Restless Legs Syndrome Foundation Blog

August 18, 2021

The Buchfuhrers — Celebrating Father’s Day as Doctor Team

By Rich Archbold

When Julia Buchfuhrer was growing up, she had a special bond with her father, Mark Buchfuhrer, but, hard as he tried, he could not persuade her to become a doctor like he was.

‘No way, no way,” she told her dad. She was interested in other things, like maybe being a marine biologist. But her dad persisted.

He finally got his wish when his daughter decided to go to medical school and become a doctor, but that wasn’t the end of the story. Julia Buchfuhrer graduated from med school at Western University of Health Sciences, did her residency at UC Irvine and is finishing her fellowship training at the University of Arizona this month to become a specialist in rheumatology.

She then had to make another big decision: Where to work after finishing her fellowship training? She decided to open up her own practice in Downey next month with — guess who — her father, who has been a doctor for almost 40 years and is nationally known for his work with restless legs syndrome.

Julia Buchfuhrer will open the JB Arthritis and Rheumatology Center at her father’s office, 11480 Brookshire Ave., in Downey.

“I am extremely excited to be working side by side with my father,” she said in an interview at his house on the east side of Long Beach last week.

“It’s the best Father’s Day present I could get,” her father said. “She is going to do great work and help a lot of people.”

Julia Buchfuhrer will be the third doctor in her family. Her mother, Laurie Buchfuhrer, practiced family medicine and was an addiction medicine specialist. She worked at Kaiser Permanente and Long Beach Memorial Medical Center. She got leukemia, though, when her daughter was 6 and retired early. Julia Buchfuhrer said her mom would always tell her to select a career she would enjoy.

“I think she was secretly proud that I followed in her footsteps,” Julia Buchfuhrer said. “When I made the Dean’s list in medical school, she told me how proud she was that I was doing medicine and doing it so well.”

Julia Buchfuhrer said she can’t wait to start working with her father. “I have so much respect for him and what he has done in his career,” she said. “I will be learning so much from him.”

Her father, though, sees it as a two-way street. “We will be learning from each other,” he said, sitting next to her in his home.

Mark Buchfuhrer was born on July 11, 1952, in Montreal, Canada. His parents were survivors of the Holocaust. His father, Norbert Buchfuhrer, was born in Poland and was a teenager when the Nazis sent him to a concentration camp in Warsaw. He escaped when he was 22 when he got on Oskar Schindler’s now-famed list. Schindler was a German businessman who saved more than a thousand Polish-Jewish refugees from the Holocaust by employing them in his factories during World War II.

Mark Buchfuhrer’s mother, Rose Katz, meanwhile, spent a year in a concentration camp in Hungary at the end of World War II and was saved. She met Norbert Buchfuhrer, her husband-to-be, on a boat going to Canada. She was a cashier in a hat design company in Hungary, but when she was asked her job skill in Canada, she said she was a hat designer — even though she had never actually designed hats, her son said. “But it turned out she had a skill in hat design and became very well known for her hat designs,” he said. She and her husband married in 1948 and had two children, Mark and his sister, Stephanie, who lives in Montreal.

Norbert Buchfuhrer died when he was 73, his wife died when she was 93.

“My mother used to tell me, ‘I’m going to live a long life to show you that you can, too,’” her son said. In high school, Mark Buchfuhrer said he wanted to be a scientist. “But my mother kept telling me to be a doctor, a doctor, a doctor. She said I could be successful as a doctor and take that skill anywhere and not be restricted to one place. She told me that 10,000 times.”

He finally listened and went to medical school at the University of Ottawa, graduating in 1977 and becoming the first in his family to become a doctor. He became a specialist in pulmonary medicine, treating diseases of the respiratory system. “My mom was overjoyed,” he said. He did his residency in Toronto where he met his wife-to-be, who was in her fourth year at medical school. They got married on June 22, 1980. They spent their honeymoon on an eight-day drive from Toronto to the Harbor-UCLA Medical Center in Torrance, where Mark had a fellowship in pulmonary medicine.

The couple spent a weekend in Seal Beach and liked the area so much they decided to live in Long Beach; they bought a condo in Marina Pacifica in Long Beach before buying a house on the east side near Long Beach State University, where they have lived for 37 years.

They have three children: David Buchfuhrer, 37, a software engineer; Michael Buchfuhrer, 35, a business owner; and Julia Buchfuhrer, 32. Mark Buchfuhrer was on the attending staff at various places, including Stanford University Medical Center, Harbor City; Downey Community Hospital (now PIH Health, Downey); USC Medical Center, Long Beach Community Hospital, and Good Samaritan Hospital, Los Angeles. He opened up his private practice in Downey in 2001 with his office now at 11480 Brookshire Ave. He became an expert, one of the few in the United States, in treating restless legs syndrome, which is a disorder causing pain and sleepless nights. The primary symptom of RLS, he said, is an urge to move one’s legs when trying to rest or relax. “This urge is often so compelling that RLS sufferers may have to walk, shake their legs, ride a bicycle, massage their legs, or stretch to alleviate their discomfort,” he wrote in a clinician’s manual on RLS. He has become beloved by his patients. “There isn’t a week that goes by without a patient telling me how my treatment has saved or changed their life,” he said.

