Restless legs syndrome (RLS) is characterized by an urge to move that occurs in the evening or night time, suggesting circadian involvement. However, objective evidence regarding the circadian phase in RLS remains limited, particularly in real-world settings. We conducted an exploratory pilot study to investigate circadian rhythm timing in patients with RLS using actigraphy-based dim light melatonin onset (DLMO) estimation and to explore its potential association with symptom severity. Patients with idiopathic RLS (n = 21) and age- and sex-matched chronic insomnia controls (n = 21) underwent 14 days of wrist actigraphy to assess rest-activity rhythms and obtain estimated DLMO (eDLMO) from an actigraphy-based mathematical model. Symptom severity was evaluated with the International RLS Study Group rating scale (IRLS). Group comparisons and correlation analyses were conducted in an exploratory manner given the sample size. Patients with RLS (mean age 61.2 ± 7.7 years, 90% female) demonstrated a non-significant trend toward delayed eDLMO compared with insomnia controls (mean age 61.7 ± 7.1 years, 90% female; 10:01 PM ± 47 min vs 9:33 PM ± 49 min, p = 0.069, Cohen's d = 0.58). Within the RLS group, higher IRLS scores were modestly associated with later eDLMO (β = 0.0726, p = 0.038), after adjusting for age and depressive symptoms. In contrast, eDLMO was not significantly associated with Insomnia Severity Index (ISI) or Pittsburgh Sleep Quality Index (PSQI) scores in the insomnia control group. In this exploratory pilot study, patients with RLS showed a tendency toward delayed estimated circadian phase compared with insomnia controls, and later estimated circadian phase was modestly associated with greater RLS symptom severity. These findings support a possible link between circadian phase delay and clinical burden in RLS but require confirmation in larger studies.

Abstract Background Effective prevention of ischemic stroke and transient ischemic attack (TIA) involves timely, guideline-concordant risk factor management. Obstructive sleep apnea (OSA), a significant but underdiagnosed cerebrovascular risk factor, affects approximately 70% of stroke and TIA patients. Untreated OSA is linked to impaired post-stroke recovery, recurrent vascular events, and increased mortality. Despite guideline recommendations to consider early post-stroke/TIA OSA screening, few patients receive sleep studies. This study explores the implementation of a multidisciplinary quality improvement intervention for OSA management at six Department of Veterans Affairs medical centers between 2021 and 2024, focusing on contextual factors influencing implementation success. Methods This mixed-methods study used data from the Addressing Sleep Apnea Post-Stroke/TIA (ASAP) stepped-wedge cluster-randomized clinical trial (NCT04322162). We conducted qualitative analyses of provider interviews and quantitative assessments via configurational comparative methods (CCMs) to identify difference-making conditions for successful implementation. The Group Organization (GO) score, a facility-level measure indicating team cohesion and activation in diagnosing and treating OSA among patients with acute cerebrovascular events, served as the primary implementation outcome. Results Successful implementation, defined by a GO score of ≥ 6, was achieved at four of the six facilities. Four conditions were sufficient by themselves for implementation success: implementation of sleep test ordering, monitoring sleep testing processes, post-discharge care coordination, and positive influence of champions during implementation. Conclusions This study highlights the interplay between local context and novel clinical practices in successful program implementation of an acute sleep service. Four difference-makers perfectly distinguished between sites with and without implementation success. These findings provide actionable insights for tailoring and timing implementation strategies to improve adoption. Trial registration ClinicalTrials.gov NCT04322162.

Periodic leg movements during sleep (PLMS) are a frequently observed motor phenomenon in polysomnography, yet their biological meaning and clinical relevance are debated. Further, how these should be assessed and tabulated for optimal evaluation is uncertain. To address these gaps, an international, multidisciplinary taskforce convened a series of online meetings followed by an in person taskforce workshop held in Troina, Italy, on November 14-15, 2025, where agreement was reached through iterative discussion (qualitative; no Delphi or predefined voting thresholds). This taskforce roadmap summarizes the taskforce conclusions across five priority domains: (1) clinical significance and impact, (2) measurement and characterization, (3) treatment, (4) basic and translational research, and (5) PLMS across the life span and epidemiology. For each domain, we delineate where the field currently stands, identify critical gaps in knowledge, and propose concrete strategies, including key milestones, study designs, and infrastructure needs, to advance the field in a coordinated and standardized manner. A central unifying theme is that PLMS should no longer be viewed solely as a countable polysomnographic index, but rather as a spectrum of sleep-related motor activity with heterogeneous neurophysiological substrates and variable clinical impact. Achieving progress will require harmonized scoring standards, validated automated and wearable technologies, large longitudinal and outcome-oriented studies, and sustained international collaboration. This roadmap provides a framework to guide research, clinical innovation, and future guideline development, but it is not a clinical practice guideline or standards statement.

