RLS Symptoms Research Articles

Effect of Restless leg syndrome on the sleep quality of medical students of university in rural Sindh

Background: Restless legs syndrome a neurological condition its symptoms appear with gnawing sensation, cramps and feels like unpleasant sensations during period of rest and mid of sleep. A set of criteria for a more consistent diagnosis of this condition, which frequently causes severe sleep problems, it was devised and published by the recently established International RLS Study Group (IRLSSG) fifty years later the research has shown that, although its symptoms are preventable and manageable, but RLS is still under diagnosed since the IRLSSG criteria were published. Materials and methods: All medical students were considered as the population of the study. Convenient specific young adults selected a sample of 200 students. Besides that, students with a history of trauma and infection had exaggerated routines and recent viral infections also having pain with cramps in calf muscles, which increased during inactivity and rest at night. The questionnaires were administered from the students, with the permission of the ethical review committee of Bhitai dental & medical College Mirpurkhas. Informed consent-form taken. Data collection procedures were applied standard questionnaire used International Restless Legs Syndrome Study Group (IRLLSG). The data were analyzed by SPSS-25. Percentage, mean, standard deviation, and chi-square were applied to measure the severity and overall score of RlS. Result: The medical students 119 were male and 81 female. Participants had demographic data mean of age 1.26, (SD=.544). 57.5% male, 42.5% female in the age group of 18–28. Sleep problem were found in male had moderate 25 (21.0%) and severe in 15 (12.6%) students, in very severe of RLS symptoms were less in count 13 (10.9%), A female participant was affected with RLS moderate 54 (27.0%), mild in 43 (21.5%), moderate RLS in 26 (32.1%) some participants in severe had low 30 (15.0%) RLS found, moreover participants had none 20 (24.5%) RLS symptoms. The significant valued (p=.296). Conclusion: It was concluded that RLS is a sleep disorder it mostly in male than female students. Severity of RLS symptoms mild to moderate among participants.

Effect of Blood Flow Restriction Training (BFRT) on Sleep Deprivation and Quality of Life in Restless Leg Syndrome – A Case Study

TITLE: Effect of blood flow restriction training (BFRT) on sleep deprivation and quality of life in restless leg syndrome – A case study BACKGROUND AND PURPOSE: To see the effect of blood flow restriction training (BFRT) on sleep deprivation and quality of life in restless leg syndrome. MATERIAL AND METHOD: A 22-year-old female was considered for this research purpose. The subject was taken for the study's conduction and given the intervention protocol. The protocol was 28 days long and the subject was asked to perform the exercises 6 times in a week, for about 2 times in a day. A total of 3 sets were performed for almost all the exercises with 20 repetitions in the first set, 15 repetitions in the second set, and 10 repetitions in the third set. Pre and Post results were recorded based on outcome measures such as RLS-QOL, PSQI, and SQS. DESIGN: A case study involving pre- and post-intervention readings. RESULT: The study found that blood flow restriction training (BFRT) can lessen RLS symptoms, enhance sleep quality, extend sleep duration, and enhance quality of life. CONCLUSION: Through this study, we can conclude that the effect of Blood flow restriction training (BFRT) on RLS patients can improve symptoms of RLS, better sleep quality, increase sleep timing, and improve quality of life. The Pre & Post reading value of RLSQOL on day 0 was 67, and on 28, it was 39. The pre- and post-reading value of PSQI on day 0 was 17 and on day 28 it was 07. And Pre & Post reading value of SQS on day 0 was 62 and on day 28 it was 44. As suggested by the study it would improve the symptoms of RLS along with better sleep quality, along with ease of living.

Successful treatment of restless legs syndrome accompanied by headaches for 30 years with herbal prescriptions containing Paeoniae Radix: A case report

