quality and fatigue in individuals with MS and symptoms of insomnia.

Methods

Forty-one individuals with MS and symptoms of insomnia were randomized into either a group that participated in a 6-week Web-based CBT-I program (wCBT-I) or a group that participated in a 6-week Web-based CBT-I program and received biweekly support telephone calls (wCBT-I + calls). Participants completed surveys online to assess insomnia severity, sleep quality, fatigue, sleep self-efficacy, depression, anxiety, and motivation to change their sleep behavior.

Results

The overall retention rate was 48.8%, and the adherence rate was 96.34%. Both groups had significant improvement in insomnia severity, sleep quality, sleep self-efficacy, and anxiety. Only the wCBT-I group had significant improvement in depression and fatigue.

Conclusions

Web-delivered CBT-I is feasible and effective in improving sleep outcomes and concomitant symptoms in individuals with MS. Web-based CBT-I may increase access to CBT-I treatment and provide a stepped-care approach to treating chronic insomnia in individuals with MS.

A comparison of diabetes self-care behavior in people with type 2 diabetes with and without insomnia symptoms

AIMS

Individuals with type 2 diabetes (T2DM) are advised to undertake diabetes self-care behavior (DSCB) in order to avoid complications of T2DM. However, comorbidities, such as insomnia symptoms which are commonly reported in people with T2DM, may limit the ability to engage in DSCB. Insomnia and the common sequelae accompanying insomnia such as pain, depression, and anxiety may negatively influence the performance of DSCB. Therefore, this study aimed to compare the DSCB of people with T2DM with and without insomnia symptoms.

METHODS

Sixty participants with T2DM were divided into two groups based on the presence of insomnia symptoms: T2DM-only group and T2DM+ insomnia group. Insomnia symptoms were identified using the Insomnia Severity Index (ISI). DSCB was assessed using the Diabetic Care Profile (DCP). A standardized composite score was established to account for all of the DCP domains. Chi-square and independent sample t tests were used to assess between-group differences in categorical and continuous variables, respectively. Stepwise linear regression analysis used the ISI score to predict standardized DCP composite score, while controlling for covariates.

RESULTS

Significant between-group differences were found in age, symptoms of pain, depression, and anxiety. The total DCP composite score was significantly lower in the T2DM+ insomnia group compared to the T2DM-only group (- 0.30 ± 0.46 vs. 0.36 ± 0.48, respectively, p < 0.001) with large effect size (g = 1.40). Stepwise linear regression results showed that a 1-point increase in ISI score significantly predicted a .03-point decrease in standardized DCP composite score, after controlling for age, symptoms of pain, depression, and anxiety (β = - 0.03, p = 0.04).

CONCLUSIONS

The data suggest that people with T2DM and insomnia symptoms had worse scores on the majority of the DSCB domains and a worse DCP composite score compared to people with T2DM only. The data suggest a negative association between insomnia severity and DSCB among people with T2DM. Further research using a larger sample size and more rigorous research design is required to examine the causal relationship between insomnia symptoms and DSCB.

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.

Effect of Cognitive Behavioral Therapy for Insomnia on Insomnia Symptoms for Individuals With Type 2 Diabetes: Protocol for a Pilot Randomized Controlled Trial

Background

Insomnia symptoms are a common form of sleep difficulty among people with type 2 diabetes (T2D) affecting sleep quality and health outcomes. Several interventional approaches have been used to improve sleep outcomes in people with T2D. Nonpharmacological approaches, such as cognitive behavioral therapy for insomnia (CBT-I), show promising results regarding safety and sustainability of improvements, although CBT-I has not been examined in people with T2D. Promoting sleep for people with insomnia and T2D could improve insomnia severity and diabetes outcomes.

Objective

The objective of this study is to establish a protocol for a pilot randomized controlled trial (RCT) to examine the effect of 6 sessions of CBT-I on insomnia severity (primary outcome), sleep variability, and other health-related outcomes in individuals with T2D and insomnia symptoms.

Methods

This RCT will use random mixed block size randomization with stratification to assign 28 participants with T2D and insomnia symptoms to either a CBT-I group or a health education group. Outcomes including insomnia severity; sleep variability; diabetes self-care behavior (DSCB); glycemic control (A_1c); glucose level; sleep quality; daytime sleepiness; and symptoms of depression, anxiety, and pain will be gathered before and after the 6-week intervention. Chi-square and independent t tests will be used to test for between-group differences at baseline. Independent t tests will be used to examine the effect of the CBT-I intervention on change score means for insomnia severity, sleep variability, DSCB, A_1c, fatigue, sleep quality, daytime sleepiness, and severity of depression, anxiety, and pain. For all analyses, alpha level will be set at .05.

