<figure><img src="image_1.png" /></figure>

HAL
open science

# Cognitive strategies to improve symptoms of restless legs syndrome

Sofiène Chenini, Lucie Barateau, Lily Guiraud, Marie-Lou Rollin, Régis Lopez, Isabelle Jaussent, Severine Beziat, Yves Dauvilliers

► To cite this version:

Sofiène Chenini, Lucie Barateau, Lily Guiraud, Marie-Lou Rollin, Régis Lopez, et al. Cognitive strategies to improve symptoms of restless legs syndrome. Journal of Sleep Research, 2022, 32, 10.1111/jsr.13794. hal-04258489

HAL Id: hal-04258489

https://hal.umontpellier.fr/hal-04258489

Submitted on 25 Oct 2023

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_2.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
RESEARCH ARTICLE

Journal of
Sleep
Research

<figure><img src="image_3.png" /></figure>

# Cognitive strategies to improve symptoms of restless legs syndrome

Sofiene Chenini<fnref n="1" />,<fnref n="2" />,<fnref n="3" /> | Regis Lopez<fnref n="1" />,<fnref n="2" />,<fnref n="3" />

Lucie Barateau<fnref n="1" />,<fnref n="2" />,<fnref n="3" /> | Isabelle Jaussent<fnref n="2" />,<fnref n="3" />

Lily Guiraud<fnref n="1" />

Severine Beziat<fnref n="2" />,<fnref n="3" />

Marie-Lou Rollin<fnref n="1" />

Yves Dauvilliers<fnref n="1" />,<fnref n="2" />,<fnref n="3" />

<figure><img src="image_4.png" /></figure>

Correspondence

Sofiene Chenini and Yves Dauvilliers, National Reference Network for Narcolepsy, CHU Gui de Chauliac, Montpellier, France; INM, University Montpellier, 80, avenue Augustin Fliche, 34295 Montpellier Cedex 5, France.
Email: ydauvilliers@yahoo.fr and
sofienechenini@hotmail.com

## Summary

Symptoms of restless legs syndrome are relieved by movement. Whether a cognitive task decreases sensory discomfort remains understudied. We aimed to assess the frequency of patients with restless legs syndrome who report decreased sensory discomfort during cognitive activities, and quantify this decrease during a cognitive task. Three-hundred and fifty-eight consecutive adults with restless legs syndrome (age 55.17 ± 14.62 years; 55.87% women; 27.65% treated) answered the question: "Does the intensity of your restless legs syndrome symptoms decrease when you perform activities other than moving your legs?" rated on a nine-point Likert scale (from fully-agree to totally-disagree). A subgroup of 65 consecutive drug-free patients underwent an 80-min suggested immobilisation test at 20:00 hours to quantify legs discomfort on a visual analogue scale before polysomnography, including 40 patients performing a cognitive task (balloon analogue risk task) from the 60 to 80 min. A total of 130 (36.3%) patients reported a decrease, 158 (44.1%) no decrease, and 70 (19.5%) uncertain changes in severity of restless legs syndrome symptoms during cognitive activities, with a similar proportion whether treated or not. Patients experiencing a decrease had less severe restless legs syndrome symptoms. In the suggested immobilisation test, mixed-effect regression models showed that legs discomfort decreased in patients performing the cognitive task while it continued to increase in those without task, with a larger difference in patients reporting a self-reported decrease in restless legs syndrome during cognitive activities. In conclusion, one-third of patients reported a self-reported decrease of restless legs syndrome symptoms during cognitive activities, this improvement in restless legs syndrome was confirmed during a sustained cognitive task. Cognitive strategies could be implemented for the management of restless legs syndrome.

## KEYWORDS

balloon analogue risk test, cognitive activities, restless legs syndrome, sensory discomfort, suggested immobilisation test

# 1 | INTRODUCTION

Restless legs syndrome (RLS) is a frequent chronic sensorimotor disorder defined by an urge to move the legs in the evening/night when at

rest, which improves with movement (Allen et al., 2014). RLS symptoms vary considerably in frequency and severity, with symptoms fluctuating significantly over 24 hr, and from day to day, and with severe forms having a significant impact on sleep, quality of life and

<figure><img src="image_5.png" /></figure>

<footnote n="1">¹Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France</footnote>

<footnote n="2">²National Reference Network for Narcolepsy, CHU Montpellier, Montpellier, France</footnote>

<footnote n="3">³Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France</footnote>
mood (Allen et al., 2005; Chenini et al., 2022; Fuhs et al., 2014). By definition, symptoms begin or worsen during periods of inactivity, and are partially or totally relieved by movement (Allen et al., 2014). Although each patient has his own strategy to relieve symptoms, the most frequently reported are walking, stretching, massages or other actions such as cold shower on the legs. Many patients also report that RLS symptoms decrease when engaging in a cognitive task such as writing, surfing the web, watching exciting movies, playing video games, doing crossword puzzles and even driving, so without necessarily having to move their legs. However, little is known about these strategies that decrease RLS symptoms, with few studies performed in this area. Moreover, to our best knowledge, no study has quantified the effect of a cognitive task on sensory discomfort in a controlled condition in RLS.

Here, we aimed: (1) to assess the frequency of patients who report a decrease in RLS sensory discomfort during cognitive activities; (2) to identify their clinical, biological and polysomnographic (PSG) characteristics; and (3) to quantify in a subgroup of consecutive patients whether their sensory RLS discomfort changes during a sustained cognitive task.

## 2 | METHODS

### 2.1 | Participants

A total of 358 consecutive adult patients (age 55.17 ± 14.62 years old; 55.87% women; 72.35% untreated) with primary RLS diagnosed at the sleep unit (Gui de Chauliac Hospital Montpellier, France) were included in this study. All patients had a clinical interview with a sleep specialist to confirm RLS diagnosis and exclude mimic conditions, according to the International RLS Study Group (IRLSSG) criteria (Allen et al., 2014). Inclusion criteria were diagnosis of primary RLS and an IRLSSG Severity Scale ≥ 15/40 (moderate to severe) for untreated patients (Walters et al., 2003). A total of 99 patients were treated for RLS at time of study. Exclusion criteria were: iron overload disorders, pregnancy, chronic kidney and liver diseases, inflammatory and neurological comorbidities (Parkinson's disease, multiple sclerosis, polyneuropathy, dementia, myelitis and spinal cerebellar ataxia).

This study was approved by the Montpellier University review board, France. The study was performed in accordance with the Declaration of Helsinki and the French Good Clinical Practices.