BackgroundRestless legs syndrome (RLS) is a neurological disorder that causes unpleasant symptoms in the legs when resting, which are relieved by movement. Pharmacotherapy is the standard treatment. However, current treatment provides only symptomatic relief and may result in adverse effects with long-term use. Treatment protocols using herbal medicines have emerged to compensate for this limitation. Case presentationA 70-year-old Asian woman visited our hospital with worsening headaches that had persisted for 30 years. Her headaches were aggravated by night-time lower-extremity discomfort. The patient was diagnosed with RLS based on the 2012 Revised International Restless Leg Syndrome Study Group Diagnostic Criteria (IRIS). The patient was prescribed herbal medicines, Shihogyeji-tang, Gyejibokryeong-hwan, and Jakyakgamcho-tang, all of which contain Paeoniae Radix. Fourteen days after starting herbal medicine treatment, the IRIS score decreased from 30 to 18. The patient experienced less leg discomfort. Moreover, her sleep time increased, and her headaches resolved. After 28 days of herbal treatment, the IRIS score decreased to 9. Importantly, the patient reported no sleep disturbance or headaches. Subsequently, conventional medications were discontinued. The patient remained stable (IRIS score: 9–10). Herbal treatment was discontinued on day 163. At the last follow-up, (day 364), the patient has not reported any symptom recurrence. ConclusionsWe described a female patient with a 30-year history of RLS symptoms and related sleep disturbances that induced chronic uncontrolled headaches, who experienced improvements shortly after using herbal medicines containing Paeoniae Radix. Conventional medications were discontinued and the patient had no recurrence of symptoms. Considering these, herbal medicines containing Paeoniae Radix may be a suitable alternative treatment for RLS and its related symptoms.

Restless legs symptoms increased during COVID-19 pandemic. International ICOSS-survey

Background and objectivesRestless legs syndrome (RLS) has been associated with anxiety, depression, insomnia, lifestyle factors and infections. We aimed to study the prevalence of symptoms of RLS during the COVID-19 pandemic versus pre-pandemic. We hypothesized that pre-existing RLS symptoms worsened and pandemic-related factors may have triggered new symptoms of RLS. MethodsAdults (≥18 years) from fifteen countries across four continents participated in an online survey between May and August 2020. The harmonized questionnaire included a validated single question on RLS with response alternatives from 1 to 5 on a scale from never to every/almost every evening or night. Other measures were the Insomnia Severity Index (ISI), measures of symptoms of anxiety (GAD-2) and depression (PHQ-2), and questions on different pandemic-related factors. ResultsAltogether, 17 846 subjects (63.8 % women) were included in the final analyses. The mean age was 41.4 years (SD 16.1). During the pandemic, symptoms of RLS (≥3 evenings/nights per week) were more common 9.1 % (95 % CI 8.7–10.1) compared to 5.4 % (95 % CI 4.9–6.0) before the pandemic (P < 0.0001). Alltogether 1.3 % (95 % CI 1.1–1.6) respondents had new-onset symptoms (≥3 evenings/nights per week). Moderate-severe insomnia was strongly associated with RLS symptoms. The occurrences of new-onset RLS symptoms were 5.6 % (95 % CI 0.9–13.0) for participants reporting COVID-19 and 1.1 % (95 % CI 0.7–1.5) for non-COVID-19 participants. In the fully adjusted logistic regression model, the occurrence of new-onset RLS symptoms was associated with younger age, social restrictions and insomnia severity. In a similar analysis, RLS symptoms (≥3 evenings/nights per week) were associated with lower education, financial hardship, sleep apnea symptoms, use of hypnotics, insomnia severity, symptoms of depression and possible post-traumatic stress disorder. DiscussionOur findings indicate that RLS symptoms were more common during the pandemic than before. Usually, the prevalence of RLS increases with age. However, during the pandemic, new-onset symptoms of RLS were more common in younger age groups. This may be due to the pandemic-related factors being more pronounced in the younger compared to the older. The association between insomnia, psychiatric symptoms and RLS warrants clinical attention.

Previous dopaminergic augmentation of RLS symptoms reduces the therapeutic response to non-dopaminergic treatments: the case of DORAs

Previous dopaminergic augmentation of RLS symptoms reduces the therapeutic response to non-dopaminergic treatments: the case of DORAs

Ferric carboxymaltose effects on restless legs syndrome and on brain iron in patients with iron deficiency anemia