Results

This study recruitment began in February 2019 and was completed in September 2019.

Conclusions

The intervention, including 6 sessions of CBT-I, will provide insight about its effect in improving insomnia symptoms, sleep variability, fatigue, and diabetes-related health outcomes in people with T2D and those with insomnia symptoms when compared with control.

Trial Registration

ClinicalTrials.gov NCT03713996; https://clinicaltrials.gov/ct2/show/NCT03713996

International Registered Report Identifier (IRRID)

DERR1-10.2196/14647

Update on Research and Practices in Major Sleep Disorders: Part II-Insomnia, Willis-Ekbom Disease (Restless Leg Syndrome), and Narcolepsy

PURPOSE

This review (Part II of a series on sleep disorders) presents an update of the characteristics, epidemiology, assessment, and latest management of insomnia, restless legs syndrome (Willis-Ekbom disease; RLS/WED), and narcolepsy. Insomnia, the most common sleep disorder and most prevalent of all psychological health disorders, is a problem of difficulty initiating and maintaining sleep and early morning awakenings. RLS/WED is characterized by a crawling sensation or urge to move the legs in the evening and nighttime. Narcolepsy is a sleep disorder that commonly results in chronic daytime sleepiness and cataplexy. Nonpharmacological management, which includes education, cognitive behavioral therapy, and complementary therapy, is used as primary or adjunctive to pharmacotherapy for the treatment of these disorders.

METHODS

This narrative review utilized medical databases such as PubMed to identify relevant English-language original and systematic review articles predominantly from peer-reviewed journals from 2012 to 2019. However, as background, findings from classic articles prior to 2012 were also included.

CLINICAL RELEVANCE

Assessment of sleep problems, excessive sleepiness, and difficulty performing activities or being productive should be routine in the care of all patients. Utilization of behavioral interventions, including cognitive behavioral therapy, in addition to education and sleep hygiene, can promote sleep quality. Management of insomnia, RLS/WED, and narcolepsy should include helping patients adjust to treatment, managing cataplexy triggers in narcolepsy, and initiating strategies to live with chronic illness to improve quality of life.

Restless Leg Syndrome in Peripheral Artery Disease: Prevalence among Patients with Claudication and Benefits from Low-Intensity Exercise

Restless leg syndrome (RLS) disrupts sleep, affecting the quality of life of patients with various chronic diseases. We assessed the prevalence of RLS in peripheral artery disease (PAD) patients and the effects of a pain-free exercise program. A total of 286 patients with claudication were enrolled in a home-based low-intensity exercise program prescribed at the hospital. RLS was determined through standardized questions. Hemodynamics, degree of calf deoxygenation, and mobility were assessed using the ankle-brachial-index, a treadmill test assisted by near-infrared spectroscopy and the 6-min walk test, respectively. During hospital visits, persistence of RLS, adherence to exercise, hemodynamics, and mobility were assessed. At the enrollment, 101 patients (35%) presented RLS, with higher prevalence among females (p = 0.032). Compared to RLS-free patients, they showed similar hemodynamics but more severe calf deoxygenation (p < 0.001) and lower mobility (p = 0.040). Eighty-seven RLS patients (83%) reported the disappearance of symptoms after 39 (36−70) days of exercise. This subgroup, compared to nonresponders, showed higher adherence (p < 0.001), hemodynamic (p = 0.041), and mobility improvements (p = 0.003). RLS symptoms were frequent in PAD but were reduced by a pain-free walking exercise aimed at inducing peripheral aerobic adaptations. The concomitant recovery of sleep and mobility may represent a synergistic action against the cardiovascular risk in PAD.

Restless Legs Syndrome in NKX2-1-related chorea: An expansion of the disease spectrum

BACKGROUND

Molecular technologies are expanding our knowledge about genetic variability underlying early-onset non-progressive choreic syndromes. Focusing on NKX2-1-related chorea, the clinical phenotype and sleep related disorders have been only partially characterized.

METHODS

We propose a retrospective and longitudinal observational study in 7 patients with non-progressive chorea due to NKX2-1 mutations. In all subjects sleep and awake EEG, brain MRI with study of pituitary gland, chest X-rays, endocrinological investigations were performed. Movement disorders, pattern of sleep and related disorders were investigated using structured clinical evaluation and several validated questionnaires.