### 2.2 | Assessment of RLS symptoms during cognitive activities

After a face-to-face clinical interview to confirm RLS, all patients answered a written question specifically created for this study: "Does the intensity of your RLS symptoms decrease when you perform activities other than moving your legs (with some proposed examples of intellectual, emotional and motor [only upper limbs] activities: computer use, crosswords, puzzles, games, reading, writing, drawing,

painting, ...)?" Responses were reported on a visual analogue scale (VAS) that ranged from 1 to 9 (1: fully agree; 3: somewhat agree; 5: neither agree nor disagree; 7: somewhat disagree; 9: totally disagree). Patients were then asked to precise the cognitive activities associated with RLS symptoms decrease and the most significant relief time slot.

### 2.3 | Sociodemographic, clinical and biological assessment

Age at RLS onset, family history of RLS, comorbidities, body mass index (BMI) and educational level (categorised as < 12 years: high school/college; ≥ 12 years: university level of education) were recorded. All patients completed the IRLSSG questionnaire (≥ 15 moderate to severe symptoms), the Epworth Sleepiness Scale (ESS) with a total score ≥ 11/24 indicating excessive daytime sleepiness (EDS; Johns, 1991), the Insomnia Severity Index (ISI; cut-off score > 14: significant insomnia and > 21: severe insomnia symptoms; Bastien et al., 2001) the Beck Depression Inventory-II (BDI-II; cut-off: 0-13 = no or minimal; 14-19 = mild; 20-28 = moderate; and 29-63 = severe depressive symptoms; Beck et al., 1996), the State-Trait Anxiety Inventory (STAI; scores range from 20 to 80, with higher scores reflecting greater anxiety; Spielberger, 1983) They also completed the Urgency, Premeditation, Perseverance, Sensation seeking (UPPS) impulsive behaviour scale that provides scores for each of the four dimensions of impulsivity, with higher scores reflecting higher levels of impulsivity (Whiteside & Lynam, 2001).

Venous blood samples were collected between 07:00 hours and 08:00 hours after overnight fasting with quantification of serum ferritin levels.

### 2.4 | Polysomnography

Untreated patients (n = 228) underwent 1-night PSG recording in the sleep laboratory monitoring electroencephalogram (EEG) leads (C3/A2, C4/A1, O2/A1), electrooculography, chin electromyography (EMG) and electrocardiogram. Respiration was monitored with a nasal cannula/pressure transducer system, mouth thermistor, chest and abdominal bands, and pulse oximeter. Leg movements were evaluated with surface EMG electrodes placed on the right and left anterior tibialis muscles. Sleep stages (N1, N2, N3 and rapid eye movement [REM] sleep) were scored manually, as well as micro-arousals, periodic leg movements during sleep (PLMS) and apnea-hypopnea index (AHI) according to standard criteria (Iber, 2007; Zucconi et al., 2006).

### 2.5 | Assessment of RLS sensory discomfort during the suggested immobilisation test (SIT)

Prior to PSG, a subgroup of 65 consecutive patients underwent an 80-min SIT at 20:00 hours to quantify RLS sensory discomfort under standardised conditions. These 65 patients were selected on a
voluntary basis and agreed to perform the modified 80-min SIT. The SIT was initially developed to quantify RLS sensory discomfort and leg movements during 60 min in standardised conditions (De Cock et al., 2012; Michaud et al., 2002; Rassu et al., 2020). In this study, we performed the sensory SIT only, without recording legs movements and EEG. Patients were instructed to stay, legs outstretched in a bed reclined at 45° for 80 min. Talking, reading or other cognitive activities were forbidden. Patients were asked to rate their sensory discomfort using a VAS ranging from 0 to 10 (no discomfort to extreme discomfort) at the start and every 10 min (nine values).

## 2.6 | Balloon analogue risk task (BART)

At the 60th minute, 40 patients were consecutively selected to perform a sustained cognitive task (i.e. BART) during 20 min, and 25 patients to continue the SIT unchanged until the 80th minute, thus constituting a control group. Patients were not aware in advance (before the 60th minute) in which group they were assigned.

The BART is a validated computer-based tool that assesses the risk-taking propensity (Lejuez et al., 2002). We used the BART as a distractive task by placing a computer in front of the patient at the 60th minute of the SIT. The computer's screen shows a deflated balloon, a button to pump the balloon, another one to collect the money, and two boxes that show the played money and the collected money in the bank. The patient begins to pump up the balloon that increase the played money. After each pump, the participant had two options: collect the accumulated played money, or pump up the balloon again to increase the played money. If the balloon pops, the trial ends and the patient loses all the played money. If the money is collected, the trial ends and the patient keeps the money safe in the bank. The balloons have a different number of inflations before explosion distributed randomly. Patients are instructed to pump up the balloon without exploding it, and earn the greatest amount of money in 30 trials, for a period of 20 min. The average number of pumps, the adjusted average number of pumps (number of pumps minus number of explosions) and the number of explosions were quantified. Higher scores indicate higher risk-taking propensity (Lejuez et al., 2003).

## 2.7 | Statistical analysis

Categorical variables were presented as numbers and percentages, and quantitative variables as means and standard deviation. Sociodemographic, clinical and PSG features were compared between the three groups (e.g. agree, RLS symptoms decreased with cognitive activities [score 1-3]; neither-agree-nor-disagree [score 4-6]; disagree, RLS symptoms did not decrease with cognitive activities [score 7-9]) using multinomial regression logistic models. When comparisons were statistically significant between groups, two-by-two comparisons were carried out, using a correction for multiple comparisons with the Bonferroni method. Binary regression logistic models were also used to analyse the association between exposures and two

groups (e.g. patients who performed the SIT with the BART versus the SIT alone). Mixed-effect regression models were used to examine the RLS sensory discomfort during the SIT changes during 80 min, by taking into account the repeated measures (nine × 10-min time periods) and the two groups (with or without the BART). Patients were considered as random effects. Time periods, groups and their interaction with the time periods were considered as fixed effects. Changes of RLS discomfort between two time points were compared using dependent t-tests for continuous variables. Statistical significance was set at *p* < 0.05. Statistical analyses were performed with SAS, version 9.4 (SAS Institute, Cary, NC, USA).