REM Sleep Behavior Disorder (RBD) is a sleep disorder in which individuals act out their dreams and strongly predicts incident Parkinson’s Disease (PD). Inflammatory Bowel Disease (IBD) is also associated with PD. Given the links among PD, RBD, and IBD, we assessed RBD prevalence in IBD and determined IBD factors associated with RBD. We hypothesized that RBD prevalence in IBD is greater than in age-sex matched controls. 158 controls from the community and 462 IBD patients from IBD Partners, an IBD patient registry, completed online questionnaires to assess RBD symptoms, medical history, and IBD-related medical history. RBD was assessed using the validated RBD Single-Question Screen (RBD1Q). Also assessed were IBD severity using IBD disease duration, number of IBD-related hospitalizations, presence of IBD-related surgery, and Crohn’s disease or simple clinical colitis activity indices. Logistic regression and generalized linear models were used for the outcome RBD1Q, while adjusting for age, sex, and race. Prevalence of RBD was assessed between groups using chi-squared testing. IBD and control participants were comparable in age; the IBD cohort had proportionally more women and more Caucasians. 462 IBD participants had a mean age of 57.1±10.9 years, 71.6% female and 95.2% Caucasian; 158 controls had a mean age of 57.4±11.7 years, 62.6% female, and 91.1% Caucasian. Among the IBD group, 14.1% had RBD, screening positively with the RBD1Q, compared to 5.1% of controls (p = 0.002). Logistic regression revealed that RBD was significantly associated with IBD after controlling for age, sex, and race (OR 3.2 [CI 1.48,6.82]; p=0.003). Among the IBD cohort, RBD was not associated with IBD type, IBD duration, or report of past gastrointestinal surgery. Males with RBD were more likely to report IBD-related hospitalizations (95.2%; p=0.004) than male IBD patients without RBD. RBD was not associated with IBD activity indices. RBD is more prevalent in IBD patients than controls without IBD and may be related to IBD disease severity. Future studies are needed to determine if those with IBD and RBD on particular immunotherapies are at decreased risk for synucleinopathy phenoconversion.

This guideline establishes clinical practice recommendations for treatment of restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) in adults and pediatric patients. The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using the grading of recommendations assessment, development, and evaluation methodology. The task force provided a summary of the relevant literature and the certainty of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations. The following good practice statement is based on expert consensus, and its implementation is necessary for the appropriate and effective management of patients with RLS: The following recommendations are intended as a guide for clinicians in choosing a specific treatment for RLS and PLMD in adults and children. Each recommendation statement is assigned a strength (“strong” or “conditional”). A “strong” recommendation (ie, “We recommend…”) is one that clinicians should follow under most circumstances. The recommendations listed below are ranked in the order of strength of recommendations and grouped by class of treatments within each PICO (Patient, Intervention, Comparator, Outcome) question. Some recommendations include remarks that provide additional context to guide clinicians with implementation of this recommendation. Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2025;21(1):137–152.

