TABLE VII.I.2.

Association between sleep movement disorders and OSA

Study	Year	LOE	Study design	Study groups	Clinical endpoints	Conclusion
REM behavior disorder
Li et al.962	2016	4	Case series	39 iRBD patients assessed pre- and post-treatment with clonazepam	Modified RBD questionnaire, ESS, PSG measures	Clonazepam reduced subjective measures of sleep related injury, nightmares, limb movements, and objective measures of REM sleep tonic mentalis surface EMG activity. Residual symptoms were common. Presence of OSA was associated with reduced response to clonazepam.
Iranzo et al.961	2005	3b	Case–control study	16 patients with dream enactment behavior and witnessed apneas were compared, via VPSG, with 20 healthy controls	Describe VPSG features of patients with OSA that mimic behaviors of RBD	Severe OSA may mimic the symptoms of RBD. A clinical history of dream enactment behavior but normal atonia during REM sleep should suggest this RBD mimic VPSG is mandatory to establish the diagnosis of RBD, and identify or exclude other causes of dream-enacting behaviors.
Gabryelska et al.963	2017	4	Cross-sectional survey study	72 out of 120 patients previously diagnosed with RBD and OSA responded to a mailed questionnaire: 27 patients reported use of CPAP. 45 patients reported noncompliance with CPAP	Determine the prevalence of obstructive sleep apnea (OSA) in RBD patients and determine whether continuous positive airway pressure (CPAP) therapy improved RBD symptoms	OSA is a common comorbidity of RBD, being self-reported in 89% of patients with diagnosed RBD. CPAP therapy might improve self-reported RBD symptoms.
Bugalho et al.979	2017	3b	Case–control study	10 patients with RBD and AHI > 14 were compared to 22 with RBD with AHI ≤14	To understand the influence of OSA on symptoms in RBD	RBD patients with OSA had less O2 desaturation compared to those without OSA.
Koo et al.964	2018	3b	Case–control study	35 patients with idiopathic RBD compared to 42 patients with RBD plus a neurodegenerative Parkinsonian syndrome (25 with PD and 17 with MSA)	Compare sleep parameters in RBD patients with vs. without neurodegenerative Parkinsonian syndromes	RBD patients with diagnosed neurodegenerative Parkinsonian syndromes may be more prone to OSA than patients with idiopathic RBD.
Restless leg syndrome
Rodrigues et al.965	2006	4	Case series	17 patients with OSA and RLS or PLMs underwent CPAP titration and follow-up assessment 3 months later	Determine if CPAP therapy improves RLS, as measured by the IRLS, in patients with OSA	IRLS severity decreased significantly post-CPAP compared to pre-CPAP levels.
Silva et al.966	2017	4	Case series	28 patients with RLS and OSA were reviewed for evolution of RLS symptoms following CPAP therapy	Determine if CPAP therapy for OSA is associated with improved RLS symptoms	RLS symptoms improved following CPAP initiation and allowed for reductions in medications for RLS.
Lakshmanan et al.980	2019	3b	Case–control study	IRLS scores were compared in 325 individuals with OSA who received PAP therapy vs. 109 controls, and participants were screened for RLS using a single question	Determine if CPAP therapy for OSA is associated with improved RLS symptoms, as measured with IRLS	OSA patients with RLS who reported adherence to PAP had significant improvements in RLS symptoms compared to those who reported non-adherence.
PLMS/PLMD
Wu et al.974	2018	3b	Case–control	30 patients with OSA and treatment-emergent PLMs vs. 30 patients with OSA without treatment-emergent PLMs	HRV spectral analysis (FFT) applied to investigate basal autonomic regulation reflecting cardiovascular risk in patients with OSA with treatment-emergent PLMs. Parameters examined included RMSSD, LF, HF, and LF/HF ratio	PLMS emerging after CPAP therapy was associated with a decreased HRV during leg movement-free intervals and a shift toward sympathetic predominance in basal autonomic regulation.
Ren et al.968	2016	3b	Case–control	(1) 182 females with OSA matched for severity and age (2) 182 males with OSA matched for severity and age	Differences in PLMS in males vs. females with OSA	In age groups of 55 or less, females with OSA are significantly more likely to have PLMS (PLMI ≥ 15) than males with OSA of similar severity (OR 2.48; 95% CI 1.06–5.79).
Haba-Rubio et al.971	2005	4	Case series	In 57 patients diagnosed with OSA on CPAP: (1) 22 patients with PLMS (PLM index ≥ 5/h) (2) 35 patients without PLMS	Examine the role of PLMS on objective and subjective parameters of sleepiness before and after CPAP use in OSA patients	The presence of PLMS showed no correlation with increased sleepiness as measured by MSLT or by ESS after a 1 year follow-up on CPAP.
Al-Alawi et al.970	2006	3b	Case series	In data of 795 patients who underwent polysomnography: (3) 351 patients had PLMS and OSA (4) 26 patients had PLMS without OSA	Examine the prevalence of PLM arousals in OSA patients Examine relationship of PLM arousal index with risk factors	There was a higher PLMI in OSA subjects (44% had both). Patient with PLM arousal index ≥ 5/h had higher relationships with predisposing conditions (depression, Fibomyalgia, and DM), older age, more predisposing medications, obesity, and more likely to have OSA. There was no difference in the relationship with ESS or hypertension between patient with OSA only or OSA and PLM with arousals.