## 3 | RESULTS

Among the 358 consecutive patients, 191 (56.01%) had educational level above 12 years. The mean BMI was 25.62 ± 4.65 kg m⁻², and 53 (15.14%) were obese. The mean age at RLS onset was 38.67 ± 16.54 years, and 133 (38.89%) reported a positive family history of RLS. The mean IRLSSG score for untreated patients was 24.94 ± 5.56, with 69 (26.64%) having moderate, 142 (54.83%) severe and 48 (18.53%) very-severe RLS symptoms. At time of evaluation, 99 (27.65%) patients were treated for their RLS and related insomnia (86 took at least one DA alone or combined with alpha-2-delta ligands, opioids or clonazepam, and 13 took at least an alpha-2-delta ligand alone or combined with opiate and clonazepam). The mean IRLSSG score for the treated group was 24.45 ± 6.59, with two patients (2.02%) having mild, 25 (25.25%) moderate, 55 (55.56%) severe and 17 (17.17%) very-severe RLS symptoms.

Compared with untreated patients, those treated were older (61.40 ± 12.11 years versus 52.78 ± 14.81 years, *p* < 0.0001), with older age at RLS onset (43.25 ± 14.98 years versus 36.88 ± 16.80 years, *p* = 0.001). They had less EDS (41.05% versus 53.33% with ESS > 10, *p* = 0.04), less insomnia symptoms (12.37% versus 20.80% with ISI > 21; 45.36% versus 50.80% with ISI = 15-21, *p* = 0.03), less sensation seeking (22.59 ± 7.59 versus 25.45 ± 8.28, *p* = 0.01) and lack of premeditation (19.49 ± 4.88 versus 20.97 ± 5.37, *p* = 0.04) on UPPS subscores.

## 3.1 | RLS symptoms decreased during cognitive activities

Based on the questionnaire, 130 (36.31%) patients experienced a decrease, 158 (44.13%) no decrease and 70 (19.55%) uncertain changes in severity of RLS symptoms when performing a cognitive activity during symptomatic periods. The most frequent intellectual, emotional and motor (only upper limbs) activities reported by participants with decreased RLS symptoms were computer use (39.23%), reading (38.46%), tinkering/knitting (16.15%), writing/drawing/painting (11.53%), watching films/series (9.23%) and crosswords/Sudoku (7.69%). The greatest time range of RLS symptoms relief was between 18:00 hours and 00:00 hours.
<figure><img src="image_6.png" /></figure>