INTRODUCTION:Obstructive sleep apnea (OSA) is characterized by repetitive episodes of complete or partial upper airway collapse during sleep. Restless legs syndrome (RLS) is a sleep-related movement disorder characterized by an uncomfortable urge to move the legs, especially during inactivity and evenings. Both OSA and RLS are common with significant overlap: RLS is present in up to 36% of those with OSA. Treatment of OSA with continuous positive airway pressure (CPAP) therapy may influence RLS outcomes. We performed a systematic review to evaluate the impact of CPAP therapy on RLS symptoms and RLS medication usage in individuals with both OSA and RLS. METHOD:A comprehensive literature search was conducted in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception to December 7, 2024. The outcomes of interest were the improvement in RLS symptom severity, as measured by standardized scales such as the International RLS Study Group RLS Severity Scale (IRLS), and changes in the usage of RLS medications. The review included clinical trials and observational studies. Inclusion criteria were: studies with a control group or comparison period before CPAP usage, adult participants diagnosed with OSA and RLS, measurements of RLS severity using standardized scales such as the IRLS, and reports on medication usage before and after CPAP therapy. Data extraction included study characteristics, participant demographics, exposure and outcome measurements, and adjusted effect estimates. Exclusion criteria included non-primary research articles such as reviews, editorials, commentaries, letters, studies without standardized assessments of RLS symptoms, and non-English articles. The quality of included studies was assessed using the Newcastle-Ottawa Quality Scale (NOS), and the risk of bias was evaluated using the ROBINS-I tool. The systematic review was registered in PROSPERO (ID: CRD42024550240). RESULTS:The search identified 2,046 articles, with 291 undergoing full-text review, and three studies (3 observational, 0 RCTs) meeting the inclusion criteria, which included 479 patients. CPAP therapy was associated with improvements in RLS symptoms and a reduction in medication usage among patients with coexistent RLS and OSA. The magnitude of these effects varied, with some studies reporting significant improvements while others showed probable changes. The variability in results can be attributed to differences in study designs, sample sizes, and adjustments for confounding factors. These factors highlight the need for more rigorous research to evaluate the benefits of CPAP therapy in patients with coexistent RLS and OSA. CONCLUSION:CPAP therapy appears beneficial for improving RLS symptoms and reducing medication usage in patients with coexistent OSA and RLS. However, further research with standardized diagnostic and treatment criteria, larger sample sizes, and robust adjustment for confounding factors is necessary to confirm these findings and better understand the underlying mechanisms.

Parkinson disease (PD) patients are particularly vulnerable to the effects of loneliness. The objective of this longitudinal study was to assess how the COVID-19 pandemic affected loneliness in PD patients by identifying the correlates of loneliness during the pandemic in the US and to establish a rationale for providing emotional support and restoring morale. Consecutive PD outpatients were recruited during June 2016-May 2017. Data on sociodemographic, clinical, and psychological variables were obtained. During October-December 2020, participants were mailed a questionnaire about some of the variables studied at baseline and new variables specifically related to the pandemic. Univariate, bivariate, and forward linear regression analyses were used to identify the correlates of loneliness. Sex, demoralization, and baseline PD health-related quality of life were significantly associated with loneliness during COVID-19 pandemic, with women reporting more loneliness than men. To examine loneliness specifically associated with the COVID-19 pandemic, loneliness prior to the pandemic was controlled, with only sex and demoralization remaining statistically significant. Interventions aimed at restoring morale and providing emotional support should be included as an essential component of any treatment plan designed to alleviate loneliness during public health emergencies that require social isolation, such as a pandemic.

Background: The Addressing Sleep Apnea Post-Stroke/TIA (ASAP) clinical trial aimed to enhance OSA management at six VA medical centers through a hybrid implementation trial, requiring coordination across hospital medicine, sleep medicine, nursing, and neurology in both inpatient and outpatient settings. This analysis evaluated the trial’s efforts to standardize early OSA screening in stroke/TIA patients. Methods: This mixed-methods evaluation used configurational comparative methods (CCMs) to identify key contextual factors for successful implementation, examining the joint effects of multiple factors. The stepped-wedge trial ran from May 2019 to January 2024 across three implementation waves. The primary outcome was the Group Organization (GO) score, which measured team cohesion in managing sleep apnea among cerebrovascular patients. Data sources included observational data, qualitative interviews, and administrative data across three periods (A, B, C), calibrated into dichotomous or multi-value categories for analysis. Results: Four key difference-makers distinguished more successful sites (GO score ≥6) from others: routines for ordering inpatient OSA tests, patient care coordination during hospitalization, involvement of field staff, and strong local champions. The ability to order and complete sleep studies was crucial for timely OSA diagnosis. Field staff (e.g., respiratory technicians, polysomnographic technologists, research) played a critical role in coordinating care during inpatient stays and post-discharge. Key pathways to success included active field staff engagement and strong champion support, particularly in the final phase. Less successful sites faced barriers like geographic separation and staff shortages. The figure describes the values for each of these factors at the 4 more successful versus 2 less successful sites. Conclusions: The study highlights the importance of flexibility in integrating new practices, particularly in stroke care requiring multi-specialty coordination. Findings provide a roadmap for healthcare systems implementing similar interventions, emphasizing leadership, coordinated care, and robust tracking for program success.