Meanwhile, his sons and daughter were growing up. Julia Buchfuhrer graduated from Hill Middle School, which has since been converted to the Sato Academy of Math and Science, before attending Poly High School where she became an outstanding student. In eighth grade, she won first place in the Press-Telegram Halloween Scary Story Contest.

She also became an excellent soccer player and was a member of the Belmont Shore Women’s Rugby team. “I got injured a lot playing rugby, but that’s where I saw how doctors could help people get better,” she said. “I liked the idea of helping people medically.”

She also became a huge fan of bike riding, which her father also liked. “We cycled together all the time,” she said. “We rode with a group in Irvine called the Orange County Rebel Riders. “We went on mountain rides and on past Father’s Days, we would go cycling for miles and come home for a family get-together.”

Julia Buchfuhrer had a scare one time when her bike hit a rock on an 8- mile trail in Rock Creek, 30 miles south of Mammoth Lakes. “I got thrown off my bike and suffered a nasty gash in my forehead,” she said. “Blood was gushing all over. Vultures were even circling in the sky. My dad bandaged me up, and hikers came by who helped us.” She still has a visible scar above her left eye.

And when she was 30, she got breast cancer, and she had a double mastectomy and reconstructive surgery. But she is a fighter. “The hardest part was enduring three-to-four months of chemotherapy, but I missed only two-to-three days of training,” she said.

Julia Buchfuhrer said she loves doing things with her father and listening to him tell stories. “He is a great storyteller. We have become great friends.”

“She’s my buddy,” her father said, putting his arm around her. “I’m so happy she’s here for Father’s Day.”

Julia Buchfuhrer said she will fly back to Arizona this afternoon, Sunday, June 20, to finish her medical training and won’t have time to do her traditional Father’s Day bike ride with her dad. But she will celebrate Father’s Day at a family get-together.

She is also already planning a few weekend trips to Mammoth Lakes in August to hike and make up for some lost bike rides. “Since we are both our own bosses, we can schedule as many of these trips together as we like,” she said with a grin.

Reprinted with permission from Rich Archbold, Press-Telegram. All rights reserved. Visit rarchbold@scng.com for more information.

https://www.presstelegram.com/2021/06/20/rich-archbold-the- buchfuhrers-celebrating-fathers-day-as-doctor-team/

July 12, 2021

The Management of Restless Legs Syndrome: An Updated Algorithm

Restless legs syndrome (RLS) is a common neurological disorder affecting up to 10% of the population in the United States, with nearly 3% experiencing severe symptoms that require daily medical treatment. An article in the Journal of Neural Transmission in 2007 reported that it takes nearly 13 years from the onset of symptoms to the initiation of a treatment plan for RLS.

Much has changed in RLS disease management in the last eight years, which has led to the update of the 2013 RLS treatment algorithm by the Scientific and Medical Advisory Board of the RLS Foundation. The updated algorithm was published in the July 2021 edition of Mayo Clinic Proceedings, a leading peer-reviewed clinical journal widely read by physicians and often cited in scientific papers. Publication in this journal will ensure the availability of this information to a broad group of clinicians, including primary care providers.

Scientific discoveries since 2013 have led to the better understanding of RLS and new approaches to disease management that include:

Clinical Advancements

• Untoward side effects of dopaminergic therapy; knowledge and understanding of the long-term risks of augmentation, impulse control disorders and rebound
• Consensus guidelines for the iron treatment of RLS
• Consensus guidelines for RLS diagnosis, treatment and management during pregnancy and lactation
• Appropriate use of opioid therapy in low total daily doses for refractory RLS
• Improved RLS diagnosis, treatment and management in children and adolescents

Research Advancements

• Clinical trials for pregabalin and oxycodone
• Adenosine and RLS relationship
• Identification and replication of 13 new RLS risk genes and confirmation of six previously identified RLS risk genes using GWAS (genome-wide association studies)

These advancements relate to ongoing research into the underlying causes of RLS and the search for durable treatments and potential cures for the disease.*

The 2021 RLS treatment algorithm is divided into sections that outline detailed guidance on clinical best practices in RLS disease management, including:

• General treatment considerations
• Alpha-2-delta ligands and iron treatment as first-line therapies
• Iron treatment guidelines for RLS
• Dopamine agonists as a second-line therapy
• Treatment for intermittent, chronic-persistent, and refractory RLS
• Special patient populations and potential future therapies