Xie et al.975	2017	2b	Cross-sectional study	In 15,414 patients who attended a PSG, 50.8% had PLMI>15/h, 36.1% had PLM>30/h, and 13.1% had PLMI between 15 and 30/h. The prevalence of atrial fibrillation was 15.3%	Examine whether PLMS is associated with the prevalence of atrial fibrillation in a group of patients with Sleep Disordered Breathing (SDB)	In a multivariate adjustment model, only mild SDB patients with PLMI > 30/h had 1.21 times higher odds for atrial fibrillation compared with patients with PLMI < 15/h (OR 1.21, 95% CI 1.00–1.47, p-value = 0.048). Similarly, PLMAI > 5/h had higher odds compared to PLMAI < 1 for atrial fibrillation in mild SDB patients (OR 1.27, 95% CI 1.03–1.56, p-value = 0.024).
Iriarte et al.969	2009	4	Cross-sectional study	In a referral sleep center for sleep symptoms, patients were recruited and grouped: (1) 35 patients with no diagnosis for OSA and PLMS (2) 94 patients with OSA only (3) 37 patients with PLMS only (4) 64 patients with PLMS and OSA	Examine the importance of PLMS on sleep quality in patient referred for sleep symptoms in patients with or without OSA	In a multivariate analysis, adjusting for age, sex, and AHI, PLMS was associated significantly with an increase in REM latency of 38 min (CI 95% CI 4.4–71.6; p-value = 0.03) and a decrease stage NREM 3 and 4 of 3.7% (CI 95% CI 0.2–7.2; p-value = 0.04), when comparing all four groups. The effects of PLMS on sleep architecture parameters were worse in the PLMS only group as compared to OSA only or combined OSA and PLMS group.
Loewen et al.981	2009	3b	Case–control	(1) 12 patients with OSA and end-stage renal disease (2) 18 patients with OSA and normal renal function	Differences in effect of PLMS on subjective and objective measures of sleep quality
Aritake-Okada et al.967	2012	3b	Case–control	997 patients diagnosed with OSA: 67 in persistent group (PLMI ≥ 15/h in both diagnositic and CPAP titration study), 80 in CPAP-emergent group (PLMI < 15/h in diagnostic, PLMI ≥ 15/h in CPAP titration study), 40 CPAP-disappeared group (PLMI ≥ 15/h in diagnostic study, PLMI < 15/h in CPAP titration study), non-PLMS group (PLMI < 15/h in diagnostic and CPAP titration study).	Examine the change in prevalence of PLMS in diagnostic and CPAP titration study in OSA patients (AHI > 20 events/h). Examine the associated factors on PLMS groups	PLMS were significantly increased from diagnostic to CPAP titration study in the persistent group, CPAP-emergent group, and non-PLMS group and decreased in the CPAP-disappeared group (all p-value < 0.001). In a multivariate regression analysis, CPAP-emergent PLMS group was associated with older age (age > 47 years: OR: 1.69, 95% CI 1.05–2.71, p-value = 0.03)) and higher AHI (diagnostic AHI > 30/h: OR: 2.19, CI: 1.16–4.11, p-value: 0.015).
Drakatos et al.972	2016	3b	Case–control	49 males without comorbid cardiovascular disease: eight controls, 13 with PLMs (defined as PLMI > 15/h), 17 OSA (defined as AHI > 10/h) and 11 OSA + PLMs	Compare stiffness index derived from the digital volume pulse (SI-DVP) among the groups	Patients with PLMS had higher arterial stiffness measures compared to controls. The OSA/PLMS group had the highest SI-DVP.
Xie et al.982	2019	3b	Case–control	14,444 PSGs conducted over a 4-year period were examined. 314 patients with CSA completed the study with CPAP titration and in cases of persistent CSA, ASV titration	To examine changes in PLMS in response to ASV for CSA	In the age group >68, presence of heart failure was associated with increases in PLMI and PLMAI, even after adjustment for age and severity of HF.
Murase et al.973	2014	3b	Case–control study	46 patients with OSA and PLMs were compared to 208 patients with OSA without PLMS	Compare inflammatory markers in OSA patients with vs. without PLMs	The OSa and PLMS group had higher CRP and fibrinogen levels compared to the OSA group without PLMS.
SRRMD; Aggregate level of evidence: D; (Level 4: one study)
Chiaro et al.978	2017	4	Case Series	5 patients with diagnosed SRRMD with RMEs seen following OSA events	Investigate the role of sleep apnea as a trigger for rhythmic motor events as a respiratory related arousal mechanism	SRRMD in adult patients may imply sleep-disordered breathing, possibly associated with longer respiratory events.
Bruxism; Aggregate level of evidence: B; (Level 2a: two studies)
Lopes977	2019	2a	Systematic review	Systematic review; 200 articles identified after initial search and seven included in the qualitative synthesis	Examine the association between sleep bruxism and OSA	Well-designed studies are lacking but based on available evidence, OSA patients do not experience sleep bruxism significantly more than controls. A subtype of patients with OSA may have sleep bruxism. Occurrence of sleep bruxism has been proposed as a protective mechanism for respiratory events.
Jokubauskas976	2017	2a	Systematic review	Systematic review; 691 articles identified after initial search and three included in the synthesis	Examine the association between sleep bruxism and OSA	There are insufficient data to establish an association between OSA and sleep bruxism. Sleep bruxism events occur during microarousal events resulting from apneas/hypopneas and most often are temporally related to the termination of an apnea/hypopnea.