Importance Obstructive sleep apnea (OSA) is common among patients with ischemic stroke and transient ischemic attack (TIA) and is associated with poor outcomes. Guidelines favor considering sleep testing among patients with cerebrovascular events. Objective To evaluate the effectiveness of a quality improvement intervention to increase OSA diagnostic testing after stroke or TIA. Design, Setting, and Participants This stepped-wedge cluster randomized trial of patients with ischemic stroke or TIA admitted to Department of Veterans Affairs facilities assessed outcomes during 8 data periods of 7-month duration (May 15, 2019, to January 24, 2024). Intervention The quality improvement intervention was implemented with a virtual kickoff; site teams reviewed their facility’s baseline data, identified improvement opportunities, considered barriers and potential solutions to diagnosing OSA among patients with cerebrovascular disease, and developed a site-specific action plan. Team members attended monthly collaborative conferences. A web-based platform provided quality data, action plans, and a resource library. The research team provided external facilitation. Main Outcomes and Measures The primary outcome was 30-day OSA diagnostic testing rate. Secondary outcomes were 30-day positive airway pressure treatment rate, 90-day recurrent vascular event rate, and 90-day readmission rate. Implementation effects were assessed using generalized linear mixed-effects models with binomial distributions and log link fit to patient-level data with site-level random effects. Results The study included 1747 patients at 6 intervention sites (mean [SD] age, 68.7 [11.1] years; 1634 [93.5%] male) and 7454 patients at 30 usual care sites (mean [SD] age, 71.8 [10.8] years; 7114 [95.4%] male). The index event was stroke (vs TIA) in 1429 (81.8%) at the intervention sites and 5931 (79.6%) at the usual care sites. The 30-day diagnostic testing rate increased from 2.1% (20 of 952) during baseline to 29.1% (189 of 650) during implementation (odds ratio [OR], 16.13; 95% CI, 8.25-31.53); the 30-day diagnostic testing rate varied from 0.7% to 2.2% among usual care sites across data periods. Thirty-day positive airway pressure treatment increased from 0.3% (3 of 952) during baseline to 2.8% (18 of 650) during implementation (OR, 14.22; 95% CI, 2.40-84.40) at the intervention sites, while varying from 0.0% (0 of 876) to 0.4% (4 of 1158) at the usual care sites. No statistically significant changes were observed in 90-day readmission or recurrent vascular event rates. Conclusions and Relevance In this cluster randomized trial of patients with acute cerebrovascular events, quality improvement approaches increased OSA testing. These results suggest that health care systems can improve the delivery of guideline-concordant care for patients with acute ischemic stroke and TIA by delivering inpatient sleep medicine services. Trial Registration ClinicalTrials.gov Identifier: NCT04322162

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the treatment of restless legs syndrome and periodic limb movement disorder. The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of pharmacological or nonpharmacological treatment to no treatment to improve patient-important outcomes. Statistical analyses were performed to determine the clinical significance of using various interventions to treat restless legs syndrome and periodic limb movement disorder in adults and children. The Grading of Recommendations Assessment, Development, and Evaluation process was used to assess the evidence for making recommendations. The literature search resulted in 3,631 studies out of which 148 studies provided data suitable for statistical analyses. The task force provided a detailed summary of the evidence along with the certainty of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations. Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2025;21(1):153–199.