ObjectiveBrain iron status is fundamental in RLS pathogenesis. The aim of this study was to determine the clinical efficacy and brain iron concentration improvement in RLS patients with IDA, using 1500 mg FCM. MethodsThis is a randomized, double-blinded, placebo-controlled study. RLS patients with IDA were grouped into either 1500 mg FCM or placebo. The primary outcomes were the change from baseline on the International Restless Legs Syndrome Study Group scale (IRLS) and brain iron measured by QSM and R2∗. ResultsA total of 18 RLS patients with IDA were enrolled, 10 in the FCM group and 8 in the placebo. At the week 6 endpoint, the FCM group showed significant improvement in both IRLS (−13.60 ± 9.47 vs. −3.63 ± 5.40, p = 0.011) and VAS (−40.50 ± 28.81 vs. −0.63 ± 28.28, p = 0.004) from baseline. Change from baseline with R2∗ techniques showed a treatment effect for the thalamus and QSM technique for both the substantia nigra and pulvinar. A correlation was proved between the IRLS difference and the difference of QSM in thalamus (p = 0.028). ConclusionThis study demonstrates that 1500 mg FCM effectively treats RLS symptoms in IDA patients over six weeks, with MRI measurements of improved brain iron content serving as a potential biomarker for RLS patients.

0707 Spinal Cord Stimulation for Restless Legs Syndrome: Case Report and Scoping Review

Abstract Introduction Restless legs syndrome (RLS) can dramatically impair sleep quality and quality of life. Some patients have insufficient treatment response or intolerance to available pharmacological options. Exploration of novel therapeutic approaches is needed. Methods We report a case of spinal cord stimulation (SCS) providing benefit in RLS. We also performed a scoping review of SCS in RLS with comprehensive literature search of MEDLINE, EMBASE, Cochrane, and Scopus. Results A 77-year-old woman with DM2, OSA (on ASV), depression, familial RLS and iron deficiency with typical RLS symptoms for all of her adult life presented for management in 2000. In 2011 she developed intractable painful peripheral neuropathy and chronic back pain. Levodopa, pramipexole, oral/intravenous iron, gabapentin, pregabalin, tramadol, oxycodone, and methadone were ineffective or poorly tolerated. A 7-day percutaneous SCS trial resulted in RLS symptoms improvement initially by 50%. A Medtronic stimulator with lead placement at T8-T9 was implanted. 6 months later, the patient toggled between a tonic program (2.1-4.6 mA, 200 us, 50 Hz) and a sub-perception, differential target multiplexed program duty-cycled to 1:2 on:off (3.7 mA, 170 us, 300 Hz). She reported 75% improvement in RLS symptoms. Pain improved by 50%. Total daily dose of Oral Morphine Equivalents was reduced from 48.75mg/day to 37.5mg/day, with a stable once daily dose of 400 mg gabapentin at night. Uninterrupted sleep went from 2-5 hours to 6 hours. RLS worsened when the device was off. Our case corroborates the current evidence of benefit of SCS for RLS from the literature. We identified other 16 unique patients from case reports and series who had undergone SCS for RLS. Leads were most often implanted in mid or low thoracic levels. Stimulation waveforms were high frequency in 4 patients, tonic in 3 patients, burst stimulation in 1 patient, and undescribed in the others. All patients had RLS symptom reduction. Comorbid pain was reported in 14 patients, which also improved with SCS. Complication with lead erosion was reported in one case. Conclusion SCS remains a promising therapeutic approach for refractory RLS that deserves further investigation. SCS may reduce hyperexcitability seen in RLS by modulating dysfunctional spinal, subcortical, and cortical networks. Support (if any)

0701 Perceptions of People with Restless Legs Syndrome on the Effect of Exercise on Symptoms: Results of a Nationwide Survey

Abstract Introduction Restless legs syndrome (RLS) is a prevalent, sensorimotor sleep disorder that significantly disrupts sleep and is associated with increased risk of cardiovascular disease, hypertension, stroke, depression and anxiety, and causes overall poorer health. As two key diagnostic features of RLS include the worsening of symptoms at rest and relief by movement, there is increasing interest in utilizing physical activity and exercise to manage symptoms. The present study describes personal perceptions of the effects of exercise on symptoms of RLS. Methods Participants (N=528) completed a mixed-methods, nationwide survey including items assessing personal experiences with exercise and RLS (both positive and negative) as well as RLS diagnosis, RLS severity, and demographic and clinical characteristics. Results Most respondents (72%) perceived that exercise improves RLS symptoms with only a small proportion (13%) perceiving exercise only makes symptoms worse. Participants described any abrupt change in exercise would almost always elicit RLS symptoms (e.g., hiking for a long time, stopping an exercise routine) and that a consistent pattern of exercise seemed to be associated with improvements in RLS symptoms and an overall beneficial effect on frequency of symptomatic bouts. Most (55%) perceived exercise in the morning (4AM to noon) improved their symptoms and 56% perceived exercise in the afternoon/evening (4PM to 11 PM) made symptoms worse. Participants described several questions that they wanted answered regarding the evidence for exercise in RLS and specific exercise prescription recommendations. Conclusion Our results suggest that there is individual variation in the response to exercise, whereby some people experience improvements in symptoms with exercise, while others experience worsening of symptoms with exercise. Such individual differences and specific attributes should be considered in exercise-based management to further optimize personalized treatment plans to prevent and manage symptoms in people with RLS. Support (if any) This work was supported, in part, by the National Heart, lung, and Blood institute [T32HL110952].