RESULTS

In patients carrying NKX2-1 mutations, chorea was mainly distributed in the upper limbs and tended to improve with age. All patients presented clinical or subclinical hypothyroidism and delayed motor milestones. Three subjects had symptoms consistent with Restless Legs Syndrome (RLS) that improved with Levodopa.

CONCLUSIONS

Patients with NKX2-1 gene mutations should be investigated for RLS, which, similarly to chorea, can sometimes be ameliorated by Levodopa.

Acceptability and feasibility of a 12-week yoga vs. educational film program for the management of restless legs syndrome (RLS): study protocol for a randomized controlled trial

Background

Restless legs syndrome (RLS) is a common and burdensome sleep disorder associated with profound impairment of health, well-being, and quality of life. Unfortunately, the medications used for RLS management carry risk of serious side effects, including augmentation of symptoms. Yoga, an ancient mind-body discipline designed to promote physical, emotional, and mental well-being, may offer a viable, low-risk new treatment. The primary objectives of this pilot, parallel-arm, randomized controlled trial (RCT) are to assess the acceptability and feasibility of a 12-week yoga vs. educational film program for the management of RLS.

Methods

Forty-four adults with confirmed moderate to severe RLS will be recruited and randomized to a 12-week yoga (n = 22) or standardized educational film program (N = 22). Yoga group participants will attend two 75-min Iyengar yoga classes per week for the first 4 weeks, then one 75-min class per week for the remaining 8 weeks, and will complete a 30-min homework routine on non-class days. Educational film group participants will attend one 75-min class per week for 12 weeks and complete a daily RLS treatment log; classes will include information on: RLS management, including sleep hygiene practices; other sleep disorders; and complementary therapies likely to be of interest to those participating in a yoga and sleep education study.

Yoga and treatment logs will be collected weekly. Feasibility outcomes will include recruitment, enrollment, and randomization rates, retention, adherence, and program satisfaction. Program evaluation and yoga-dosing questionnaires will be collected at week 12; data on exploratory outcomes (e.g., RLS symptom severity (IRLS), sleep quality (PSQI), mood (POMS, PSS), and health-related quality of life (SF-36)) will be gathered at baseline and week 12.

Discussion

This study will lay the essential groundwork for a planned larger RCT to determine the efficacy of a yoga program for reducing symptoms and associated burden of RLS. If the findings of the current trial and the subsequent larger RCTs are positive, this study will also help support a new approach to clinical treatment of this challenging disorder, help foster improved understanding of RLS etiology, and ultimately contribute to reducing the individual, societal, and economic burden associated with this condition.

Trial registration

ClinicalTrials.gov, ID: NCT03570515. Retrospectively registered on 1 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3217-7) contains supplementary material, which is available to authorized users.

Conservative management for patients with chronic kidney disease refusing dialysis

Estimates suggest that 20-30% of the deaths of patients with chronic kidney disease with indication to undergo dialysis occur after refusal to continue dialysis, discontinuation of dialysis or inability to offer dialysis on account of local conditions. Contributing factors include aging, increased comorbidity associated with chronic kidney disease, and socioeconomic status. In several occasions nephrologists will intervene, but at times general practitioners or family physicians are on their own. Knowledge of the main etiologies of chronic kidney disease and the metabolic alterations and symptoms associated to end-stage renal disease is an important element in providing patients with good palliative care. This review aimed to familiarize members of multidisciplinary care teams with the metabolic alterations and symptoms arising from chronic kidney disease treated clinically without the aid of dialysis.

Decline in dopamine agonists prescribing and characteristics of drugs prescribed during ambulatory office visits for restless legs syndrome: the National Ambulatory Medical Care Survey 2007-2015

OBJECTIVE

To examine prescribing of drugs treating or exacerbating restless legs syndrome (RLS) during U.S. physician office visits for RLS for the years 2007-2015; and to assess potential prescribing predictors of these drugs.

METHODS

Using the National Ambulatory Medical Care Survey data, we conducted a retrospective cross-sectional study. We calculated weighted percentages of RLS-related office visits associated with RLS treatment drugs (alpha-2-delta ligands, dopamine agonists, and other drugs used for RLS) and exacerbating drugs. Using logistic regression, we examined the adjusted association between potential predictors and prescribing of major RLS treatment (dopamine agonists and alpha-2-delta ligands) and exacerbating drugs.