Background: Obstructive sleep apnea (OSA) is common among patients with ischemic stroke and transient ischemic attack (TIA) and has been associated with poor outcomes. Guidelines recommend evaluating eligible patients with cerebrovascular events for OSA. Objective: to examine whether a quality improvement (QI) intervention could increase OSA testing post-stroke/TIA. Methods: ASAP (NCT04322162) was a stepped-wedge cluster-randomized trial evaluating the effectiveness of a QI intervention to increase OSA testing among ischemic stroke or TIA patients at intervention (N=6) vs. control sites (N=30). Recruitment was at the facility level. The study involved 3 phases: baseline, implementation, and sustainability. The primary outcome was: 30-day OSA diagnostic testing rate. Secondary outcomes were: 30-day continuous positive airway pressure treatment rate, and 90-day recurrent vascular event and readmission rates. ASAP was powered to detect a difference in the primary outcome: baseline vs. implementation. Generalized linear mixed-effects models with binomial distribution and log link fit to patient-level data with site-level random effects were used. The QI intervention included: a virtual kickoff (teams reviewed data, identified improvement opportunities, considered barriers and solutions to diagnosing OSA post-stroke/TIA, and action plan development); monthly collaborative conferences; web-based platform displaying quality data and resource library; and external facilitation. Results: Among 1747 patients at 6 intervention sites the diagnostic rate increased from 2.1% (baseline, 20/952) to 29.1% (implementation, 189/650); among 7454 patients at 30 control sites the 30-day diagnostic rate varied (0.6%-2.2%; adjusted odds ratio (aOR) 16.90 (95%CI, 9.49-30.10). The diagnostic rate during sustainability was 11.7% (17/145); aOR 3.58 (1.59-8.04). The 30-day treatment rate varied (0.0%-0.4%) at control sites and increased at intervention sites: 0.3% (baseline, 3/952) to 2.8% (implementation, 18/650; OR 14.22 (2.40-84.40). The treatment rate during sustainability was 0.7% (1/145); aOR 2.66 (0.13-56.21). 90-day readmission and recurrent event rates were lower during implementation and sustainability (vs. baseline); these changes were not statistically significant. Conclusions: QI approaches can markedly increase OSA testing among patients with acute cerebrovascular events. Additional work should identify strategies to increase treatment rates among stroke/TIA patients with OSA.

Study Objectives The pathobiology of restless legs syndrome (RLS) remains poorly understood, complicating effective treatment. This observational cross-sectional study aimed to identify a cerebrospinal fluid proteomic signature of RLS and to explore sex-specific differences in cerebrospinal fluid proteomics.Methods Cerebrospinal fluid samples were collected from 22 untreated RLS patients and 18 controls, matched for age, body mass index, and sex. Proteomic analysis was conducted using the SOMAscan platform, assessing over 7000 peptides.Results Eight proteins were differentially abundant between patients and controls, with CRP and JAML increased, and TAPBPL and IL1RL1 decreased. Pathway analysis highlighted significant involvement in immune response, coagulation, and cytoskeletal regulation. Analyses were then carried out using sex stratification, comparing men and women separately. Sex-specific analyses revealed more pronounced proteomic alterations in males (68 differentially abundant proteins vs. control males) than in females (17 proteins). Gene enrichment analysis revealed that men with RLS had more involvement in gene regulation and epigenetic factors than control males and women with restless legs syndrome had greater involvement in systemic inflammatory and vascular processes than control females.Conclusions This study identified a cerebrospinal fluid proteomic signature in RLS, implicating immune and inflammatory pathways in the disease's pathophysiology. Significant sex differences in protein level suggest potential sex-specific mechanisms in RLS, warranting further investigation. These findings contribute to the current understanding of RLS and could inform future therapeutic strategies.

REM sleep behavior disorder (RBD) and inflammatory bowel disease (IBD) are associated with Parkinson’s Disease. Using a cross-sectional design, we assessed RBD prevalence in IBD and controls. In total, 158 controls and 462 IBD patients completed IBD-related history questionnaires, the RBD Single-Question Screen (RBD1Q), and the RBD-Screening Questionnaire. RBD prevalence was compared using chi-squared testing. Logistic regression explored IBD-related factors associated with RBD (RBD1Q), adjusting for age, sex, race, and antidepressant usage. RBD prevalence was higher in IBD (14.1% vs. 5.1%; P = 0.002), driven by differences in women; 13.3% IBD and 1.0% controls had RBD. Among men, 16.0% IBD and 11.9% controls had RBD. IBD was associated with >threefold RBD odds (OR = 3.08, 95% CI [1.43, 6.62], P = 0.003). Men with RBD and IBD had higher IBD-related hospitalization rates than IBD males without RBD (95.2% vs. 63.0%; P = 0.004). RBD is more prevalent in IBD than in controls and is associated with severe IBD.