0713 Long-term response to tonic motor activation (TOMAC) therapy for refractory restless legs syndrome

Abstract Introduction There is a large population of patients who have become refractory to first-line treatments for Restless Legs Syndrome, partially due to augmentation to dopamine agonist medications. For patients with refractory RLS, tonic motor activation (TOMAC) is a noninvasive medical device therapy with promising short-term safety and efficacy. Here, we evaluated the response to TOMAC over a longer duration of &amp;gt;24 weeks. Methods In the RESTFUL study, 133 patients with primary moderate-severe refractory RLS were 1:1 randomized to TOMAC or sham control for weeks 1 to 4 followed by open-label TOMAC for weeks 5 to 8. The final 50 participants to complete the RESTFUL study were invited to continue TOMAC treatment for an additional 24 weeks (weeks 9 to 32) in an extension study. Participants were instructed to self-administer one 30-minute TOMAC session bilaterally over the peroneal nerve whenever RLS symptoms presented. Efficacy was assessed by comparing responses from baseline (RESTFUL study entry, week 0) to week 32 on Clinician Global Impressions-Improvement (CGI-I) responder rate, Patient Global Impressions-Improvement (PGI-I) responder rate, and International RLS Study Group Rating Scale (IRLS) total score. Additional analyses compared responses from week 8 (RESTFUL study completion) to week 32. Results Of the 50 eligible participants, 44 consented to the extension study and 42 completed. CGI-I responder rate relative to baseline increased from 64% at week 8 to 76% at week 32. PGI-I responder rate relative to baseline increased from 68% at week 8 to 77% at week 32. IRLS total score reduced from 24.5 at baseline to 17.1 at week 8 to 12.9 at week 32, a reduction of 11.6 points from baseline to week 32. There were no moderate or severe device-related AEs. Conclusion TOMAC resulted in substantial and clinically significant reduction in RLS symptom severity that was maintained through &amp;gt;24 weeks of treatment. Furthermore, there was a trend towards increased efficacy with continued use of TOMAC. These data suggest that TOMAC could represent a potential long-term treatment for the chronic condition of refractory RLS. Support (if any) Funding was provided by Noctrix Health, Inc.

Exploration of restless legs syndrome under the new concept: A review

Restless leg syndrome (Restless legs syndrome, RLS) is a common neurological disorder. The pathogenesis of RLS remains unknown, and recent pathophysiological developments have shown the contribution of various genetic markers, neurotransmitter dysfunction, and iron deficiency to the disease, as well as other unidentified contributing mechanisms, particularly chronic renal dysfunction. RLS enhancement syndrome is frequently observed in patients with RLS who have received long-term dopamine agonist therapy, manifesting as a worsening of RLS symptoms, usually associated with an increase in the dose of dopamine agonist. Some patients with RLS can adequately control their symptoms with non-pharmacological measures such as massage and warm baths. First-line treatment options include iron supplementation for those with evidence of reduced iron stores, or gabapentin or pregabalin, as well as dopamine agonists, such as pramipexole. Second-line therapies include opioids such as tramadol. RLS seriously affects the quality of life of patients, and because its pathogenesis is unclear, more biological evidence and treatment methods need to be explored.