RESULTS

A total of 456 RLS-related office visits were included for analysis, representing approximately 9.9 million visits. The weighted percentages of visits with dopamine agonists (excluding levodopa) decreased from 50% to 22% (RR 0.44; 95% CI 0.26, 0.77). A visit to a neurologist was associated with a 76% increase in prescribing of the major RLS treatment drugs compared with a visit to a family/general or internal medicine physician (RR 1.76; 95% CI 1.29, 2.42). RLS exacerbating drugs were listed in 28% (95% CI 21-36) of RLS-related visits, mostly for antidepressants (83%). Younger age groups (18-44 and 45-64) were predictors of RLS exacerbating drug prescribing, compared with the older age group (RR 2.46; RR 2.00, respectively).

CONCLUSION

Prescribing of dopamine agonists during RLS-related visits decreased during 2007-2015, but prescribing of RLS exacerbating drugs remained high. More investigation is necessary concerning whether clinicians assess the appropriateness of RLS exacerbating drugs for RLS patients before newly prescribing or continuing those drugs. Also, future research would need to investigate what factors contribute to the difference in the RLS treatment prescribing patterns between neurologists and family/general or internal medicine physicians.

Heart rate variability in restless legs syndrome and periodic limb movements of Sleep

INTRODUCTION

The relationship between the autonomic nervous system and restless legs syndrome (RLS) and periodic limb movements of sleep (PLMS) consists of varied and somewhat conflicting reports. In order to further elucidate these complexities, a retrospective analysis of polysomnography (PSG) records and clinical data was performed.

METHODS

Records from 233 adult subjects were randomly selected and organized into one of four groups ("non-RLS/PLMS" [n=61], "RLS" [n=60], "PLMS" [n=58], and "RLS/PLMS" [n=54]). Heart rate variability (HRV) analysis was based on 5-minute samples of 2-lead electrocardiogram data isolated from PSG recordings during wakefulness and NREM sleep, and included mean RR interval (labeled "NN") and standard deviation of the RR intervals (labeled "SDNN"), and HRV power, very low frequency (VLF), low frequency (LF), and high frequency (HF) spectral bands.

RESULTS

A significant reduction in the VLF band in the PLMS group as compared to the non-RLS/PLMS group (542±674 vs. 969±1025 ms², p=0.038) was found in wakefulness. Statistically significant differences were seen in the PLMS group as compared to the non-RLS/PLMS group with a reduction in SDNN (p=0.001) and the HF (p=0.001) band, and an increase in HRV power (p=0.001), and the VLF (p=0.005) and LF (p=0.001) bands in NREM sleep.

CONCLUSIONS

The PLMS group exhibited reduced basal sympathetic activity in wakefulness, but basal sympathetic predominance during NREM sleep, distinguishing this group from the RLS and RLS/PLMS groups.

Symptom Experience in Late Pregnancy

OBJECTIVE

To evaluate the frequency, severity, distress, and correlates of common and rare symptoms reported by nulliparous women during the last month of pregnancy.

DESIGN

Secondary cross-sectional analysis of data obtained in a larger randomized clinical trial.

SETTING

San Francisco Bay area.

PARTICIPANTS

Nulliparous, ethnically diverse, predominantly low-income pregnant women 18 to 47 years of age (N = 151).

METHODS

Participants at or beyond 36 weeks gestation used the Memorial Symptom Assessment Scale (MSAS) to provide self-reports of general symptom experience. Other symptom measures were also completed for comparison. Demographic characteristics, including gestational weight gain, were also collected. Gestational weight gain was categorized in relation to the Institute of Medicine's 2009 recommendations for weight gain during pregnancy.

RESULTS

Women endorsed an average of 10.6 ± 5.6 symptoms on the MSAS. Prevalent symptoms (reported by at least half the sample) included lack of energy, pain, difficulty sleeping, worrying, irritability, drowsiness, shortness of breath, and nervousness. Among the women who reported these symptoms, relatively few described them as occurring with high frequency or severity or as causing much distress. One of the most prevalent symptoms (reported by 68% of women) was difficulty sleeping, which also had among the greatest ratings for frequency, severity, and distress. Although few maternal characteristics were associated with symptom experience, women who gained more weight than the Institute of Medicine's recommendation had worse MSAS total scores than women who gained the recommended amount or less.

CONCLUSION

In nulliparas, symptom frequency, severity, and distress varied and were related to excessive gestational weight gain.