The new treatment algorithm describes medication selection, use, dose and side effects. Decision trees and tables provide visual guidance for treatment consideration. Nondrug therapies and other approaches are highlighted, which include activities to stimulate the mind and the avoidance of medications and substances known to worsen symptoms. For example, RLS specialists who practice at certified RLS Quality Care Centers report that augmentation from certain medications is the No. 1 reason that patients seek specialized care from a knowledgeable and experienced provider. The 2021 RLS treatment algorithm pays special attention to the use of combination therapies and the appropriate use of opioids in low total daily doses to treat refractory RLS – a common, yet manageable treatment challenge. For the first time, the new treatment algorithm also discusses RLS management in pregnancy, lactation and childhood.

The 2021 RLS treatment algorithm is a comprehensive approach to the management of RLS in the various stages of disease progression and across the life span. Michael Silber, M.B., Ch.B., lead author on the article and director of the Center for Sleep Medicine at Mayo Clinic, says, “This updated algorithm is based on current research, consensus documents and the combined practical experience of a team of practitioners highly experienced in the management of RLS. We hope it will provide practical guidelines for primary care providers and specialists who are needed to treat patients with this common and highly distressing disorder.”

The RLS Foundation has made this an open-access article, available for free download by patients, clinicians and researchers. The RLS Foundation encourages members to share this article with their healthcare providers at www.rls.org/21Algorithm. Executive Director Karla Dzienkowski says, “The publication of the 2021 RLS treatment algorithm is based on the latest scientific knowledge and clinical experience of RLS experts from around the globe who serve on our Scientific and Medical Advisory Board. I thank these members for their service to the Foundation and the RLS community and for their work on this seminal publication that furthers our mission and goals to educate and support RLS research leading to better treatments and a cure.”

*The RLS Foundation funds the only research grant program dedicated to RLS. Member support for the Foundation’s Research Grant Program has funded nearly $2 million for 47 grants to RLS researchers, whose research forms part of these key advancements. A revised RLS Research Grant Program protocol will be announced later this year to further the quest toward a cure.

June 29, 2021

Statement has been endorsed by more than 25 medical, scientific, patient, and safety organizations

A new position statement from the American Academy of Sleep Medicine emphasizes that sleep is a biological necessity, and insufficient sleep and untreated sleep disorders are detrimental for health, well-being, and public safety.

Published online in the Journal of Clinical Sleep Medicine, the statement notes that sleep is vital for health and well-being in children, adolescents, and adults. While awareness of the value of sleep has risen in the last decade, there is a significant need for greater emphasis on sleep health in education, clinical practice, inpatient and long-term care, public health promotion, and the workplace.

“Healthy sleep is as important as proper nutrition and regular exercise for our health and well-being, and sleep is critical for performance and safety,” said AASM President Dr. Kannan Ramar. “It is the position of the AASM that sleep is essential to health, and we are urging educators, health care professionals, government agencies, and employers to prioritize the promotion of healthy sleep.”

The statement was written by the members of the 2020 – 2021 AASM board of directors, comprising 11 sleep medicine physicians and a clinical psychologist. In recognition of sleep’s significant and multi-faceted connections to health and chronic disease, the authors outlined the following positions:

• Sleep education should have a prominent place in K-12 and college health education, medical school and graduate medical education, and educational programs for other health professionals.
• Clinicians should routinely inquire about sleep habits and symptoms of sleep and circadian rhythm sleep-wake disorders during patient encounters, and hospitals and long-term care facilities should optimize sleep conditions.
• Healthy sleep should be targeted by public health and workplace interventions to improve health-related outcomes, and behaviors that help people attain healthy sleep should be actively promoted.
• More sleep and circadian research is needed to further elucidate the importance of sleep for public health and the contributions of insufficient sleep to health disparities.

“Education about sleep and sleep disorders is lacking in medical school curricula, graduate medical education, and education programs for other health professionals,” said Ramar. “Better sleep health education will enable our health care workforce to provide more patient-centered care for people who have common sleep disorders such as obstructive sleep apnea and insomnia.”

According to the authors, chronic insufficient sleep and untreated sleep disorders are linked to increased health and safety risks such as cardiovascular disease, diabetes, obesity, workplace accidents, and motor vehicle crashes. Data from surveys conducted by the Centers for Disease Control and Prevention and the Maternal and Child Health Bureau show that 34.1% of children, 74.6% of high school students, and 32.5% of adults in the U.S. fail to get a sufficient duration of sleep on a regular basis. Therefore, helping people get enough sleep is one of the goals of Healthy People 2030, which provides 10-year, measurable public health objectives for the U.S.

