Restless arms syndrome: prevalence, impact, and management strategies

Restless arms syndrome with oral olanzapine: case based review

Background

Restless arms syndrome (RAS) is a specific variant of restless legs syndrome (RLS). RAS is characterised by an uncomfortable, painful, burning or uneasy sensation confined to the arm.

Case presentation

We report a case of RAS with oral olanzapine, which improved with medication reduction. In addition, all reported cases of RAS were reviewed to explore the underlying mechanisms, diagnosis and treatment for psychiatric drug-induced RAS. The literature review and new case suggest that iron deficiency may be a predisposing factor for RAS. Psychiatric medications are closely associated with RAS, especially olanzapine, quetiapine, and mirtazapine. Discontinuation is the recommended treatment for psychotropic drug-induced RAS, while α2δ calcium channel ligand drugs and benzodiazepines may be considered.

Conclusion

In conclusion, psychiatrists should be alert to the possibility of RAS when administering psychiatric medications for the first time to psychiatric patients with iron deficiency.

Restless Back Syndrome: A Case Report and Literature Review

Restless back syndrome is characterized by uncomfortable pain, burning, ant crawling, or itching sensations in the back. Restless back syndrome is regarded as a back variant of restless legs syndrome. The lack of specific diagnostic criteria makes it difficult to recognize the restless back syndrome, which is usually neglected in clinical practice. Moreover, when a patient was diagnosed with restless back syndrome, the adjustment of medications was the first choice for doctors, which may make the patient's condition unstable. To describe the restless back syndrome and collect and review the related lecture, and the possible mechanism of restless back syndrome was analyzed. A 50-year-old man was diagnosed with schizophrenia 15 years ago. Starting with 25 mg/day aripiprazole, which was switched to amisulpride 0.6 g/day due to no effectiveness, the patient reported symptoms of restless back syndrome in the 2 weeks since the treatment with 0.6 g/day of amisulpride. With the reduction of amisulpride adjustment, restless back syndrome spontaneously remitted. The central dopaminergic dysfunction may play an important role in the development of restless back syndrome. This case suggests that psychiatrists should pay attention to restless back syndrome when using antipsychotics. Moreover, when a patient manifests restless back syndrome, observation or decreasing medication may be one choice.

Stroke-related restless legs syndrome: Clinical and anatomo-functional characterization of an emerging entity

BACKGROUND AND PURPOSE

Stroke-related restless legs syndrome (sRLS) secondary to ischemic lesions is an emerging entity and an interesting condition, but there are limited available data to help us further understand its underlying pathways. In this study, we characterized sRLS clinically, neuroanatomically and functionally.

METHODS

Consecutive patients hospitalized in the Stroke Unit of the University Hospital of Strasbourg were assessed clinically and electrophysiologically for sRLS characteristics. They underwent brain magnetic resonance imaging for the neuroanatomical study of involved structures, and received functional evaluations with ¹⁸ F-FDG (2-deoxy-2-[fluorine-18]fluoro-D-glucose) positron emission tomography (PET) for glucose consumption, ¹²³ I-FP-CIT ([123]I-2beta-carbometoxy-3beta-[4-iodophenyl]-N-[3-fluoropropyl]nortropane) single-photon emission computed tomography for dopamine reuptake and PET with ¹⁸ F-FDOPA ((3,4-dihydroxy-6-[18]F-fluoro-l-phenylalanine) for presynaptic dopaminergic synthesis.

RESULTS

Sixteen patients with sRLS, eight women and eight men, aged 41-81 years, were included. The clinical characteristics of sRLS and idiopathic RLS were similar. Most patients presented with bilateral and symmetric de novo RLS. Eight patients had infarction in the lenticulostriate area (middle cerebral artery and internal carotid arteria). The body of the caudate nucleus was most commonly affected. Seven patients had sRLS secondary to ventral brainstem infarction (perforating branches of the basilar arteria) affecting the pons in six patients and the medulla oblongata in one patient. Both the corticospinal tract and the cortico-pontocerebellar fibres were lesioned in all patients with brainstem stroke. One patient had infarction in the left posterior cerebellar vermis and occipital area (posterior cerebral artery and superior cerebellar artery). Isotopic explorations showed a significantly increased dopaminergic tone in the striatum ipsilateral to lenticulostriate infarction. Dopamine fixation was normal in patients with stroke outside of the lenticulostriate area.