Restless legs syndrome augmentation among Japanese patients receiving pramipexole therapy: Rate and risk factors in a retrospective study

To investigate the rate of and risk factors for restless legs syndrome (RLS) augmentation in Japanese patients receiving pramipexole (PPX) treatment. Records of 231 consecutive patients with idiopathic RLS who received PPX therapy for more than one month in a single sleep disorder center were analyzed retrospectively. Augmentation was diagnosed based on the Max Planck Institute criteria; associated factors were identified by logistic regression analysis. Mean age at PPX initiation was 60.6 ± 14.9 years and mean treatment duration was 48.5 ± 26.4 months. Augmentation was diagnosed in 21 patients (9.1%). Daily PPX dose and treatment duration were significantly associated with augmentation. By analyzing the receiver operating characteristic curve, a PPX dose of 0.375 mg/day was found to be the optimal cut-off value for predicting augmentation. After stratifying patients according to PPX treatment duration, at median treatment duration of 46 months, optimal cut-off values for daily doses were 0.375 and 0.500 mg/day for <46 months and ≥46 months of treatment, respectively. The RLS augmentation with PPX treatment in Japanese patients was occurred at rate of 9.1%, being quite compatible with previously reported rates in Caucasian patients. The symptom could appear within a relatively short period after starting the treatment in possibly vulnerable cases even with a smaller drug dose. Our results support the importance of keeping doses of PPX low throughout the RLS treatment course to prevent augmentation.

The Effect of Gabapentin Enacarbil on Pain Associated with Moderate-to-Severe Primary Restless Legs Syndrome in Adults: Pooled Analyses from Three Randomized Controlled Trials

BACKGROUND

Adults with moderate-to-severe primary restless legs syndrome (RLS) often experience painful dysesthesias, which may lead to impaired quality of life.

OBJECTIVES

The aim of this study was to assess the effects of gabapentin enacarbil (GEn) on pain associated with moderate-to-severe primary RLS in adults.

METHODS

Data were pooled from three double-blind, randomized, placebo-controlled, 12-week trials (NCT00298623, NCT00365352, NCT01332305) for adults receiving GEn or placebo once daily. Change in average daily RLS pain score and a combined International Restless Legs Scale (IRLS)-pain response were examined.

RESULTS

The modified intention-to-treat population included 671 adults (placebo, n = 244; GEn 600 mg, n = 161; GEn 1200 mg, n = 266). Both GEn doses significantly improved average daily RLS pain score at week 12 (p < 0.001 for GEn 600 mg vs. placebo and GEn 1200 mg vs. placebo). The combined IRLS-pain response subanalysis included 366 patients with a baseline IRLS total score ≥15 and pain score ≥4 (placebo, n = 133; GEn 600 mg, n = 86; GEn 1200 mg, n = 147). Most patients were both IRLS and pain responders (placebo, 40 %; GEn 600 mg, 70 %; GEn 1200 mg, 67 %). Spearman rank correlations between IRLS total and pain score (change from baseline to week 12) were moderate or strong. The most frequent treatment-emergent adverse events were somnolence (placebo, 5 %; GEn 600 mg, 20 %; GEn 1200 mg, 23 %) and dizziness (placebo, 4 %; GEn 600 mg, 13 %; GEn 1200 mg, 22 %).

CONCLUSIONS

This post hoc pooled analysis suggests that GEn (600 and 1200 mg) once daily significantly improved pain associated with moderate-to-severe primary RLS in adults; however, the analysis was not powered to detect statistical differences between the two GEn doses. Numerically, more GEn-treated patients had a combined IRLS-pain response than placebo-treated patients.

Targinact for restless legs syndrome

Idiopathic restless legs syndrome (RLS)--also known as Willis-Ekbom disease--is a neurological condition characterised by an overwhelming urge to move the legs, occurring during rest or inactivity, especially at night. Symptoms are highly variable in frequency and severity, and can affect sleep and quality of life. First-line management includes addressing precipitating or aggravating factors and providing explanation, reassurance and advice on self-help strategies. Drug therapy (e.g. a dopamine agonist) is used for patients with more severe symptoms. In December 2014, the marketing authorisation for a modified-release preparation containing oxycodone and naloxone (Targinact-Napp Pharmaceuticals) was expanded to include use in the treatment of severe to very severe RLS after failure of dopaminergic therapy.(10)Here we review the management of adults with RLS, including the place of oxycodone/naloxone.

The Effect of Gabapentin Enacarbil on Quality of Life and Mood Outcomes in a Pooled Population of Adult Patients with Moderate-to-Severe Primary Restless Legs Syndrome

OBJECTIVE

The aim was to assess gabapentin enacarbil (GEn) treatment effects on quality of life (QOL) and mood in adults with moderate-to-severe primary restless legs syndrome (RLS).