The AASM position statement declaring that sleep is essential to health has been endorsed by more than 25 medical, scientific, patient, and safety organizations:

• Alliance of Sleep Apnea Partners
• American Academy of Cardiovascular Sleep Medicine
• American Academy of Dental Sleep Medicine
• American Academy of Neurology
• American Academy of Otolaryngology—Head and Neck Surgery
• American Academy of Physician Assistants
• American Association of Clinical Endocrinology
• American Association of Sleep Technologists
• American College of Preventive Medicine
• American Geriatrics Society*
• American Society for Metabolic and Bariatric Surgery
• American Society of Addiction Medicine
• American Society of Anesthesiologists*
• American Thoracic Society
• Circadian Sleep Disorders Network
• International REM Sleep Behavior Disorder Study Group
• National Safety Council
• National Sleep Foundation
• Obesity Action Coalition
• Project Sleep
• Restless Legs Syndrome Foundation
• Sleep Research Society
• Society for Research on Biological Rhythms
• Society of Anesthesia and Sleep Medicine
• Society of Behavioral Sleep Medicine
• Start School Later
• Wake Up Narcolepsy
• World Sleep Society

*The American Geriatrics Society supports the general principles in the document and believes it is of general benefit to its membership. The American Society of Anesthesiologists’ Administrative Council approved support for the position statement with qualifications; since the document has neither been presented to nor approved by either the ASA Board of Directors or House of Delegates, it is not an official or approved statement or policy of the Society. Variances from the recommendations contained in the document may be acceptable based on the judgment of the responsible anesthesiologist.

June 14, 2021

Magnesium and RLS

By Maddie Lionberger, RLS Foundation Research Coordinator

Magnesium is a naturally occurring mineral in our bodies that plays an essential role in a diverse array of biochemical processes, including protein synthesis, muscle and nerve function and blood glucose control. Deficiencies in magnesium can lead to muscle contractions, cramps and problems with conduction of electric signals along nerves. Because of magnesium’s important function in the nervous system, considerable attention has been given to using magnesium supplements to relieve the symptoms of restless legs syndrome (RLS). However, the evidence behind magnesium as an RLS treatment is largely anecdotal. To assess whether taking a magnesium supplement could benefit you, consider the normal values and functions of magnesium and the research as it pertains to RLS.

Magnesium Intake

According to the Office of Dietary Supplements of the National Institutes of Health (NIH) the adult body contains about 25 milligrams (mg) of magnesium. Total magnesium level is tightly regulated by the kidneys, which excrete about 120 mg of magnesium in the urine per day. The Food and Nutrition Board of the National Academy of Medicine recommends an average daily intake of about 240 to 420 mg for men and 240 to 320 mg for women. These recommendations vary by age and sex and are higher during pregnancy. Most people can obtain daily recommended magnesium levels through diet alone – for example, by eating dark green, leafy vegetables such as spinach and kale; nuts and seeds; fish like mackerel and tuna; beans and lentils; avocados; bananas and low-fat or nonfat dairy products. Consuming caffeine, on the other hand, can decrease magnesium levels. Magnesium is also present in dietary supplements and in some medicines, such as antacids and laxatives.

Overall magnesium status is difficult to assess, with 50% to 60% of magnesium present in the bones and the rest mostly in the blood and soft tissues. The most common method for assessing magnesium is by measuring serum magnesium concentration. Normal serum magnesium concentrations range between 0.75 and 0.95 millimoles per liter (mmol/L). Other methods for assessing magnesium status include measuring concentrations in erythrocytes (red blood cells), saliva and urine. However, no single test is considered sufficient without comprehensive laboratory tests and clinical assessment.

Magnesium Deficiency

Symptomatic magnesium deficiency due to low dietary intake is uncommon. Symptoms of deficiency are more likely to arise from excessive losses of magnesium due to certain health conditions and medications. Early signs of magnesium deficiency include loss of appetite, nausea, vomiting, fatigue and weakness. As deficiency worsens, numbness, tingling, muscle contractions and cramps, seizures and personality changes may develop. In severe cases, magnesium deficiency can result in hypocalcemia (low blood calcium) or hypokalemia (low blood potassium). Individuals more likely to be at risk of magnesium inadequacy include those with gastrointestinal diseases such as Crohn’s disease, celiac disease and enteritis (small bowel inflammation); Type II diabetes; or alcohol dependence. Older adults in general are more at risk because they typically consume insufficient amounts of magnesium in their diets or have medical conditions requiring medications that reduce magnesium absorption in the gut.