Clinical difficulties in the treatment of restless legs syndrome: it is the dose that makes poison

IntroductionPolyfarmacy and unjustified use of high dosages of medicaments represent an unmet need in modern psychiatry. Therefore, tidal medication review of hospitalized geriatric patients is an essential step of the disease management as it can be often of vital importance and, as illustrated by current case, can exhibit a tremendeus impact on their quality of life.ObjectivesA case rapport on geriatric patient with iatrogenic damage due to ultra high dosage of ropinirole as a treatment for restless legs syndromeMethodsAuthors of current paper address pharmacodynamic particularities of psychopharmaca and their reasonable choice in context to RLSResultsA clinical case of a 72 y.o. patient, known with chronic minor depressive symptomes over the past decades. Since few years he did not take any medicaion, except ropinirol for RLS. Because of the worsening of RLS symptomes, he decided on his own to increase the dose of ropinirol up to 12 mg/day. Two moths later he has been admitted to the psychiatric ward with major depression symptomes, suicidal plans, insomnia and profound edema of his both lower legs.ConclusionsCurrent case demonstrates that high dose of ropinirole led to tremendous decrease of quality of life of the patient, and pushed him towards concrete suicidal plans. We advocate for careful assessing of the dose of every drug used; avoiding of polypharmacy by any means and for keeping in consideration that the majority of psychopharmaca leads to deterioration of RLS symptoms through modulation of dopamine pathways.DisclosureNo significant relationships.

0825 A Case of Familial Restless Legs Syndrome and Raynaud's Phenomenon

Abstract Introduction Restless legs syndrome (RLS) is a common sensory-motor disorder that frequently leads to sleep disturbances and reduced quality of life. Raynaud's phenomenon (RP) is characterized by episodes of reduced blood flow mainly to the fingers due to vasospasms, with subsequent pain and discoloration, usually triggered by cold exposure or by stress. We present an interesting case report of co-occurrence and familial transmission of RLS and RP which has not been reported previously. Report of Cases: A 64-year-old woman presented for evaluation of long-standing RLS. She had a history of RP, osteoarthritis (OA), and recurrent late pregnancy losses. The patient, and one brother and a sister had RLS and RP. She had another sister and two maternal first cousins with RLS. Her mother suffered from neither and her father and his brother both had RP. She has a daughter who also has RLS. The patient's mother was treated with Diethylstilbestrol (DES) and had five pregnancy losses. The patient also had 3 miscarriages and the patient's daughter miscarried her first pregnancy as well. The patient first experienced RLS symptoms at the age of 12 and has been treated with several medications since then, most recently clonazepam. Since she was taken off clonazepam, she experienced a worsening of RLS and was subsequently started on Pregabalin up to 300 mg at bedtime but without significant relief. She was then started on pramipexole, titrated up to 0.375 mg which resulted in significant improvement of RLS symptoms. Her RP symptoms were infrequent, occurring every few months and not bothersome. She did not report rheumatological complaints other than chronic OA from lifelong sports. Conclusion This case report suggests a possible shared genetic abnormality in the transmission of both RLS and RP in this family. This genetic association may be related to a vascular dysfunction common to both disorders. The co-occurrence of frequent miscarriages (although could be related to DES), in association with the presence of RLS and RP, may also suggest an underlying auto-immune disorder. Further genetic research is needed to confirm above findings with the potential uncovering of new therapeutic targets for RLS. Support (If Any) None.

0549 Prevalence and Impact of Muscle Cramps in Patients with Restless Legs

Abstract Introduction Recent studies have shown alterations in Vitamin D binding protein in RLS, and Vitamin D is intimately related to calcium metabolism, while hypocalcemia is a well-known trigger for muscle cramps. The presence and consequences of muscle cramps in RLS has never been systematically studied. Therefore, the aim of this study was to determine the prevalence and impact of muscle cramps in RLS patients. Methods An email was sent to 4222 active members of the RLS foundation (RLSF) with a link to survey adult RLS patients. The survey included demographic information, questions on muscle cramps (including a visual analogue scale rating intensity), the Pittsburgh Sleep Quality Index assessing sleep disturbances, the 36-Item Short Form Survey Instrument (SF-36) evaluating health status, the 13-item short-form Cambridge-Hopkins diagnostic questionnaire (CH-RLSq13) for diagnosing RLS, and the International RLS Severity Scale measuring RLS severity. Patients who answered “yes” to the question “In the last 3 months have you experienced muscle cramps (defined as involuntary painful muscle contraction occurring at rest, not associated with exercise)?” were considered to have muscle cramps. Results A total of 509 RLSF members completed the whole electronic survey, while 317 participants (Age: 68.9±10.2; 73.1% Women; 97.8% White/Caucasian; BMI: 27.4±5.8) qualified as RLS patients and were included in further analysis. The prevalence of muscle cramps in RLS patients was 60.3%. RLS patients with (versus without) muscle cramps were more overweight (p=0.0119) and had lower scores (more disability) on several SF-36 health concepts including physical functioning (p=0.0093), role limitations due to emotional problems (p=0.0429), social functioning (p=0.0017), and more pain (p=0.0387). In addition, there was a weak (Spearman coefficient ρ=0.253) but significant positive correlation (p=0.0004) between intensity of muscle cramps and severity of RLS symptoms. Conclusion Muscle cramps were present in almost two-third of RLS patients and were associated with a negative impact on health status and severity of RLS. Therefore, from a clinical practice point of view, it seems warranted to screen for muscle cramps in RLS patients. RLS and leg cramps may theoretically be related to each other through calcium metabolism and/or through inflammatory mechanisms. Support (If Any) This study was not funded.