METHODS

Data were pooled from three placebo-controlled, randomized, double-blind, 12-week trials for adults receiving GEn (600 mg or 1200 mg) or placebo once daily. QOL was assessed with the RLS QOL questionnaire in two studies. Mood was examined with the Profile of Mood States Brief Form (POMS-B), and as an exploratory analysis with International Restless Legs Scale (IRLS) item 9 (daily affairs) and item 10 (mood disturbance) across all three studies. Mood and QOL were secondary endpoints in the individual clinical trials. No adjustments for multiplicity were applied.

RESULTS

The QOL analysis modified intent-to-treat (MITT) population included 541 adults (placebo, n = 204; GEn 600 mg, n = 114; GEn 1200 mg, n = 223). Both GEn doses significantly improved QOL versus placebo (week 12; p < 0.01). The mood analysis MITT population included 671 adults (placebo, n = 244; GEn 600 mg, n = 161; GEn 1200 mg, n = 266). GEn 600 mg significantly improved POMS vigor-activity versus placebo (week 12; p < 0.05); other POMS criteria were not significantly affected. GEn 1200 mg significantly improved POMS scores for total mood disturbance, depression-dejection, fatigue-inertia, vigor-activity, and confusion-bewilderment versus placebo at week 12 (p < 0.05); tension-anxiety and anger-hostility were not significantly affected. Both GEn doses significantly improved IRLS item 9 and item 10 versus placebo at week 12 (p < 0.05). The most frequent treatment-emergent adverse events with GEn were somnolence and dizziness.

CONCLUSIONS

GEn (600 mg and 1200 mg) once daily significantly improved QOL in adults with moderate-to-severe primary RLS at all time points examined. While the only POMS item significantly improved by GEn 600 mg versus placebo at week 12 was vigor-activity, GEn 1200 mg significantly improved total mood disturbance and several other POMS items versus placebo at week 12. Both QOL and mood improvements were numerically greater with GEn 1200 mg versus 600 mg.

TRIAL REGISTRATIONS

Clinicaltrials.gov identifiers NCT00298623, NCT00365352, NCT01332305.

Restless Legs Syndrome in Patients with Hypertension and Diabetes Mellitus

Aim:

The aim of this study was to analyze frequency of restless legs syndrome (RLS) in patients with hypertension and diabetes mellitus.

Patients and Methods:

It was analyzed 120 subjects (from Health Center Živinice/Family Medicine Department) through a survey conducted in the period from March to June 2015, of which 30 (8 men/22 women). Subjects were 30 patients with longtime hypertension (HT)(18 men/12 women), 30 patients with diabetes mellitus (DM) type I or II (9 men/21 women), 30 patients with long standing DM type I or II and HT (12 men /18 women), and 30 control subjects (12 men/18 women). RLS were evaluated by questionnaire - International RLS Study Group Criteria. The average age of patients in the group with HT was 58.70 ± 9.07, in the group with DM 48.43 ± 15.37, and in the group of patients with HT and DM 63.90 ± 7.49 years. In the control group mean age was 52.76 ± 14.83 years. Statistical data were analyzed in Excel and SSPS statistical program.

Results:

RLS was identified in 10 (30%) of those with HT; 7 (21%) in patients with DM, and 10 (30%) in patients with HT+DM. In the control group RLS was verified in 4 (12%) patients. Comparing the results, it was observed significant difference between the HT and the control group (p=0.0012) and HT+ DM and control group (p=0.0012). The frequency of RLS between DM and the control group was not significantly significant (p=0.107).

Conclusion:

RLS is frequent in patients with hypertension (30%), hypertension+ diabetes mellitus (30%), and patients with DM (21%).

The Relationship of Restless Legs Syndrome to History of Pregnancy-Induced Hypertension

BACKGROUND

Restless legs syndrome (RLS), a burdensome sleep disorder, has been associated with cardiovascular disease (CVD), hypertension, diabetes, and related disorders. However, the relationship of RLS to history of pregnancy-induced hypertension (PIH), a predictor of subsequent CVD, diabetes, and associated conditions, remains little explored. In this study, we investigated the relationship of RLS to history of PIH in a sample of primary care patients.

METHODS

Participants were women aged ≥40 years drawn from an anonymous survey study of West Virginia primary care patients. Data collected included detailed information on demographics, lifestyle factors, sleep patterns, and reproductive/medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or unsure about their pregnancy status were excluded from the analyses.

RESULTS

Of the 498 participants in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms ≥once/week, 11.9% with symptoms ≥3 times/week); 73 (16.5% of parous women) reported a history of PIH, defined as physician-diagnosed preeclampsia or gestational hypertension. After adjustment for demographics, lifestyle characteristics, obesity, reproductive history, health conditions, and other factors, those reporting a history of PIH were approximately twice as likely to meet criteria for RLS (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.1, 3.6). These associations increased in magnitude with increasing symptom frequency (adjusted OR for RLS with symptoms ≥3 times/week = 3.8; CI 1.9, 7.6; p for trend = 0.003).