Supplementation

In the event of a deficiency, magnesium can be taken as a supplement. There are several different doses and forms available, including magnesium oxide, citrate and chloride. Absorption depends on the type of magnesium. Although magnesium oxide is the most commonly available oral supplement, studies reported by the NIH suggest that magnesium in the aspartate, citrate, lactate and chloride forms is absorbed more completely than magnesium oxide or sulfate. Magnesium sulfate can also be administered intravenously (IV), but that method is generally reserved for more severe cases of hypomagnesemia (low levels of magnesium in the blood). The most common use of IV magnesium sulfate is for the prevention of seizures in pregnant women with preeclampsia, eclampsia or toxemia. The Food and Drug Administration recommends against prolonged use of magnesium sulfate; too much magnesium sulfate, or excessive amounts of any supplement for that matter, can be toxic. It is important to consume plenty of fluids while taking magnesium supplements. Consult your doctor before making any changes to your medication regimen.

One of the main roles of magnesium in the nervous system is to block the calcium channel in nerve cells. In other words, magnesium needs to be removed for signaling to occur. Thus, low magnesium levels or magnesium deficiency can result in an over-excited state and eventually cell death of the neuron called excitotoxicity (a pathological process by which neurons are damaged and killed by overactivation). Abnormal neurotransmission of this kind has been implicated in many neurological disorders, including migraine, chronic pain, Alzheimer’s disease and Parkinson’s disease. In a 2018 analysis, "The Role of Magnesium in Neurological Disorders," by Anna E. Kirkland et al., researchers reviewed literature on the role of magnesium in the prevention and treatment of certain neurological disorders. One study showed that high magnesium concentrations were associated with a reduced risk of Parkinson’s disease. However, research examining magnesium levels in people with Parkinson’s has yielded mixed results overall.

Effective for RLS?

With the similarities that RLS and Parkinson’s disease share in pathologies to the dopamine system, it may seem intuitive to try magnesium as a preventive measure for RLS symptoms. However, there is little to no research to support the use of magnesium for idiopathic RLS. Much of the research addressing magnesium and RLS involves symptoms during pregnancy. It is likely that taking magnesium is perceived as an effective therapy for RLS when magnesium deficiency is a contributing factor, i.e., the supplement provides relief for muscle cramps that are easily confused with RLS symptoms. An existing magnesium deficiency may also explain why some individuals report that caffeine triggers their RLS symptoms. If this is the case, it may be beneficial to test magnesium levels. Despite the lack of any scientific correlation with low magnesium levels and RLS, there are many anecdotal reports of people with RLS benefiting from taking magnesium supplements. However, since there is a very strong placebo response for any potential RLS treatment, it is difficult to determine whether these reports truly reflect a benefit for magnesium supplementation and RLS. Large double-blinded medical trials would be necessary to prove that magnesium would be helpful for RLS symptoms.

If you suspect that a magnesium deficiency may be contributing to a worsening of your RLS symptoms, discuss this with your healthcare provider and follow their recommendations and guidelines before making any changes to your medications or supplements.

May 28, 2021

In-Person and Virtual Meetings

By Steven Zucker, Metro Denver RLS Support Group Leader

As a member of the RLS Foundation, I eagerly anticipate each new edition of NightWalkers. A few years ago, I would immediately flip to the back pages, checking to see if a Colorado support group had been started. My disappointment eventually led me to inquire about starting one. In April 2019, I was approved to become the Metro Denver RLS Support Group leader.

As I planned for our first meeting, I had several initial goals in mind. I envisioned this group as a source of social-emotional support in our struggles to cope with RLS; a vehicle for educating ourselves as fully as possible regarding RLS symptoms, treatments and ongoing research; and, a way to help one another become effective advocates for our own treatment when visiting doctors and other healthcare practitioners. Feedback from the group suggests that we are upholding these goals.

Our first three support group meetings were held in person. We had ample opportunity to share our stories and compare notes regarding the physicians we see and our treatment regimens. We discussed the remarkable range of medications and treatments used by group members and the ever-changing regimen we all seemed to follow trying to stay one step ahead of our symptoms. Prior to each meeting, I would share a tentative agenda and numerous scholarly articles in hope of facilitating group discussion. The group consistently requested that we invite experts in the field to speak at our meetings. We were very fortunate to have Jacci Bainbridge, PharmD, join our last in-person meeting; her expertise was very much appreciated!

When COVID-19 became our new reality, all in our group were in favor of waiting out COVID until we could resume in-person meetings. But after five months, the group seemed more open to trying virtual meetings. We went from having roughly 25 people attending to only six or seven consistently joining our virtual meetings.

Despite fewer members in attendance, virtual support group meetings have proved successful. Members continued to share successes and frustrations in their attempts to cope effectively with their RLS symptoms. We continued to review pertinent research articles and discussed how to make our time together as valuable as possible and how to eliminate aspects of virtual meetings that were problematic to some. For example, the inability for everyone to speak during the discussion, the lack of opportunity to provide feedback, and various technical issues.