Severe restless legs syndrome in a family with Alport syndrome

BackgroundRestless legs syndrome (RLS) is a common sleep-related movement disorder characterized by an urge to move the legs during inactivity, especially at evening-night. RLS is highly prevalent in patients with kidney failure and have an impact on quality of life, mood, sleep quality and overall on compliance to the dialysis. Alport syndrome (AS) is a rare inherited disease, predominantly X-linked, secondary to mutations in genes encoding α3, α4 or α5 chains of type IV collagen, and characterized by hematuria, chronic kidney disease, neurosensory deafness, and lenticonus.Case presentationHere we describe a family with a combination of X-linked AS and severe RLS accompanied by periodic limb movements during sleep (PLMS). In the first patient we identified, RLS was complicated by a paradoxical response to dopamine agonists named “augmentation”, leading to sleep disruption, hallucinations and five peritoneal perforations during the peritoneal dialysis due to the difficulty to rest still. Therapeutic adjustments and renal transplantation improved RLS and PLMS. In two brothers, severe RLS prevented a compliance with hemodialysis. Female family members carrying the mutation were also affected by RLS, while those without the mutations were RLS-free.ConclusionsRLS has not been reported earlier in association with AS, but the peculiar combinations observed in this family will stimulate further clinical studies and motivate nephrologists to seek for RLS symptoms and sleep disturbances in AS patients.

Acupressure reduces the severity of restless legs syndrome in hemodialysis patients: A cluster-randomized crossover pilot study

BackgroundRestless legs syndrome (RLS), a neurological disorder, often affects sleep quality in hemodialysis patients. This study aimed to evaluate acupressure's effect on the severity of RLS symptoms and sleep quality in hemodialysis patients with RLS. MethodsThis study is a cluster-randomized crossover pilot study. Patients were randomized to two sequences: acupressure for one month and observation for another month (AC); and observation for one month and acupressure for another month (CA). For the four-week acupressure intervention, patients received 36 min of acupressure three times weekly during their hemodialysis sessions. The acupoints were on the bilateral lower limbs, including Zusanli (ST36), Yanglingquan (GB34), Sanyinjiao (SP6), Xuanzhong (GB39), Chengshan (BL57), and Taichong (LR3). RLS severity and sleep quality (measured with the Pittsburgh sleep quality index, PSQI) were measured at baseline, month 1, and month 2. ResultsAC sequence (n = 14) was similar to the CA sequence (n = 9) in terms of gender, age, education, employment, marital status, comorbid disease, BMI, duration of dialysis, medication for RLS and insomnia, RLS severity, and PSQI. The general linear mixed model revealed no significant carryover effect on RLS severity, PSQI, and the seven subscales of PSQI. A significant treatment effect (acupressure) was only observed in RLS severity (p = 0.0013) but not in PSQI and the seven subscales. The significant period effect was observed in RLS severity (p = 0.0250) and the subscale of sleep disturbance (p = 0.0021). ConclusionIn hemodialysis patients with RLS, acupressure can alleviate the severity of RLS but cannot improve sleep quality.