CONCLUSIONS

History of PIH was strongly and positively related to current RLS in this study of primary care patients; these findings further support a possible role for metabolic dysregulation in RLS etiology.

In the Clinic. Restless Legs Syndrome

This issue provides a clinical overview of restless legs syndrome, focusing on diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

The Association of Restless Legs Syndrome to History of Gestational Diabetes in an Appalachian Primary Care Population

OBJECTIVES

Restless legs syndrome (RLS) is a burdensome sensorimotor disorder that has been linked to diabetes and obesity. However, the relationship of RLS to gestational diabetes mellitus (GDM), a common pregnancy complication strongly associated with obesity and a harbinger of diabetes, remains unknown. In this study, we examined the association of RLS to history of GDM in a sample of older female primary care patients.

METHODS

Participants were community-dwelling women aged ≥ 40 years drawn from an anonymous survey study of West Virginia adult primary care patients. Data gathered included detailed information on demographics, lifestyle factors, reproductive history, sleep patterns, and medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or had missing data on key variables were excluded from the analyses.

RESULTS

Of the 498 participants included in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms at least once/week). After adjustment for demographics, lifestyle characteristics, body mass index, diabetes and other comorbid conditions, parity, and other factors, those reporting history of GDM were almost three times as likely to meet criteria for RLS (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.3, 5.3). This association increased in magnitude with increasing symptom frequency (adjusted OR for RLS symptoms ≥ 3×/week = 4.8, CI 2.1, 11.2, p for trend = 0.004).

CONCLUSIONS

History of GDM was strongly and positively related to RLS in this study of older female primary care patients, offering further support for a possible role of metabolic dysregulation in RLS development.

Pharmacological management of antipsychotic-induced akathisia: an update and treatment algorithm

Akathisia is a common and distressing side-effect of antipsychotic medication. The treatment of this condition is difficult and options are limited. This review of the literature was performed to develop an evidence-based algorithm for the management of antipsychotic-induced akathisia. There is limited high-level evidence to support the use of anticholinergics. Centrally acting β-adrenergic antagonists are potential treatments, although their use is limited by troublesome side-effects. Long-acting benzodiazepines and mirtazapine are potential well-tolerated treatments for the acute management of akathisia.

Oxycodone/Naloxone PR: A Review in Severe Refractory Restless Legs Syndrome

An oral, fixed-dose combination of prolonged-release (PR) oxycodone with PR naloxone (Targin(®), Targiniq(®), Targinact(®); hereafter referred to as oxycodone/naloxone PR) is approved in Europe for the second-line symptomatic treatment of patients with severe to very severe idiopathic restless legs syndrome (RLS), after failure of dopaminergic therapy. Coadministration of naloxone represents a targeted approach to counteracting opioid-induced bowel dysfunction without compromising therapeutic efficacy; because of its very low oral bioavailability, naloxone blocks the action of oxycodone at opioid receptors locally in the gut. The efficacy of oxycodone/naloxone PR in patients with severe RLS inadequately controlled by previous (mainly dopaminergic) treatment has been demonstrated in RELOXYN, a 12-week, randomized, double-blind study with a 40-week open-label extension. In this pivotal study, oxycodone/naloxone PR significantly improved RLS symptoms compared with placebo from week 2 onwards; a beneficial effect of oxycodone/naloxone PR was maintained through 1 year of treatment. Furthermore, improvements in RLS symptoms in oxycodone/naloxone PR recipients were accompanied by similarly sustained improvements in disease-specific quality of life and subjective sleep variables. Oxycodone/naloxone PR was generally well tolerated, with a treatment-related adverse event profile (e.g. gastrointestinal disorders, CNS disorders, fatigue and pruritus) that was consistent with that expected for opioid therapy. Notably, there were no confirmed cases of augmentation among oxycodone/naloxone PR recipients throughout the course of the study. Results from the well-designed RELOXYN trial have thus demonstrated the value of oxycodone/naloxone PR as a second-line therapy for severe refractory RLS; further investigation of this combination product as a first-line treatment for severe RLS is now warranted.