Body language is not nearly as effective when meeting virtually. One big challenge for me as the moderator of the virtual format has been to monitor speaking time and ensure that all members have sufficient opportunity to share and feel truly heard by the group. As members grew more comfortable with the virtual format, conversations among members outside of meetings via email seemed to increase substantially. These email conversations seemed comparable to the naturally occurring in-person conversations during break times, or while leaving our meeting space and packing up food and supplies.

I asked group members for their input regarding the effectiveness of virtual meetings. Many people enjoyed being able to participate in their sweats and especially appreciated eliminating a three-hour drive each way to attend in- person meetings. Here are some additional responses:

One benefit of virtual meetings may be that it allows easier access to speakers and experts in the field. It seems more reasonable to ask for one hour of a speaker’s time online to answer questions than to request that they travel to our meeting site. I hope there is willingness on the part of the experts I contact to participate in this way!

In these times of COVID-induced isolation, it's great to actually see some faces and hear some voices that share common concerns… to pass on and receive encouragement, share experiences with various treatments and medications, and share notes about different doctors. The support of Clara and the Foundation seems to make the virtual meetings go very smoothly.

Meeting and speaking with the group (whether in person or virtually) is something of a comforting balm and gives the additional gift of knowing that we are not crazy, nor are we alone.

When it is safe to meet in person once again, it is my hope that virtual meetings can and will continue. In so many beneficial ways, they are the perfect complement to gathering in person. I trust our group members will agree.

Virtual Support Meetings on Zoom are open to all - RLS Foundation members and non-members, RLS patients and their families, anyone interested in learning more about RLS looking for a safe place to share RLS concerns and victories! To register, go to www.rls.org/VSG.

May 17, 2021

What You Need to Know About COVID-19 Vaccines

By Maddie Lionberger, RLS Foundation Research Coordinator

In March of 2021 the world passed the one-year mark since the coronavirus pandemic was declared a Public Health Emergency of International Concern by the World Health Organization. As of May 17, nearly 34 million cases have been confirmed, with over 600,000 deaths attributed to COVID-19 in the United States alone. Amid the devastation and tragedy, communities and organizations have pulled together in unprecedented ways to overcome the challenges of the pandemic – the development of COVID-19 vaccines is an extraordinary example. Thanks to the concerted efforts of the medical science community, the world has gone from identifying a novel coronavirus to developing safe and effective vaccines in less than 12 months. To add perspective, in the past the fastest vaccine to go from development to deployment took about four years. Unfortunately, misinformation has created a lack of confidence in scientific evidence regarding COVID-19 and about the vaccines designed to fight it.

If you’re on the fence about getting vaccinated, it is important to recognize that anyone of any age can experience severe illness and even death if they contract COVID-19, and certain factors put some groups at greater risk than others. Because people who are age 65 and older are at a higher risk of severe illness from COVID-19, and restless legs syndrome (RLS) is significantly more common among older individuals, it is important for members of the RLS community to review the most up-to-date facts about COVID-19 and vaccines.

The Basics of COVID-19

COVID-19 is caused by coronavirus 2 (SARS-CoV-2). It is predominantly a respiratory illness, but it can also affect other organs. People with COVID-19 experience a wide range of symptoms from mild to severe, including fever, chills, loss of taste or smell, cough, shortness of breath, fatigue, muscle or body aches, headache, sore throat, congestion, runny nose and diarrhea. The incubation period for COVID-19 is estimated to be up to 14 days, with symptoms appearing on average four to five days after exposure. COVID-19 spreads from person to person mainly through the respiratory route; the closer people interact and the longer they interact, the more likely they are to transmit the virus, even if they are not showing symptoms. In a study with a large cohort of 44,000 people with COVID-19, 81% of individuals exhibited mild to moderate symptoms, 14% developed severe symptoms and 5% were reported to be in critical condition. According to the Johns Hopkins Coronavirus Resource Center, the United States is experiencing a 1.8% observed case-fatality ratio, which means the number of deaths for every 100 confirmed cases (almost two deaths per 100 persons infected).

Yet, despite the grim numbers, things appear to be looking up. In mid- February, the director of the Centers for Disease Control and Prevention, Rochelle Walensky, MD, PhD, reported that COVID-19 cases in the US had been in decline for five consecutive weeks. Furthermore, new hospitalizations have consistently gone down since early January. The downward trend is multifactorial, resulting from a combination of behavior changes (masking, social distancing and restricted travel), seasonality, past infections, and vaccinations. To date, three vaccines have been issued Emergency Use Authorization by the US Food and Drug Administration for the prevention of COVID-19. However, the speed at which these vaccines were developed has raised questions in many people’s minds about how they work and how effective they are.