<table><caption>TABLE 1 Socio-demographic, clinical, biological and PSG characteristics of patients with RLS based on the self-reported changes in severity of RLS symptoms during cognitive activities</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">A-Decrease in RLS symptoms during cognitive activities</th><th colspan="2">B-Uncertain</th><th colspan="2">C-No decrease in RLS symptoms during cognitive activities</th><th rowspan="2">Global p</th><th rowspan="2">Post hoc comparisons</th></tr><tr><th>N = 130</th><th></th><th>N = 70</th><th></th><th>N = 158</th><th></th></tr><tr><th></th><th>n</th><th>%</th><th>n</th><th>%</th><th>n</th><th>%</th><th></th><th></th></tr></thead><tbody><tr><td>Sex, male</td><td>62</td><td>47.69</td><td>31</td><td>44.29</td><td>65</td><td>41.14</td><td>0.54</td><td></td></tr><tr><td>Age (years)<sup>a</sup></td><td>130; 56.11 (±14.60)</td><td></td><td>70; 56.21 (±14.28)</td><td></td><td>158; 53.93 (±14.77)</td><td></td><td>0.36</td><td></td></tr><tr><td>Educational level, ≥12 years</td><td>69</td><td>55.20</td><td>35</td><td>51.47</td><td>87</td><td>58.78</td><td>0.59</td><td></td></tr><tr><td>BMI (kg m<sup>-2</sup>)<sup>a</sup></td><td>126; 25.03 (±3.87)</td><td></td><td>70; 26.18 (±5.16)</td><td></td><td>154; 25.85 (±4.96)</td><td></td><td>0.18</td><td></td></tr><tr><td>BMI (kg m<sup>-2</sup>), ≥30</td><td>13</td><td>10.32</td><td>15</td><td>21.43</td><td>25</td><td>16.23</td><td>0.11</td><td></td></tr><tr><td>Treatment status, treated</td><td>41</td><td>31.54</td><td>16</td><td>22.86</td><td>42</td><td>26.58</td><td>0.39</td><td></td></tr><tr><td>Age at RLS symptom at onset (in years)<sup>a</sup></td><td>126; 39.27 (±16.39)</td><td></td><td>68; 40.93 (±16.12)</td><td></td><td>158; 37.23 (±16.80)</td><td></td><td>0.27</td><td></td></tr><tr><td>Duration of RLS (in years)<sup>a</sup></td><td>126; 16.85 (±13.56)</td><td></td><td>68; 15.13 (±13.08)</td><td></td><td>158; 16.70 (±13.68)</td><td></td><td>0.67</td><td></td></tr><tr><td>RLS family history, yes</td><td>50</td><td>40.32</td><td>24</td><td>37.50</td><td>59</td><td>38.31</td><td>0.91</td><td></td></tr><tr><td>RLS severity scale<sup>a</sup></td><td>130; 24.08 (±6.08)</td><td></td><td>70; 23.99 (±5.34)</td><td></td><td>158; 25.76 (±5.78)</td><td></td><td>0.02</td><td>-</td></tr><tr><td>RLS severity scale, >20</td><td>88</td><td>67.69</td><td>47</td><td>67.14</td><td>127</td><td>80.38</td><td>0.03</td><td>A &lt; C</td></tr><tr><td>Ferritin (µg L<sup>-1</sup>)<sup>a</sup></td><td>113; 146.15 (±127.93)</td><td></td><td>63; 156.73 (±104.22)</td><td></td><td>141; 149.09 (±139.23)</td><td></td><td>0.87</td><td></td></tr><tr><td>Cardiovascular comorbidities<sup>b</sup>, yes</td><td>41</td><td>33.61</td><td>16</td><td>23.88</td><td>36</td><td>25.17</td><td>0.22</td><td></td></tr><tr><td>ESS score<sup>a</sup></td><td>126; 9.62 (±5.89)</td><td></td><td>69; 10.14 (±4.83)</td><td></td><td>155; 11.19 (±5.40)</td><td></td><td>0.05</td><td>-</td></tr><tr><td>ESS score, >10</td><td>52</td><td>41.27</td><td>37</td><td>53.62</td><td>86</td><td>55.48</td><td>0.05</td><td>A &lt; C</td></tr><tr><td>ISI score<sup>a</sup></td><td>126; 16.09 (±5.78)</td><td></td><td>69; 17.19 (±5.02)</td><td></td><td>152; 16.81 (±5.27)</td><td></td><td>0.34</td><td></td></tr><tr><td>ISI score</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>≤14</td><td>49</td><td>38.89</td><td>20</td><td>28.99</td><td>43</td><td>28.29</td><td>0.40</td><td></td></tr><tr><td>15-21</td><td>56</td><td>44.44</td><td>35</td><td>50.72</td><td>80</td><td>52.63</td><td></td><td></td></tr><tr><td>>21</td><td>21</td><td>16.67</td><td>14</td><td>20.29</td><td>29</td><td>19.08</td><td></td><td></td></tr><tr><td>BDI-II total score<sup>a</sup></td><td>120; 16.52 (±9.66)</td><td></td><td>65; 15.11 (±8.65)</td><td></td><td>152; 15.39 (±10.42)</td><td></td><td>0.55</td><td></td></tr><tr><td>BDI-II total score, ≥20</td><td>48</td><td>40.00</td><td>21</td><td>32.31</td><td>47</td><td>30.92</td><td>0.27</td><td></td></tr><tr><td>UPPS - Urgency<sup>a</sup></td><td>116; 29.53 (±6.44)</td><td></td><td>57; 27.19 (±6.11)</td><td></td><td>129; 29.37 (±7.07)</td><td></td><td>0.07</td><td></td></tr><tr><td>UPPS - Urgency, ≥32</td><td>48</td><td>41.38</td><td>10</td><td>17.54</td><td>52</td><td>40.31</td><td>0.007</td><td>A, C &gt; B</td></tr><tr><td>UPPS - Lack of premeditation<sup>a</sup></td><td>116; 20.50 (±5.23)</td><td></td><td>56; 20.43 (±4.95)</td><td></td><td>128; 20.88 (±5.51)</td><td></td><td>0.82</td><td></td></tr><tr><td>UPPS - Lack of premeditation, ≥22<sup>c</sup></td><td>48</td><td>41.38</td><td>24</td><td>42.86</td><td>58</td><td>45.31</td><td>0.82</td><td></td></tr><tr><td>UPPS - Lack of perseverance<sup>a</sup></td><td>117; 19.41 (±5.18)</td><td></td><td>57; 18.93 (±4.25)</td><td></td><td>128; 18.98 (±4.41)</td><td></td><td>0.72</td><td></td></tr><tr><td>UPPS - Lack of perseverance, ≥21<sup>c</sup></td><td>46</td><td>39.32</td><td>18</td><td>31.58</td><td>41</td><td>32.03</td><td>0.42</td><td></td></tr><tr><td>UPPS - Sensation seeking<sup>a</sup></td><td>116; 24.96 (±8.00)</td><td></td><td>56; 23.46 (±8.36)</td><td></td><td>129; 25.26 (±8.32)</td><td></td><td>0.38</td><td></td></tr><tr><td>UPPS - Sensation seeking, ≥28<sup>c</sup></td><td>39</td><td>33.62</td><td>16</td><td>28.57</td><td>50</td><td>38.76</td><td>0.39</td><td></td></tr><tr><td>STAI - State anxiety<sup>a</sup></td><td>41; 40.41 (±13.84)</td><td></td><td>18; 36.89 (±14.14)</td><td></td><td>52; 39.17 (±11.86)</td><td></td><td>0.63</td><td></td></tr><tr><td>STAI - Trait anxiety<sup>a</sup></td><td>42; 44.64 (±12.54)</td><td></td><td>17; 39.65 (±11.22)</td><td></td><td>49; 44.65 (±11.70)</td><td></td><td>0.29</td><td></td></tr><tr><td>PSG characteristics<sup>d</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Total sleep time (min)<sup>a</sup></td><td>75; 336.05 (±87.93)</td><td></td><td>45; 311.44 (±127.55)</td><td></td><td>108; 352.81 (±88.98)</td><td></td><td>0.06</td><td></td></tr><tr><td>Total sleep time, &lt; 6 hr</td><td>45</td><td>60.00</td><td>27</td><td>60.00</td><td>47</td><td>43.52</td><td>0.05</td><td>-</td></tr><tr><td>Sleep efficiency (%)<sup>a</sup></td><td>75; 71.02 (±17.36)</td><td></td><td>44; 65.42 (±24.79)</td><td></td><td>107; 74.86 (±17.08)</td><td></td><td>0.03</td><td>B &lt; C</td></tr><tr><td>Sleep efficiency, ≥85%</td><td>15</td><td>20.00</td><td>9</td><td>20.45</td><td>37</td><td>34.58</td><td>0.05</td><td></td></tr><tr><td>WASO (min)<sup>a</sup></td><td>75; 97.99 (±73.68)</td><td></td><td>45; 98.78 (±92.88)</td><td></td><td>108; 81.59 (±65.22)</td><td></td><td>0.24</td><td></td></tr><tr><td>Sleep latency (min)<sup>a</sup></td><td>75; 32.26 (±42.59)</td><td></td><td>45; 39.89 (±45.48)</td><td></td><td>108; 30.64 (±44.11)</td><td></td><td>0.50</td><td></td></tr></tbody></table>
<figure><img src="image_7.png" /></figure>