530 Restless Legs Syndrome Prevalence and Severity Among Patients Treated with Buprenorphine and Naloxone for Opioid Use Disorder

Abstract Introduction Restless Legs Syndrome (RLS) is a sensory-motor neurological disorder which is associated with sleep disturbance and emotional distress. Opioid medications are effective treatments for RLS, and a high percentage of patients undergoing opioid withdrawal exhibit symptoms of RLS. Despite the known connection between RLS and opioids, there has been no assessment of RLS in patients actively treated with buprenorphine and naloxone for opioid use disorder (OUD). Methods We conducted a study to determine the prevalence of RLS among patients with OUD at an outpatient buprenorphine and naloxone clinic at Lemuel Shattuck Hospital in Jamaica Plain, Massachusetts. With the help of nurses, participants completed questionnaires which inquired about demographic information, previous opioid use, current medications, and RLS. Patients were categorized as having RLS if, according to the Cambridge-Hopkins Questionnaire, they answered positively to the four essential RLS criteria and if common mimics were not endorsed. A final determination of RLS status in those with ambiguous answers to RLS mimics was made by a trained sleep medicine physician (JWW). Results Participants (n=129) were primarily male (n=86; 66.7%), white (n=101; 78.3%), and the median age was 37.5 years. Approximately half of the sample (n=59; 45.7%) used medications for depression and/or anxiety. The median duration of buprenorphine and naloxone use was 3 years. 13.2% were judged to have RLS. RLS symptoms tended to be of moderate severity, disturb sleep to a moderate degree, and occur 5–15 days per month. There were no significant demographic or clinical differences in those with and without RLS. Of the 103 participants without suspected RLS, 15.5% (n=16) were taking a non-opioid medication known to treat RLS symptoms (e.g. gabapentin). Only 1/17 people (5.9%) with RLS were taking a treatment that would control such symptoms. Conclusion Approximately 13% of this sample currently taking buprenorphine and naloxone for OUD had RLS. RLS can greatly interfere with sleep and quality of life, and those with untreated or partially treated symptoms may be motivated to use unprescribed opioids to control them. With this in mind, clinicians treating OUD should be aware that there are effective non-opioid medications that can treat RLS. Support (if any):

526 Characteristics of Augmented RLS Patients on Dopamine Agonists at a Tertiary Referral Center: Where Do We Go From Here?

Abstract Introduction Augmentation is a management dilemma in RLS patients on dopaminergic therapy. Understanding the clinical characteristics of such patients may assist in better management strategies. Methods Consecutive new consultations for RLS from 4/2016-6/2020 were identified from a single tertiary referral center in Boston, USA. Patients were included in this analysis if they had augmentation and current treatment with a dopamine agonist. Clinical information from initial consultation was collected. RLS severity at time of consultation was determined retrospectively with a modified IRLSSG severity score (0–12), assessing RLS symptom frequency (0–4), duration (0–4), and severity (0–4). Results Out of 209 referrals with RLS, 105 patients had augmentation, of whom 88 were on dopamine agonists at initial evaluation. Average age was 67 years (SD 11 years, range 39–88); 62 were female (59%). Mean duration of RLS symptoms was 27 years (SD 20), and 91% had symptoms &amp;gt; 10 years. Mean duration of dopamine agonist therapy was 11 years; 72% had previously been treated with pramipexole, 65% with ropinirole, 73% with rotigotine, and 16% with levodopa; 72% of patients had been treated with alpha-2-delta ligands, and 28% with opioids. Common comorbidities included obstructive sleep apnea (47%), obesity (49%), and depression (44%). Serotonergic medications were currently used by 25%. Of the 88 augmented patients on dopamine agonist therapy, 97% had earlier onset of symptoms and 33% had symptoms in both morning and afternoon; 53% reported anatomical extension. The mean modified IRLSSG score was 8.4 (SD 3.2). 66% of patients had either ferritin &amp;lt;75 mcg/L or transferrin saturation &amp;lt;20%. At the time of initial assessment, 49% were on pramipexole, 47% on rotigotine, 5% on rotigotine and 7% on levodopa: mean daily dopamine agonist dose was 1.23 mg (SD 1.20) of pramipexole equivalent. 37% were on alpha-2-delta ligands: mean daily dose 1014 mg (SD 830, median 700 mg) of gabapentin equivalent. Conclusion Higher than FDA-recommended dopamine agonist dosing and high prevalence of iron deficiency in patients with augmented RLS represent a treatment gap in the care of RLS patients in the community. Controlled studies of guideline-based therapy are indicated to determine optimal management of augmented RLS. Support (if any) Baszucki Brain Research Fund