How the Vaccines Work

First, to understand how vaccines work, it helps to look at how the human body fights disease. When pathogens invade the body, the immune system deploys several tools to fight them. Specialized white blood cells recognize foreign substances (antigens) as dangerous and launch an attack on infected cells. Meanwhile, the immune system produces antibodies that allow the body to remember the antigens specific to that disease. Vaccines work by injecting a weakened or inactive virus that triggers an immune response and allows the body to build up a disease-specific memory, so that it’s ready to fight should an infection occur.

The most basic difference among the three vaccines available for COVID-19 has to do with how the vaccine prompts the body to launch an immune response. The Moderna and Pfizer-BioNTech vaccines are both mRNA vaccines, which means that they contain strands of genetic material, called mRNA, that give cells instructions on how to make a harmless version of the protein (the “spike protein”) that is unique to SARS-CoV-2. The immune system recognizes the protein as foreign and builds a defense to fight the antigen specific to COVID- 19. The Johnson & Johnson (J&J) Janssen vaccine is a viral vector vaccine. Instead of using mRNA to provide cells with instructions on how to make the spike protein, vector vaccines contain a harmless adenovirus inserted with DNA genetic material specific to COVID- 19. The DNA then produces mRNA, which causes the same immune response as the Moderna and Pfizer-BioNTech vaccines. Because none of the COVID-19 vaccines contains the live (either weakened or inactivated) virus that causes COVID-19, none of the vaccines can make you sick with COVID-19.

All the vaccines that have received Emergency Use Authorization have been carefully evaluated in clinical trials to ensure that they are safe and effective. The Pfizer and Moderna vaccines have shown astonishing degrees of effectiveness (95% and 94.1%, respectively) in preventing symptomatic COVID-19 infection after two doses of vaccine. The Pfizer and Moderna vaccines require two doses (21 and 28 days after the first shot, respectively). The second dose of the same vaccine is important to ensure that you get robust, long-term protection from COVID-19 soreness at the site of the injection, swelling, body aches, fever, chills, tiredness or headache. Such side effects are normal; they are a sign that your body is building up protection. They are not a sign of infection from COVID-19. Comparing the efficacy of the Pfizer and Moderna vaccines to the efficacy of the J&J vaccine is challenging because of differences in the timing of the trials (the J&J vaccine had to face the more virulent African and British strains, which were not present during the earlier Pfizer and Moderna trials). Overall, across eight countries, the J&J vaccine was shown to be 66% protective (72% in the US) against moderate to severe disease, and 85% effective in protecting against severe disease after a period of at least 28 days.

Another distinction of the J&J vaccine is that it requires only one dose, which has significant public health implications in terms of vaccine distribution. What’s more, the J&J vaccine proved to be 64% effective against moderate to severe or critical disease in South Africa, where coronavirus variants have raised concerns.

COVID-19 Variants

To date, three notable variants of COVID-19 have been documented in the United States and globally: B.1.1.7, B.1.351 and P.1. Virus variants emerge when one or more mutations occur, differentiating the new virus from the wild-type (the term in genetics referring to the typical or predominant form). Mutations can have different characteristics. For instance, these three variants of COVID-19 share a specific mutation that gives them the ability to spread more quickly. It is not surprising that variants have developed, because viruses are constantly evolving; however, the development of variants underscores the importance of keeping up measures that stop the spread of infection and getting the majority of the population vaccinated before more virulent mutations can occur.

Protecting Yourself and Your Loved Ones

As demand for the vaccines has skyrocketed, it has proven difficult for many people to be vaccinated as soon as they would wish, in part because distribution differs from state to state. Many resources are available to help people find vaccine appointments. For example, National Public Radio created a tool in which you can search by your state to find step-by-step instructions as well as tips for signing up and receiving the vaccine. See below for links to this and other resources. In addition to protecting individuals, the goal of wide-spread vaccination is to achieve “herd immunity,” which only happens when enough people in a community are protected because they’ve already had the disease or because they’ve been vaccinated against it. Pass along the helpful, science-based information to your family, friends and neighbors as well. In the meantime, while waiting for your vaccination(s), you can work to stop the spread of COVID-19 by taking four simple actions: 1) Wear a mask, 2) wash your hands, 3) stay at least six feet away from others who don’t live with you, and 4) avoid crowds.

More Information

For the most up-to-date information on COVID-19, visit:

• https://www.cdc.gov/coronavirus
• https://www.npr.org/sections/health- shots/2021/02/18/967448680/how-to-sign-up-for-a-covid-19-vaccine- in-your-state
• https://www.cdc.gov/vaccines/covid-19/reporting/vaccinefinder.html

May 5, 2021

By Stefan Clemens, PhD, HdR, Chair, Research Committee, RLS Foundation Scientific and Medical Advisory Board

The RLS Foundation’s Research Grant Program is a return-on-investment initiative; member contributions lead to advances in the understanding of RLS and to potential improvements in treatment options. The RLS Foundation established the Research Grant Program in 1997 under the leadership of Bob Waterman (Board of Directors member with two terms as Board Chair, 1995–2005 and 2011–2019). The idea was to award small research grants seed funding to provide the critical data necessary to secure additional research grants from national and international agencies.