This guideline establishes clinical practice recommendations for the treatment of restless legs Syndrome (RLS) and periodic limb movement disorder (PLMD) in adults and pediatric patients. This clinical practice guideline updates the previously published American Academy of Sleep Medicine (AASM) practice parameter for the treatment of RLS and PLMD in adults. The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The task force provided a summary of the relevant literature and the certainty of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations. The following recommendations are intended as a guide for clinicians in choosing a specific treatment for RLS and PLMD in adults and children. Each recommendation statement is assigned a strength (“strong” or “conditional”). A “strong” recommendation (i.e., “The AASM recommends…”) is one that clinicians should follow under most circumstances. A “conditional” recommendation (i.e., “The AASM suggests…”) is one that requires that the clinician use clinical knowledge and experience, and to strongly consider the patient’s values and preferences to determine the best course of action. Adult with RLS 1. In adults with RLS, the AASM recommends the use of gabapentin enacarbil over no gabapentin enacarbil (strong recommendation, moderate certainty of evidence) 2. In adults with RLS, the AASM recommends the use of gabapentin over no gabapentin (strong recommendation, moderate certainty of evidence). 3. In adults with RLS, the AASM recommends the use of pregabalin over no pregabalin (strong recommendation, moderate certainty of evidence). 4. In adults with RLS, the AASM recommends the use of IV ferric carboxymaltose over no IV ferric carboxymaltose in patients with appropriate iron status (see good practice statement for iron parameters) (strong recommendation, moderate certainty of evidence). 5. In adults with RLS, the AASM suggests the use of IV low molecular weight iron dextran over no IV low molecular weight iron dextran in patients with appropriate iron status (see good practice statement for iron parameters) (conditional recommendation, very low certainty of evidence). 6. In adults with RLS, the AASM suggests the use of IV ferumoxytol over no IV ferumoxytol in patients with appropriate iron status (see good practice statement for iron parameters) (conditional recommendation, very low certainty of evidence). 7. In adults with RLS, the AASM suggests the use of ferrous sulfate over no ferrous sulfate in patients with appropriate iron status (see good practice statement for iron parameters) (conditional recommendation, moderate certainty of evidence). 8. In adults with RLS, the AASM suggests the use of dipyridamole over no dipyridamole (conditional recommendation, low certainty of evidence). 9. In adults with RLS, the AASM suggests the use of extended-release oxycodone and other opioids over no opioids (conditional recommendation, moderate certainty of evidence). 10. In adults with RLS, the AASM suggests the use of bilateral high-frequency peroneal nerve stimulation over no peroneal nerve stimulation (conditional recommendation, moderate certainty of evidence). 11. In adults with RLS, the AASM suggests against the standard use of levodopa (conditional recommendation, very low certainty of evidence). 12. In adults with RLS, the AASM suggests against the standard use of pramipexole (conditional recommendation, moderate certainty of evidence). 13. In adults with RLS, the AASM suggests against the standard use of transdermal rotigotine (conditional recommendation, low certainty of evidence). 14. In adults with RLS, the AASM suggests against the standard use of ropinirole (conditional recommendation, moderate certainty of evidence). 15. In adults with RLS, the AASM suggests against the use of bupropion for the treatment of RLS (conditional recommendation, moderate certainty of evidence). 16. In adults with RLS, the AASM suggests against the use of carbamazepine (conditional recommendation, low certainty of evidence). 17. In adults with RLS, the AASM suggests against the use of clonazepam (conditional recommendation, very low certainty of evidence). 18. In adults with RLS, the AASM suggests against the use of valerian (conditional recommendation, very low certainty of evidence). 19. In adults with RLS, the AASM suggests against the use of valproic acid (conditional recommendation, low certainty of evidence). 20. In adults with RLS, the AASM recommends against the use of cabergoline (strong recommendation, moderate certainty of evidence). Special adult populations with RLS 21. In adults with RLS and end-stage renal disease (ESRD), the AASM suggests the use of gabapentin over no gabapentin (conditional recommendation, very low certainty of evidence). 22. In adults with RLS and ESRD, the AASM suggests the use of IV iron sucrose over no IV iron sucrose in patients with ferritin < 200 ng/mL and transferrin saturation < 20% (conditional recommendation, moderate certainty of evidence). 23. In adults with RLS and ESRD, the AASM suggests the use of vitamin C over no vitamin C (conditional recommendation, low certainty of evidence). 24. In adults with RLS and ESRD, the AASM suggests against the standard use of levodopa (conditional recommendation, low certainty of evidence). 25. In adults with RLS and ESRD, the AASM suggests against the standard use of rotigotine (conditional recommendation, very low certainty of evidence). Adults with PLMD 26. In adults with PLMD, the AASM suggests against the use of triazolam (conditional recommendation, very low certainty of evidence). 27. In adults with PLMD, the AASM suggests against the use of valproic acid (conditional recommendation, very low certainty of evidence). Children with RLS 28. In children with RLS, the AASM suggests the use of ferrous sulfate over no ferrous sulfate in patients with appropriate iron status (see good practice statement for iron parameters) (conditional recommendation, very low certainty of evidence). The treatment of RLS and PLMD should be based on a diagnosis established using ICSD-3 criteria and a comprehensive clinical history. The standard of care should be to provide one of the recommended interventions discussed within the guideline, taking into consideration the accessibility and resource requirements when deciding on the most appropriate treatment for a given patient. The treating clinician and the patient must make the ultimate judgment regarding any specific care.