<table><caption>TABLE 1 (Continued)</caption><thead><tr><th rowspan="2">Variable</th><th colspan="2">A-Decrease in RLS symptoms during cognitive activities</th><th colspan="2">B-Uncertain</th><th colspan="2">C-No decrease in RLS symptoms during cognitive activities</th><th rowspan="2">Global p</th><th rowspan="2">Post hoc comparisons</th></tr><tr><th colspan="2">N = 130</th><th colspan="2">N = 70</th><th colspan="2">N = 158</th></tr><tr><th></th><th>n</th><th>%</th><th>n</th><th>%</th><th>n</th><th>%</th><th></th><th></th></tr></thead><tbody><tr><td>N1 (%)<sup>a</sup></td><td>75; 9.19 (±6.28)</td><td></td><td>45; 12.44 (±15.78)</td><td></td><td>108; 7.98 (±8.24)</td><td></td><td>0.06</td><td></td></tr><tr><td>N2 (%)<sup>a</sup></td><td>75; 51.43 (±10.07)</td><td></td><td>45; 49.77 (±12.81)</td><td></td><td>108; 50.95 (±10.55)</td><td></td><td>0.71</td><td></td></tr><tr><td>N3 (%)<sup>a</sup></td><td>75; 21.03 (±9.43)</td><td></td><td>44; 20.13 (±11.63)</td><td></td><td>107; 21.25 (±9.22)</td><td></td><td>0.81</td><td></td></tr><tr><td>REM sleep (%)<sup>a</sup></td><td>75; 18.33 (±6.6)</td><td></td><td>44; 18.51 (±8.7)</td><td></td><td>106; 20.37 (±6.44)</td><td></td><td>0.11</td><td></td></tr><tr><td>PLMS index (per hr)<sup>a</sup></td><td>75; 31.96 (±41.82)</td><td></td><td>45; 47.59 (±57.99)</td><td></td><td>108; 32.98 (±45.16)</td><td></td><td>0.17</td><td></td></tr><tr><td>PLMS index (per hr)<sup>a</sup>, ≥15</td><td>40</td><td>53.33</td><td>24</td><td>53.33</td><td>58</td><td>53.70</td><td>0.99</td><td></td></tr><tr><td>AHI (per hr)<sup>a</sup></td><td>75; 9.97 (±11.18)</td><td></td><td>45; 9.68 (±15.23)</td><td></td><td>107; 8.96 (±12.76)</td><td></td><td>0.86</td><td></td></tr><tr><td>SaO<sub>2</sub>, %<sup>a</sup></td><td>75; 94.79 (±1.63)</td><td></td><td>45; 94.18 (±4.75)</td><td></td><td>107; 95.22 (±1.9)</td><td></td><td>0.12</td><td></td></tr></tbody></table>

Abbreviations: AHI, apnea-hypopnea index; BDI-II, Beck Depression Inventory-II; BMI, body mass index; ESS, Epworth Sleepiness Scale; ISI, Insomnia Severity Index; PLMS, periodic leg movements during sleep; REM sleep, rapid eye movement sleep; RLS, restless legs syndrome; SaO₂, average oxygen saturation; STAI, State-Trait Anxiety Inventory; UPPS, urgency, premeditation, perseverance, and sensation seeking; WASO, wake time after sleep onset.

<sup>a</sup>Continuous variables are expressed as number; means (± standard deviation).

<sup>b</sup>At least one of the following comorbidities: diabetes, hypertension, hypercholesterolaemia or cardiovascular diseases (coronary artery disease, chronic heart failure, arrhythmia and stroke).

<sup>c</sup>Last tertile of the distribution.

<sup>d</sup>PSG for untreated RLS patients.

Compared with patients without a self-reported decrease, patients with decreased RLS symptoms during a cognitive activity (n = 130) had less severe RLS symptoms based on the IRLSSG score, with a similar trend for EDS (Table 1). Unexpectedly, the urgency dimension on UPPS was higher in patients with or without a self-reported decrease in RLS symptoms during a cognitive activity compared with those with uncertain changes. In contrast, we found no age, gender, disease duration, insomnia and depressive symptoms, and treatment effect. In a sensitivity analysis including only untreated patients with RLS, 89 (34.36%) patients reported a decrease in RLS symptoms during a cognitive activity, 116 (44.79%) no decrease, and 54 (20.85%) uncertain changes. We also found that untreated patients with a self-reported decrease of RLS symptoms during a cognitive activity had less RLS symptoms than those with no RLS decrease, and higher urgency dimension than those with uncertain changes. In the untreated subgroup with PSG (n = 228), sleep efficiency was lower in the group with uncertain changes compared with the group without a self-reported decrease in RLS symptoms, with a similar trend for total sleep time being higher in the group with no RLS decrease (Table 1).

## 3.2 | RLS symptoms during the SIT based on the presence of the BART

No differences between the groups performing or not the BART were found for demographic and clinical characteristics (Table 2). Among

the 40 patients who underwent the BART, 14 (35.00%) experienced a decrease, 20 (50.00%) no decrease, and six (15.00%) uncertain self-reported changes in severity of RLS symptoms during cognitive activities, with no differences between these percentage distributions with the group that did not perform the BART.

Mixed-effect regression models showed that over the SIT, the mean sensory RLS discomfort differed in the two groups (with or without the BART; Figure 1). Interactions between groups and the SIT periods were found for sensory RLS discomfort ($p_{TestxGroup} < 0.0001$), showing differences in the response profiles. Specifically, we observed a significant decrease in legs discomfort assessed by the VAS score from 5.33 ± 2.80 to 3.68 ± 2.90 between the 60th and 80th minute in the BART group, while the sensory discomfort continued to increase from 4.28 ± 2.51 to 5.08 ± 2.72 between the 60th and 80th minute in the group without the BART. Moreover, patients with a self-reported decrease in RLS symptoms during cognitive activities who underwent the SIT-BART (n = 14) showed greater differences in mean legs discomfort between the 60th and 80th minute compared with other groups (−3.43 ± 3.18 versus −0.69 ± 1.49, *p* = 0.007). During the BART, the mean unadjusted number of pumps was 22.05 ± 11.41, the mean adjusted number of pumps 23.92 ± 13.10, and the mean number of explosions 5.97 ± 3.27. The 22 patients with decreased legs discomfort between 60 and 80 min during the SIT-BART had a lower number of explosions than the 18 patients with stable or increased legs discomfort (4.86 ± 2.24 versus 7.28 ± 3.83, *p* = 0.03), without differences for unadjusted and adjusted number of pumps. Finally, we found a positive correlation between the sensation seeking subscore on the UPPS scale
<figure><img src="image_8.png" /></figure>