The first research grant was awarded in 1999. Since then, an average of about two projects per year have been funded. To date, 48 grants have been supported by the RLS Foundation, totaling nearly $2 million in research funding. These 48 projects were carried out by 41 clinicians and researchers. Their findings have led to over 25 publications in a wide range of neurological and neurobiological journals and books. More importantly, the seed-funding grants provided by the RLS Foundation have led to over $10 million in additional grant support from other sources, thereby further strengthening research in the field of RLS.

Research grant applications are first reviewed by the RLS Foundation’s Scientific and Medical Advisory Board (SMAB); details about its members can be found at www.rls.org/SMAB. The SMAB consists of both clinicians and basic science researchers who are responsible for monitoring RLS medical and scientific research issues and bringing their respective expertise to the grant review sessions. In addition to reviewing research grant applications, the SMAB reviews all Foundation publications and advises the RLS Foundation’s Board of Directors on issues of medical or scientific interest and importance. A group of external specialists approved by the SMAB has agreed to serve as grant reviewers to strengthen the rigor of the research supported by the RLS Foundation and to provide additional guidance. Research grant proposals that receive a favorable decision by the SMAB are then presented to the RLS Foundation’s Board of Directors for funding consideration.

Since its inception, the grant program has focused on specific areas of study: genetics, epidemiology, iron regulation, neurophysiology, the development of novel treatment options and RLS animal models. Based on the findings of research in these areas, the SMAB recently developed new guidelines and funding priorities for future grant proposals that are summarized here:

Brain Iron Homeostasis: RLS is regularly associated with changes in brain iron function.

• Research Target: Elucidate the biological factors that contribute to RLS-relevant alterations in iron homeostasis in the nervous system.

Genetic/Epigenetic Factors: Multiple studies have underscored the role of specific genetic and epigenetic factors in the development of RLS. Genetic factors refer to factors that stem from familial heredity or gene mutations; epigenetic factors refer to changes in a person’s genome as a function of, for example, exposure to environmental factors.

• Research Target: Identify genetic and epigenetic factors and their interactions in RLS patients and develop animal models in which these interactions can be better explored in mechanistic detail.

Comorbidities: RLS is often associated with a wide range of other neurological and non-neurological diseases. What is the impact of RLS on other ailments such as cardiovascular disease, sleep apnea or Parkinson’s disease?

• Research Target: Identify any possible causal links between RLS and these other diseases.

Neurobiological Interactions: A variety of signaling molecules have been identified in the nervous system that are changed with RLS. It is often unclear, however, if the changes in these signaling molecules are themselves causing RLS symptoms or if they are a result of other changes.

• Research Target: Identify RLS-relevant neurotransmitters and neural pathways that may be implicated in RLS.

Therapeutics, Pharmacological Treatments and Therapeutic Responsiveness: A wide range of medications is used to treat RLS, and many of these compounds can lead to unwanted side effects, such as tolerance or augmentation.

• Research Target: Explain the pharmacology of existing RLS medications, develop novel approaches that show better efficacy or fewer side effects, and generally advance knowledge toward development of better treatments of RLS.

Nonpharmacological Treatments: In addition to current pharmacological treatment options, RLS patients may find benefit from nonpharmacological approaches. These include, but are not limited to: transcranial or spinal magnetic or electric stimulation; transcranial direct current stimulation; cognitive behavioral therapy; and intermittent compression of the lower limbs.

• Research Target: Describe the mechanisms in nonpharmacological treatments that lead to the improvement of RLS symptoms.

Novel Diagnostic Markers: Identifying RLS relies on the subjective feedback of a patient to their clinician.

• Research Target: Develop better assessment techniques or devices that will provide improved outcome measures for clinical research.

The RLS Foundation plans to open a new series of biannual calls for submissions of research grant applications with rotating main themes, in which submissions will be prioritized around the above-listed research areas. The RLS Foundation will also be seeking grant submissions from specialists in these respective areas, to increase the scientific depth and widen the breadth in RLS-related research. Additionally, the RLS Foundation has set aside funds for one predoctoral or postdoctoral fellowship grant per year to attract promising young investigators to the field. To contribute directly to that fund, go to www.rls.org/AllenFund.

These changes to the RLS Foundation’s Research Grant Program will improve our understanding of RLS in the clinic, spearhead new approaches and treatments in the lab, identify new and emerging drugs and technologies, and improve patient outcomes by engaging an increasing number of clinicians and researchers dedicated to finding a cure for RLS.