Generalized Restless Body Syndrome: A case of opioid withdrawal- induced restlessness extending beyond the legs

Abstract

Introduction:Restless leg syndrome (RLS) has been described in those undergoing opioid withdrawal as a factor exacerbating heroin dependence. RLS, however, has not been described as involvingmore than the legs.Therefore, a case of generalized Restless Body Syndrome (RBS) induced by opioid withdrawal is reported. Methods: Case Report:The case involves a 67-year-old male with a history of major depressive disorder, Parkinson's disease, RLS, and chronic pain treated with opioids. Opioid use included hydrocodone/acetaminophen, hydromorphone, fentanyl patch, tramadol, and buprenorphine/naloxone. During opioid detoxification, he experienced new-onset restlessness throughout his body for three days, hindering sleep and prompting constant walking for relief. Restlessness resembled RLS sensations, affecting the thorax, abdomen, back of legs, lower back, arms, and legs, excluding the face. The sensation felt like periodic electric waves, worsened at night or during inactivity, and improved with walking. Similar sensations occurred during opioid or buprenorphine/naloxone withdrawal, particularly when reducing buprenorphine/naloxone to 1mg/day, and resolved upon reintroduction of buprenorphine/naloxone. Results:Neurological Examination: Recent recall of 2 out of 4 objects in three minutes without improvement with reinforcement. Facial akinesia, decreased blink frequency, 2+ cogwheeling in both upper extremities, Stooped shuffling gait, and resting tremor in both upper extremities were noted. Neuropsychiatric Test: Go-No-Go Test: 4/6 (abnormal). Beck Depression Inventory Type-II score: 9 (Minimal depression). Michigan Alcohol Screening Test: 35 (Problem drinker). Center for Neurologic Study Lability Scale: 8 (average). Discussion:The semiology of RBS exhibits similarities to RLS but involves additional areas such as the upper extremities, thorax, and back. While this could indicate a variant of RLS, it could also be a distinct condition. It has been observed that opioid withdrawal can trigger RLS and cause jerking movements in both upper extremities. Alternatively, this may not be RLS but rather a form of serotonin syndrome induced by opioid use, including fentanyl, and can result in generalized myoclonus. Although RLS associated with opioid withdrawal is well-documented, the underlying mechanisms responsible for its extension throughout the body, including the neck, remain unclear. One possibility is a generalized polyneuropathy affecting the upper limbs and lower extremities, particularly in iron deficiency. The coexistence of Parkinson's disease in this patient may have increased their susceptibility to RBS. Alternatively, dopamine replacement therapy used to treat Parkinson's disease may have rendered them more prone to abnormal movements, such as choreiform movements or sensations interpreted as a restless body. The absence of facial involvement suggests that the trigeminal spinothalamic tract was unaffected. It is plausible that variants of RBS may occur in individuals undergoing opioid withdrawal, potentially necessitating low-dose opioids for treatment. Therefore, evaluation of RBS as part of the assessment for opioid withdrawal is warranted.