<table><caption>TABLE 2 Comparison of socio-demographic and clinical characteristics between patients with RLS performing the BART (n = 40) or not (n = 25) during the SIT</caption><thead><tr><th rowspan="2">Variables</th><th colspan="2">Patients without BART N = 25</th><th colspan="2">Patients with BART N = 40</th><th rowspan="2">p</th></tr><tr><th>n</th><th>%</th><th>n</th><th>%</th></tr></thead><tbody><tr><td>Age (years)<sup>a</sup></td><td>25; 57.12 (±12.99)</td><td></td><td>40; 53.80 (±15.02)</td><td></td><td>0.36</td></tr><tr><td>Sex, male</td><td>11</td><td>44.00</td><td>21</td><td>52.50</td><td>0.51</td></tr><tr><td>Educational level, ≥12 years</td><td>16</td><td>66.67</td><td>18</td><td>46.15</td><td>0.12</td></tr><tr><td>BMI (kg m<sup>-2</sup>)<sup>a</sup></td><td>25; 24.86 (±2.66)</td><td></td><td>39; 25.40 (±3.26)</td><td></td><td>0.48</td></tr><tr><td>BMI (kg m<sup>-2</sup>), ≥30</td><td>1</td><td>4.00</td><td>3</td><td>7.69</td><td>0.56</td></tr><tr><td>Age at RLS symptom onset (years)<sup>a</sup></td><td>25; 38.72 (±17.51)</td><td></td><td>40; 36.68 (±15.14)</td><td></td><td>0.61</td></tr><tr><td>Duration of RLS (years)<sup>a</sup></td><td>25; 18.40 (±17.35)</td><td></td><td>40; 17.13 (±12.09)</td><td></td><td>0.72</td></tr><tr><td>RLS family history, yes</td><td>9</td><td>37.50</td><td>19</td><td>47.50</td><td>0.44</td></tr><tr><td>RLS severity scale<sup>a</sup></td><td>25; 24.08 (±6.03)</td><td></td><td>40; 24.60 (±5.34)</td><td></td><td>0.71</td></tr><tr><td>RLS severity scale<sup>a</sup></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>[11-20]</td><td>9</td><td>36.00</td><td>10</td><td>25.00</td><td>0.51</td></tr><tr><td>[21-30]</td><td>12</td><td>48.00</td><td>25</td><td>62.50</td><td></td></tr><tr><td>[31-40]</td><td>4</td><td>16.00</td><td>5</td><td>12.50</td><td></td></tr><tr><td>Self-reported changes on the severity of RLS symptoms during cognitive activities</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Decrease</td><td>11</td><td>44.00</td><td>14</td><td>35.00</td><td>0.72</td></tr><tr><td>Uncertain</td><td>4</td><td>16.00</td><td>6</td><td>15.00</td><td></td></tr><tr><td>No decrease</td><td>10</td><td>40.00</td><td>20</td><td>50.00</td><td></td></tr></tbody></table>

Abbreviations: BART, balloon analogue risk task; BMI, body mass index; RLS, restless legs syndrome.

<figure><img src="image_9.png" /><figcaption>FIGURE 1 Sensory restless legs syndrome (RLS) discomfort during the suggested immobilisation test (SIT) in patients with RLS performing the balloon analogue risk task (BART; n = 40) or not (n = 25)</figcaption></figure>

and the number of explosions on the BART (r = 0.40; p = 0.02), with no significant association with other subscores.

4 | DISCUSSION

This study found that one-third of patients with primary RLS reported a decrease in RLS symptoms during cognitive activities, with a similar proportion in patients treated or untreated for RLS. In a 80-min SIT,

we highlighted that legs discomfort decreased in patients performing a sustained cognitive task, while it continued to increase in those without a cognitive task.

There are important inter- and intra-individual differences in RLS symptoms, and those symptoms are not always present every day and at the same time for a single patient (Fuhs et al., 2014). Although RLS symptoms are partially or totally relieved by movement, some patients also reported that RLS symptoms decrease when engaging in a dis- tractive cognitive task. Using a self-reported questionnaire, we found

<footnote><sup>a</sup>Continuous variables are expressed as number; means (±standard deviation).</footnote>
that one-third of patients with primary RLS reported a decrease in RLS symptoms during cognitive activities, especially those that require more attention (e.g. computer use, reading, ...). However, these activities are less effective to reduce severe RLS symptoms, but with similar effectiveness in untreated and drug-treated RLS patients. Patients with a self-reported decrease in RLS symptoms during cognitive activities tend to be less sleepy, which may help them engage in a cognitive task. We also reported impulsive behaviour characterised by a higher urgency dimension on UPPS in these subjects, a symptom previously reported in RLS (Chenini et al., 2022), which may in this context help them engage in another activity despite RLS symptoms. Here, we found no other key differences in the clinical RLS phenotype (age at RLS onset, family history of RLS), insomnia and depressive symptoms, nor for the characteristics of PSG to individualise this population reporting a decrease of RLS symptoms during cognitive activities.

In a 80-min SIT, we highlighted that legs discomfort decreased in patients performing a sustained cognitive task, while it continued to increase in those without a cognitive task. The SIT is a reliable tool to induce RLS symptoms by intentional immobilisation in standardised conditions to avoid the confounding effect caused by changing degrees of physical activity (De Cock et al., 2012; Michaud et al., 2002; Rassu et al., 2020). We administered the 80-min SIT at a fixed time (starting at 20:00 hours) during the symptomatic period for the 65 consecutive participants to assess in a controlled condition the evolution of the sensory discomfort during the test. The mean leg discomfort improvement was greater in patients with a self-reported decrease in RLS symptoms during cognitive activity. The BART is a validated tool that assesses the risk-taking propensity, which involves the brain mesolimbic-frontal pathway (Rao et al., 2008), but used primarily in this study as a distractive task. However, patients with decreased legs discomfort during the SIT-BART had a lower number of balloon explosions, which may suggest less severe risk-taking propensity. The number of explosions is a good marker of risk-taking, and positively correlates with self-reported risky behaviours, sensation seeking and impulsivity (Bornovalova et al., 2009; Canning et al., 2022; Hunt et al., 2005; Lejuez et al., 2002, 2003, 2004). Here, we found that more balloon explosions on the BART were associated with higher sensation seeking, further supporting the link between the impulsive dimension and RLS symptoms during the uncomfortable SIT.

Restless legs syndrome is not strictly speaking a chronic pain dis-
order; however, the word “pain” is not infrequently used by patients
(Karroum et al., 2012). The pain experience can be influenced by emo-
tional and attentional processes (Bushnell et al., 2013). Clinical and
experimental studies showed that a distraction can have a powerful
effect on our perception of pain (Villemure & Bushnell, 2002;
Wiech, 2016). Our emotional state also has an influence on pain; a
negative emotional state increases pain, whereas a positive state
lowers pain (Villemure & Bushnell, 2009). The neural mechanisms
underlying the modulation of pain by cognitive and emotional states
are not yet fully understood, but certainly involved anterior cingulate
cortex, insula, prefrontal cortex, somatosensory and periaqueductal
grey/midbrain areas. In RLS, functional imaging studies also found an

involvement of the nociceptive network (von Spiczak et al., 2005).
Our current results highlighted the positive impact of cognitive activi-
ties on sensory symptoms in RLS that may share similar pathways
with pain disorder modulating sensory perception and activating
endogenous opioid circuits. Based on our data, non-pharmacological
management such as engagement in mental activities (e.g. card games
and computer work) should be recommended for mild to moderate
cases to better control the symptoms (Garcia-Borreguero et al., 2016;
Sharon, 2015), and may be effective individually or in combination in
at least one-third of patients with RLS.