CONCLUSIONS

Clinicians should be aware of the characteristics of sRLS for the appropriate diagnosis and treatment of this condition.

Restless legs syndrome affecting the head region: "restless head syndrome"

OBJECTIVE

Restless legs syndrome (RLS) is a well-established disease that has recently been shown to have variants affecting the arms, face, abdomen, and genital area. To our knowledge, there has been no study reporting on the RLS variant affecting the head region.

METHODS

The retrospective study reviewed a total of 460 patients who presented to Fırat University Medical School and were diagnosed as having RLS based on the International Restless Legs Syndrome Study Group (IRLSSG) criteria between June 2017 and January 2020. Of these, 18 patients that presented with head-related RLS symptoms (in addition to legs or arms) and four cases that presented with isolated head involvement were included in the study.

RESULTS

In 15 out of 18 (81.8%) patients, the restless head syndrome was accompanied by restless arm syndrome (RAS). In the remaining four (18.2%) patients, the disease involved the head region alone. The disease initially emerged in a single region in the body and gradually spread to one or multiple other regions in most patients and the symptoms were relieved by head rubbing. Serum iron level was low in 8 (36.4%) patients and normal in 14 (63.6%) patients. All the patients had normal cranial imaging and the symptoms were eliminated after dopaminergic therapy.

CONCLUSIONS

Although RLS typically involves the legs alone, it may also affect other body parts such as upper extremities, abdomen, face, and genital area. We propose that the novel RLS variant described in the present study could be termed "restless head syndrome."

Restless arm syndrome: a rare disease?

Restless legs syndrome (RLS) is a common neurological disorder characterised by an irresistible urge to move the lower limbs, often accompanied by unpleasant sensations in the legs, typically occurring in the evening and at night and improving with movement. Restless arms syndrome (RAS) predominantly affects the arms, while the legs are rarely affected. RAS appears to be very rare, with very few cases described to date, but the diagnosis of RAS is probably made too infrequently, especially for milder and transient forms. The patient reported here even had severe symptoms for years that could have indicated RAS. He observed an immediate improvement in all RAS-related symptoms after administration of 100 mg L-dopa +25 mg benserazide, which continues to this day. Clinicians should always be alert for RLS-like symptoms in one or both arms that worsen at rest and improve with movement, thinking of possible RAS.

Transitory restless arms syndrome in a patient with antipsychotics and antidepressants: a case report

BACKGROUND

Restless arms syndrome (RAS) is characterized by uncomfortable aching or burning sensations in the arms. RAS is regarded as an upper limb variant of restless legs syndrome (RLS). The lack of specific diagnostic criteria makes it difficult to recognize the RAS. Therefore, RAS is usually neglected in clinical practice. Moreover, when a patient was diagnosed with RAS, the adjustment of medications was the first choice for doctors, which may make the patient's condition unstable.

CASE PRESENTATION

A 33-year-old woman was diagnosed with schizophrenia and major depressive disorder. Starting with 0.6 g/d amisulpride, 0.1 g/d quetiapine, 75 mg/d venlafaxine sustained-release tablets, the patient reported symptoms of RAS (itching arms) on the fourth day since the latest hospitalization. After ruling out other factors, her RAS was suspected to be induced by antidepressants or antipsychotics. Without medication adjustment, RAS spontaneously remitted.

CONCLUSIONS

This case suggests that psychiatrists should pay attention to RAS when using antipsychotics and/or antidepressants. Moreover, RAS may be transitory. When a patient manifests RAS, observation may be one choice instead of an immediate medication adjustment.

Sleep Disorders and Mood, Anxiety, and Post-Traumatic Stress Disorders: Overview of Clinical Treatments in the Context of Sleep Disturbances

Sleep disruptions are frequently reported by persons with mood, anxiety, and post-traumatic stress disorders, and co-occur with psychiatric disorders. There is evidence that sleep disorders can predict the likelihood of developing a future psychiatric disorder and exacerbate existing symptoms. Understanding the inter-relationships between sleep and psychiatric disorders is important. The primary goals of this article are to describe the interactions between psychiatric and sleep disorders in the context of sleep disturbances, underscore the bidirectional effects of mental health treatments on sleep disorder outcomes, and provide general recommendations to optimize treatment in the context of sleep disturbances.