BACKGROUND:Addressing Sleep Apnea Post-Stroke and TIA (ASAP) evaluated a quality improvement (QI) intervention to increase sleep apnea testing among patients with ischemic stroke or transient ischemic attack (TIA). We describe ASAP methods highlighting two features: inclusion of usual care control sites and validation of electronic health record (EHR) data. METHODS:ASAP was a stepped-wedge cluster-randomized clinical trial at N = 6 intervention sites augmented with N = 30 control sites to evaluate the effectiveness, implementation, sustainability, and business case of a quality improvement intervention to increase sleep apnea testing among stroke/TIA patients. The study period included the COVID-19 pandemic and an international device recall. EHR data were compared with chart review for cerebrovascular diagnosis, sleep study eligibility, sleep study receipt, and patient characteristics. EHR data accuracy (ACC) was assessed as: (true positives + true negatives)/(true positives + false positives + true negatives + false negatives). RESULTS:During the baseline period (May 2019-February 2021), the average 30-day diagnostic rate was 2.0 % (implementation sites) and 1.3 % (control sites). Among N = 1658 implementation site patients, the index event was stroke in 78.7 %. EHR data accuracy was high for cerebrovascular diagnoses (ACC 0.918-0.953), sleep study receipt (ACC 0.949), and patient characteristics (0.898-0.996). EHR data accuracy was lower for sleep study eligibility (ACC 0.850). CONCLUSIONS:The addition of control sites to stepped-wedge trials allows for intervention evaluation within the context of potential temporal trends influencing outcomes. EHR data can be used to evaluate sleep apnea diagnostic testing after ischemic stroke or TIA. Trial registration ClinicalTrials.govNCT04322162 Date of trial registration: 04/02/2020.

The objective of this scoping review is to quantify the literature on motivation states (e.g., urges, impulses) surrounding bodily movement as applied to movement disorders.

Introduction: Rates of guideline-concordant obstructive sleep apnea (OSA) testing among those with a recent cerebrovascular event are exceedingly low. Understanding the role contextual factors play is necessary to inform successful implementation of quality improvement (QI) initiatives designed to address this gap in stroke/transient ischemic attack (TIA) care. Methods: Longitudinal data was collected via questionnaires and semi-structured interviews to evaluate the implementation of QI initiatives conducted at six diverse VA Medical Centers (VAMCs) participating in Addressing Sleep Apnea Post-Stroke/TIA (ASAP), a Hybrid Type I, stepped-wedge cluster-randomized trial. Intervention components included a Systems Redesign Virtual Collaborative and data monitoring (Figure 1). Implementation strategies included external facilitation and audit and feedback. Provider- (e.g., clinical training) and systems-level contextual elements (e.g., Champion Team members and their roles) were collected. Select Consolidated Framework for Implementation Research (CFIR) constructs were rated in terms of magnitude and valence. The primary outcome of successful implementation was defined at the end of 21 months of active implementation as obtaining a Group Organizational (GO) score of ≥6 a measure of programmatic development and maturation. Comparisons of sites were conducted across contextual elements and stratified by those achieving a GO score of ≥6 (Figure 2). Results: ASAP Sites 1 through 4 obtained a GO score ≥6 (range: 7-9); across these sites, the Clinical Champion had: (1) field staff engaged in activities such as care coordination; (2) full to partial support of their local sleep personnel, and; (3) consistently positive CFIR scores values. These sites also received a greater amount of external facilitation and used a quality dashboard more often. All 4 sites created a change in health care personnel and medical center culture that stressed the importance of OSA testing soon after a cerebrovascular event occurred. Conclusions: Developing strong and consistent Champion teams who meaningfully engaged with local VAMC personnel within and across sleep medicine and stroke service lines was important for implementation success. Other key contextual factors for changing culture and creating a healthcare system wide approach to improving OSA testing for stroke/TIA patients included external facilitators and using performance data. Clinical Trials registration: NCT04322162