This study has several limitations. This is a single-centre study.
The population might not be representative of the general RLS popu-
lation, with a lower percentage of women than generally seen in
practice. The question on performing activities other than leg move-
ments may be too general, although some examples of intellectual,
emotional and motor (only upper limbs) activities have been pro-
posed. We performed the BART task during the SIT in a subgroup of
patients only. The persistence of improvement in leg discomfort
after the cognitive task was not assessed. We also assessed the sen-
sory SIT only, without the motor component or EEG record. The
absence of EEG failed to control for the arousal effect of the cogni-
tive task that may participate in the mechanism that improves RLS
symptoms during the last 20 min of the BART. These changes in
CNS arousal can modulate the severity of RLS symptoms, with wors-
ening frequently associated with drowsiness, and improvement with
motor and cognitive activities that may compromise the applicability
of these cognitive strategies at bedtime.

To conclude, in a large sample of patients with primary moder-
ate to severe RLS, we found that one-third of patients reported a
self-reported decrease of RLS symptoms during cognitive activities
with its confirmation in a controlled setting. Further studies are
needed to confirm the usefulness of such non-pharmacological
strategies, under controlled conditions, but distractive activities
could be easily implemented in the management of RLS symptoms
and effective individually or in combination in at least one-third of
patients.

AUTHOR CONTRIBUTIONS

Sofiene Chenini: study concept and design, data acquisition, result interpretation, preliminary draft writing. Lucie Barateau: data acquisition, manuscript revision. Lily Guiraud: data acquisition, manuscript revision. Marie Lou Rollin: data acquisition, manuscript revision. Régis Lopez: data acquisition, manuscript revision. Isabelle Jaussent: statistical analysis and interpretation. Séverine Béziat: statistical analysis and interpretation. Yves Dauvilliers: study concept and design, data acquisition, result interpretation, manuscript revision and drafting.

ACKNOWLEDGEMENT

The authors thank all the participants of this study, and the French
Association of RLS patients (Association France Ekbom). The authors
also thank all their collaborators of the Sleep-Wake Unit of Montpel-
lier University hospital.
## CONFLICT OF INTEREST

The authors declare no conflicts of interest related to this article. YD received speaking honoraria and board engagements with UCB Pharma, JAZZ; Orexia, Bioprojet, Avadel, Idorsia and Takeda. LB received speaking honoraria from UCB Pharma, JAZZ and Bioprojet; board engagements from Jazz, Bioprojet and Takeda; travel to congress from UCB Pharma and Bioprojet. RL received funds for speaking by UCB Pharma and Shire. LG, MLR, SB, SC and IJ report no disclosure.

## DATA AVAILABILITY STATEMENT

The data that support this study findings are available from the corresponding authors, upon reasonable request.

## ORCID

Yves Dauvilliers https://orcid.org/0000-0003-0683-6506

## REFERENCES

Allen, R. P., Picchietti, D. L., Garcia-Borreguero, D., Ondo, W. G., Walters, A. S., Winkelman, J. W., Zucconi, M., Ferri, R., Trenkwalder, C., & Lee, H. B. (2014). Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: Updated international restless legs syndrome study group (IRLSSG) consensus criteria - History, rationale, description, and significance. *Sleep Medicine*, 15(8), 860-873. https://doi.org/10.1016/j.sleep.2014.03.025

Allen, R. P., Walters, A. S., Montplaisir, J., Hening, W., Myers, A., Bell, T. J., & Ferini-Strambi, L. (2005). Restless legs syndrome prevalence and impact: REST general population study. *Archives of Internal Medicine*, 165(11), 1286-1292. https://doi.org/10.1001/archinte.165.11.1286

Bastien, C. H., Vallières, A., & Morin, C. M. (2001). Validation of the insomnia severity index as an outcome measure for insomnia research. *Sleep Medicine*, 2(4), 297-307. https://doi.org/10.1016/s1389-9457(00)00065-4

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). *Manual for the beck depression inventory-II* (Vol. 10). Pearson. https://psycnet.apa.org/doiLanding?doi=10.1037%2Ft00742-000

Bornovalova, M. A., Cashman-Rolls, A., O'Donnell, J. M., Ettinger, K., Richards, J. B., deWit, H., & Lejuez, C. W. (2009). Risk taking differences on a behavioral task as a function of potential reward/loss magnitude and individual differences in impulsivity and sensation seeking. *Pharmacology Biochemistry and Behavior*, 93(3), 258-262. https://doi.org/10.1016/j.pbb.2008.10.023

Bushnell, M. C., Čeko, M., & Low, L. A. (2013). Cognitive and emotional control of pain and its disruption in chronic pain. *Nature Reviews Neuroscience*, 14(7), 502-511. https://doi.org/10.1038/nrn3516

Canning, J. R., Schallert, M. R., & Larimer, M. E. (2022). A systematic review of the balloon analogue risk task (BART) in alcohol research. *Alcohol and Alcoholism*, 57(1), 85-103. https://doi.org/10.1093/alcalc/agab004

Chenini, S., Barateau, L., Guiraud, L., Denis, C., Rassu, A. L., Lopez, R., Jaussent, I., & Dauvilliers, Y. (2022). Depressive symptoms and suicidal thoughts in restless legs syndrome. *Movement Disorders*, 37, 812-825. https://doi.org/10.1002/mds.28903

De Cock, V. C., Bayard, S., Yu, H., Grini, M., Carlander, B., Postuma, R., Charif, M., & Dauvilliers, Y. (2012). Suggested immobilization test for diagnosis of restless legs syndrome in Parkinson's disease. *Movement Disorders*, 27(6), 743-749. https://doi.org/10.1002/mds.24969

Fuhs, A., Bentama, D., Antkowiak, R., Mathis, J., Trenkwalder, C., & Berger, K. (2014). Effects of short- and long-term variations in RLS severity on perceived health status-The COR-study. *PLoS One*, 9(4), e94821. https://doi.org/10.1371/journal.pone.0094821

Garcia-Borreguero, D., Silber, M. H., Winkelman, J. W., Högl, B., Bainbridge, J., Buchfuhrer, M., Hadjigeorgiou, G., Inoue, Y., Manconi, M., Oertel, W., Ondo, W., Winkelmann, J., & Allen, R. P. (2016). Guidelines for the first-line treatment of restless legs syndrome/Willis-Ekbom disease, prevention and treatment of dopaminergic augmentation: A combined task force of the IRLSSG, EURLSSG, and the RLS-foundation. *Sleep Medicine*, 21, 1-11. https://doi.org/10.1016/j.sleep.2016.01.017