817 A Case of Parasomnia Overlap Disorder in a Patient on Lithium

Abstract Introduction The literature contains few case reports of parasomnia overlap disorder. There are also few case reports of lithium inducing sleep walking behaviors. Here we seek to present a case of a patient with multiple parasomnias, is taking a number of psychotropic medications for bipolar I disorder, and is on PAP for OSA. Report of case(s) The patient is a 43 year old male with a history of occasional mild sleep walking since childhood that remitted approximately 10 years prior to the onset of treatment, but returned when he traveled out of area for a family gathering approximately one year prior to presentation in the sleep clinic. He reported not only the return of sleepwalking, on a nightly basis, as well as more severe symptoms (including enuresis and violence/aggression). He also reported several episodes of dream enactment, as well as a history of sleep paralysis and vivid hypnogogic hallucinations, both of which had been improved in the last year. He denied any history of cataplexy. He did complain of symptoms of significant RLS symptoms. He was partially compliant with CPAP for obstructive sleep apnea, though the sleep behaviors continued regardless of CPAP usage. His psychiatrist had started him on clonazepam (titrated to 2mg/night) prior to his intake in the sleep clinic, but with minimal benefit. His other medications included propranolol 40mg BID, lithium 900mg/1200mg, oxcarbazepine 600mg bid, lamictal 225mg bid, lurasidone 80mg qday, and benztropine 2mg bid. Attended polysomnography demonstrated five episodes of sleep behaviors, as well as loss of atonia during REM, and severe obstructive sleep apnea (AHI of 61.2). Conclusion The patients various parasomnias could be due to the side effects of his psychotropic medications, represent a genetic or structural defect that is causing the various parasomnias, or be due to or worsened by his undertreated obstructive sleep apneas. His workup and treatment is still ongoing, but he has continued on clonazepam 2mg but taken 2 hours earlier, and has started a new APAP. Because of the severity of his bipolar disorder (including severe suicidal ideation), he is not a candidate to tapering the lithium or to taking serotonergic antidepressants. Support (if any):

DBS in restless legs syndrome: a new therapeutic approach?

ObjectiveRestless legs syndrome (RLS) is a sleep disorder characterized by an urge to move legs or arms, with a typical circadian rhythm. RLS can be treated with pharmacological and non-pharmacological therapies. Nevertheless, in some patients RLS can be refractory to all medical and non-medical treatments.Deep brain stimulation (DBS) of the globus pallidus internus (GPi) has been reported to improve RLS symptoms in Parkinson's disease (PD) patients with RLS. We describe the case of a patient suffering from refractory idiopathic RLS implanted with bilateral GPi DBS. MethodThe patient underwent DBS targeting the bilateral GPi. Follow up for three years involved clinical evaluation and polysomnography (PSG). ResultsThe patient reported subjective improvement, with reduction in the IRLS score. Furthermore, the polysomnography (PSG) showed an objective improvement of polysomnographic parameters, which remained stable during the follow-up. ConclusionDBS for RLS can be a new therapeutic approach for severe RLS, but further studies are needed.

Baseline and 1-year longitudinal data from the National Restless Legs Syndrome Opioid Registry.

Restless legs syndrome (RLS) is a sensory-motor neurological disorder. Low dose opioid medications are prescribed for treatment-refractory RLS. We describe baseline and 1-year longitudinal dosing and symptom outcomes for the National RLS Opioid Registry. Individuals currently taking a prescribed opioid for diagnosed RLS are included in the registry. Information on initial and current opioid dosages, side effects, past and current concomitant RLS treatments, RLS severity, psychiatric history, and opioid abuse risk factors were collected at baseline. Follow-up online surveys were performed at 6 months and 1-year. Participants (n = 500) are primarily white, elderly, educated, and retired. Half of all subjects are on opioid monotherapy. Nearly 50% of all subjects are taking methadone, and one-quarter are taking oxycodone formulations. The median total daily opioid dose is 30.0 morphine milligram equivalents (MME). At baseline, three-quarters of registry participants had been taking a prescribed opioid for RLS for more than 1 year and one-third for more than 5 years, and had mild-moderate RLS symptoms. At 1-year follow-up, 31.2% increased dose (median = 10 MME) and 16.0% decreased dose of their opioid. An MME increase ≥25 was associated with: opioid use for non-RLS pain, <1 year of opioid use, opioid switch to methadone, and discontinuation of non-opioid RLS medications which, combined, accounted for 91.7% of those with 1-year follow-up increases ≥25 MME. In refractory RLS, prescribed opioids are generally used at low doses with good efficacy. Longitudinally over 1 year, roughly one-third of participants increased their prescribed opioid dose, though generally by small amounts, with larger dose increases accounted for by predictable features.