Suspected Agomelatine-induced restless legs syndrome: a case report

BACKGROUND

Restless Legs Syndrome (RLS) is a sensorimotor disorder characterized by unpleasant and distressing sensations in the lower limbs that are more pronounced in the evening, commence or worsen at rest, and show partial or complete relief following movement. It can occur as a primary disorder, secondary to medical conditions or treatment with medications including but not limited to antidepressants or antipsychotics.

CASE PRESENTATION

A 32-year old man with major depressive disorder showed partial response to Escitalopram 10 mg daily. Agomelatine 25 mg at night was added to Escitalopram to treat his residual depressive symptoms, namely insomnia and tiredness. Within two days he developed restlessness and unpleasant sensations in his legs which were worse at night. Symptom severity increased over the following days, prompting an urgent consultation a week later. The patient's presentation met the criteria for RLS. Agomelatine was discontinued leaving the patient on Escitalopram alone. The patient's symptoms improved within 24 h of stopping Agomelatine, with complete resolution four days later. There was no recurrence of RLS during follow-up. The patient scored 6 on Naranjo's adverse drug reaction probability scale, indicating a probable adverse drug reaction caused by Agomelatine.

CONCLUSIONS

To the best of our knowledge, this is the first case report of suspected Agomelatine-induced RLS. Clinicians need to be aware of RLS to enable prompt diagnosis and management. We suggest adding Agomelatine to the list of agents that can potentially induce RLS.

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.

Clinical and neuropathological variability in the rare IVS10 + 14 tau mutation

Mutations in the microtubule-associated protein tau gene are known to cause progressive neurodegenerative disorders with variable clinical and neuropathological phenotypes, including the intronic 10 + 14 (IVS10 + 14) splice site mutation. Three families have been reported with the IVS10 + 14 microtubule-associated protein tau mutation. Here, we describe the clinical and neuropathological data from an additional family. Neuropathological data were available for 2 of the 3 cases, III-4, and III-5. While III-5 had widespread tau deposition and atrophy, III-4 exhibited more mild neuropathological changes except for the substantia nigra. The previously reported families that express the IVS10 + 14 mutation exhibited significant interfamilial heterogeneity, with symptoms including amyotrophy, dementia, disinhibition, parkinsonism, and breathing problems. In addition to expressing many of these symptoms, members of this fourth family experienced profound sensory abnormalities and sleep disturbance. Although there were probable clinicopathological correlates for the symptoms expressed by the earlier families and III-5 from our cohort, pathology in III-4 did not appear sufficient to explain symptom severity. This indicates the need to explore alternate mechanisms of tau-induced brain dysfunction.

Restless Legs Syndrome: Contemporary Diagnosis and Treatment

Restless legs syndrome (RLS) is characterized by an uncomfortable urge to move the legs while at rest, relief upon movement or getting up to walk, and worsened symptom severity at night. RLS may be primary (idiopathic) or secondary to pregnancy or a variety of systemic disorders, especially iron deficiency, and chronic renal insufficiency. Genetic predisposition with a family history is common. The pathogenesis of RLS remains unclear but is likely to involve central nervous system dopaminergic dysfunction, as well as other, undefined contributing mechanisms. Evaluation begins with a thorough history and examination, and iron measures, including ferritin and transferrin saturation, should be checked at presentation and with worsened symptoms, especially when augmentation develops. Augmentation is characterized by more intense symptom severity, earlier symptom occurrence, and often, symptom spread from the legs to the arms or other body regions. Some people with RLS have adequate symptom control with non-pharmacological measures such as massage or temperate baths. First-line management options include iron-replacement therapy in those with evidence for reduced body-iron stores or, alternatively, with prescribed gabapentin or pregabalin, and dopamine agonists such as pramipexole, ropinirole, and rotigotine. Second-line therapies include intravenous iron infusion in those who are intolerant of oral iron and/or those having augmentation with intense, severe RLS symptoms, and opioids including tramadol, oxycodone, and methadone. RLS significantly impacts patients' quality of life and remains a therapeutic area sorely in need of innovation and a further pipeline of new, biologically informed therapies.

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.