Hunt, M. K., Hopko, D. R., Bare, R., Lejuez, C. W., & Robinson, E. V. (2005). Construct validity of the balloon analog risk task (BART): Associations with psychopathy and impulsivity. *Assessment*, 12(4), 416-428. https://doi.org/10.1177/1073191105278740

Iber, C. (2007). The AASM manual for the scoring of sleep and associated events. In *Rules Terminology and Technical Specification*. American Academy of Sleep Medicine, https://ci.nii.ac.jp/naid/10024500923/

Johns, M. W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. *Sleep*, 14(6), 540-545. https://doi.org/10.1093/sleep/14.6.540

Karroum, E. G., Golmard, J.-L., Leu-Semenescu, S., & Arnulf, I. (2012). Sensations in restless legs syndrome. *Sleep Medicine*, 13(4), 402-408. https://doi.org/10.1016/j.sleep.2011.01.021

Lejuez, C. W., Aklin, W. M., Zvolensky, M. J., & Pedulla, C. M. (2003). Evaluation of the balloon analogue risk task (BART) as a predictor of adolescent real-world risk-taking behaviours. *Journal of Adolescence*, 26(4), 475-479. https://doi.org/10.1016/S0140-1971(03)00036-8

Lejuez, C. W., Read, J. P., Kahler, C. W., Richards, J. B., Ramsey, S. E., Stuart, G. L., Strong, D. R., & Brown, R. A. (2002). Evaluation of a behavioral measure of risk taking: The balloon analogue risk task (BART). *Journal of Experimental Psychology. Applied*, 8(2), 75-84. https://doi.org/10.1037/1076-898x.8.2.75

Lejuez, C. W., Simmons, B. L., Aklin, W. M., Daughters, S. B., & Dvir, S. (2004). Risk-taking propensity and risky sexual behavior of individuals in residential substance use treatment. *Addictive Behaviors*, 29(8), 1643-1647. https://doi.org/10.1016/j.addbeh.2004.02.035

Michaud, M., Lavigne, G., Desautels, A., Poirier, G., & Montplaisir, J. (2002). Effects of immobility on sensory and motor symptoms of restless legs syndrome. *Movement Disorders*, 17(1), 112-115. https://doi.org/10.1002/mds.10004

Rao, H., Korczykowski, M., Pluta, J., Hoang, A., & Detre, J. A. (2008). Neural correlates of voluntary and involuntary risk taking in the human brain: An fMRI study of the balloon analog risk task (BART). *NeuroImage*, 42(2), 902-910. https://doi.org/10.1016/j.neuroimage.2008.05.046

Rassu, A. L., Chenini, S., Barateau, L., Lopez, R., Evangelista, E., Guiraud, L., Jaussent, I., & Dauvilliers, Y. (2020). Increased blood pressure during the suggested immobilization test in restless legs syndrome. *Sleep*, 43(4), zsz263. https://doi.org/10.1093/sleep/zsz263

Sharon, D. (2015). Nonpharmacologic Management of Restless Legs Syndrome (Willis-Ekbom disease): Myths or science. *Sleep Medicine Clinics*, 10(3), 263-278. https://doi.org/10.1016/j.jsmc.2015.05.018

Spielberger, C. (1983). State-Trait Anxiety Inventory for Adults. https://psycnet.apa.org/doiLanding?doi=10.1037%2Ft06496-000

Villemure, C., & Bushnell, C. M. (2002). Cognitive modulation of pain: How do attention and emotion influence pain processing? *Pain*, 95(3), 195-199. https://doi.org/10.1016/S0304-3959(02)00007-6

Villemure, C., & Bushnell, M. C. (2009). Mood influences supraspinal pain processing separately from attention. *The Journal of Neuroscience: The Official Journal of the Society for Neuroscience*, 29(3), 705-715. https://doi.org/10.1523/JNEUROSCI.3822-08.2009

von Spiczak, S., Whone, A. L., Hammers, A., Asselin, M.-C., Turkheimer, F., Tings, T., Happe, S., Paulus, W., Trenkwalder, C., & Brooks, D. J. (2005). The role of opioids in restless legs syndrome: An [11C]diprenorphine PET study. *Brain*, 128(4), 906-917. https://doi.org/10.1093/brain/awh441

Walters, A. S., LeBrocq, C., Dhar, A., Hening, W., Rosen, R., Allen, R. P., Trenkwalder, C., & International Restless Legs Syndrome Study Group.
<figure><img src="image_10.png" /></figure>

(2003). Validation of the international restless legs syndrome study group rating scale for restless legs syndrome. *Sleep Medicine, 4*(2), 121-132. https://doi.org/10.1016/s1389-9457(02)00258-7

Whiteside, S. P., & Lynam, D. R. (2001). The five factor model and impulsivity: Using a structural model of personality to understand impulsivity. *Personality and Individual Differences, 30*(4), 669-689. https://doi.org/10.1016/S0191-8869(00)00064-7

Wiech, K. (2016). Deconstructing the sensation of pain: The influence of cognitive processes on pain perception. *Science, 354*(6312), 584-587. https://doi.org/10.1126/science.aaf8934

Zucconi, M., Ferri, R., Allen, R., Baier, P. C., Bruni, O., Chokroverty, S., Ferini-Strambi, L., Fulda, S., Garcia-Borreguero, D., Hening, W. A., Hirshkowitz, M., Högl, B., Hornyak, M., King, M., Montagna, P., Parrino, L., Plazzi, G., & Terzano, M. G. (2006). The official world Association of Sleep Medicine (WASM) standards for recording and scoring

periodic leg movements in sleep (PLMS) and wakefulness (PLMW) developed in collaboration with a task force from the international restless legs syndrome study group (IRLSSG). *Sleep Medicine*, 7(2), 175-183. https://doi.org/10.1016/j.sleep.2006.01.001

**How to cite this article:** Chenini, S., Barateau, L., Guiraud, L., Rollin, M.-L., Lopez, R., Jaussent, I., Beziat, S., & Dauvilliers, Y. (2023). Cognitive strategies to improve symptoms of restless legs syndrome. *Journal of Sleep Research*, 32(3), e13794. https://doi.org/10.1111/jsr.13794