Pediatric Sleep Pharmacology: A Primer

"What will you give my child to help him sleep?" is a common question parents ask and some health care providers abhor hearing. Entire families may suffer when one member does not sleep well. Poor sleep may complicate the management of other comorbid conditions. Health care providers may have received only limited education on sleep disorders and are frequently forced to choose between treatment options that are poorly studied in children. Fortunately, when addressed correctly, many children with chronic sleep disorders may improve their sleep and daytime behavior in a relatively short time. This review provides a framework to help understand the causes of poor sleep in children and the potential pharmacologic options.

Treatment response to sleep, pain, and mood disturbance and their correlation with sleep disturbance in adult patients with moderate-to-severe primary restless legs syndrome: Pooled analyses from 3 trials of gabapentin enacarbil

INTRODUCTION

This pooled analysis investigated the effects of gabapentin enacarbil (GEn) on clinical correlates of sleep disturbance in adults with moderate-to-severe primary restless legs syndrome (RLS) and no-to-moderate or severe-to-very severe baseline sleep disturbance.

METHODS

Co-primary end-points were mean change from baseline to week 12 in International Restless Legs Scale (IRLS) total score and proportion of responders ('much'/'very much' improved) on the investigator-rated Clinical Global Impression-Improvement (CGI-I) scale (week 12). Pain, mood, individual IRLS items, and safety were assessed.

RESULTS

The modified intent-to-treat population was 671 adults randomized to GEn 600 mg (n = 161), GEn 1200 mg (n = 266), or placebo (n = 244). GEn significantly improved least squares mean change in IRLS total score from baseline versus placebo for no-to-moderate (GEn 600 mg,- 12.3; 1200 mg, - 11.3; placebo, - 7.7) and severe-to-very severe (- 16.6; - 17.0; - 12.7) groups (all P < 0.01). Significantly more GEn-treated patients (both doses) were CGI-I responders (week 12) versus placebo in both sleep subgroups (all P < 0.01). GEn substantially improved mood and pain scores for both sleep subgroups versus placebo. The most frequent treatment-emergent adverse events were somnolence and dizziness.

CONCLUSION

GEn (600 mg and 1200 mg) was effective and well tolerated in adults with moderate-to-severe primary RLS regardless of baseline sleep disturbance level.

Effect of prior exposure to dopamine agonists on treatment with gabapentin enacarbil in adults with moderate-to-severe primary restless legs syndrome: pooled analyses from 3 randomized trials

Background

Dopamine agonists (DAs) are a first-line therapy for moderate-to-severe restless legs syndrome (RLS), but these treatments may lead to complications, such as augmentation and impulse control disorders, requiring switching to another therapeutic class. Here we assess efficacy and tolerability of gabapentin enacarbil (GEn) in adults with moderate-to-severe primary RLS, with or without prior DA exposure.

Methods

Data from 3 trials were pooled. Patients were identified as DA-naive or DA-exposed, based on prior treatment with ropinirole, pramipexole, rotigotine, or pergolide mesylate, and the dopamine precursor levodopa. Details on prior treatment duration and dose were unavailable. Patients with a history of augmentation were excluded. Within DA-naive/DA-exposed patients we investigated the co-primary end points from the pivotal trials: mean change from baseline to week 12 in International RLS (IRLS) Rating Scale total score and proportion of responders (“much”/“very much” improved) on the investigator-rated Clinical Global Impression–Improvement (CGI-I) scale. Safety was also assessed.

Results

671 patients were randomized (DA-naive: placebo, n = 194; GEn 600 mg, n = 131; GEn 1200 mg, n = 214; DA-exposed: placebo, n = 50; GEn 600 mg, n = 30; GEn 1200 mg, n = 52). Across treatment arms, no significant differences between DA-naive and DA-exposed subgroups in IRLS Rating Scale total score change from baseline at any visit were seen, except week 1 in the placebo group (−6.1 DA-naive vs −3.4 DA-exposed, P = .020). No significant differences in the odds of CGI-I response at week 12 between DA-naive vs DA-exposed patients in any treatment group were seen; however, with placebo there was a nonsignificant trend toward fewer responders among DA-exposed (34.0%) vs DA-naive (44.3%) patients. Both GEn doses significantly improved the IRLS Rating Scale total score change from baseline and CGI-I response vs placebo, regardless of prior DA exposure. The most common treatment-emergent adverse events were dizziness and somnolence.

Conclusions

Prior DA exposure had no significant effect on efficacy or tolerability of GEn (600 or 1200 mg) in this pooled analysis of adults with moderate-to-severe primary RLS. These data support the use of GEn in DA-exposed and DA-naive patients.

Trial registration

ClinicalTrials.gov NCT00298623, NCT00365352, and NCT01332305