Cramps part 3

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What is the treatment of skeletal muscle cramps?

Most cramps can be stopped if the muscle can be stretched. For many cramps of

the feet and legs, this stretching can often be accomplished by standing up

and walking around. For a calf muscle cramp, the person can stand about 2 to

21/2 feet from a wall (possibly farther for a tall person) and lean into the

wall to place the forearms against the wall with the knees and back straight

and the heels in contact with the floor. (Learn this maneuver at a time when

you don’t have the cramp!) Another technique involves pulling the toes up

towards the head while still lying in bed with the leg as straight as

possible. For cramps such as those that occur in writer’s cramp, pressing the

hand on a flat surface will stretch the cramping finger flexor muscles.

Gently massaging the muscle will often help it to relax, as will applying

warmth from a heating pad or hot soak. Interestingly, since the normal

response of the muscle to cold is to shorten, ice packs may also relax a

cramp. If the cramp is associated with fluid loss -- as is often the case

with vigorous physical activity -- fluid and electrolyte (especially sodium

and potassium) replacement is essential. Medicines are not generally needed

to treat an ordinary cramp that is already present, since most cramps subside

spontaneously before enough medicine would be absorbed to even have an

effect.

One enthusiastic non-scientific recommendation has been to firmly pinch the

tissues above the lip, just under the nose, and hold the pinch until the

cramp stops (said to be within 15 minutes.) Of course, why this might work,

or even if it is causing anything that wouldn’t have happened anyway, is

uncertain, and no scientific study of this technique has been reported.

In recent years, injections of therapeutic doses of botulism toxin have been

used successfully for some dystonic muscle disorders that are localized to a

limited group of muscles. A good response may last several months or more,

and the injection may then be repeated.

The treatment of cramps that are associated with specific medical conditions

generally focuses on treating the underlying condition. Sometimes, additional

medications specifically for cramps are prescribed with certain of these

conditions.

Of course, if cramps are severe, frequent, persistent, respond poorly to

simple treatments, or are not associated with an obvious cause, the patient

and the doctor need to consider the possibility that more intensive treatment

is indicated or that the cramps are a manifestation of another disease. As

alluded to above, the possibilities are extremely varied and include problems

with circulation, nerves, metabolism, hormones, medications, and nutrition.

It is not common that muscle cramps would result from a medical condition

without some other obvious signs that the medical condition is present.

In the long run, however, the most important aspect of dealing with common

muscle cramp disorders is prevention.

How can muscle cramps be prevented?

Activity. For cramps that are caused by vigorous physical activity,

authorities recommend stretching before and after the activity, along with an

adequate warm-up and cool down. Good hydration before, during, and after the

activity is important, as well as replacement of lost electrolytes

(especially sodium and potassium, which are major components of

perspiration). Excessive fatigue, especially in warm weather, should be

avoided.

Pregnancy. Supplemental calcium and magnesium have each been shown to help

prevent cramps associated with pregnancy. An adequate intake of both of these

minerals during pregnancy is important for this and other reasons, but

supervision by a qualified health professional is essential.

Dystonic cramps. Cramps that are induced by repetitive non- vigorous

activities can sometimes be prevented or minimized by careful attention to

ergonomic factors such as wrist supports, avoiding high heels, adjusting

chair position, activity breaks, and using comfortable positions and

equipment while performing the activity. Learning to avoid excessive tension

while executing problem activities can help. However, cramps can remain very

troublesome for activities that are difficult to modify, such as playing a

musical instrument.

Rest Cramps. Night cramps and other rest cramps can often be prevented by

regular stretching exercises, particularly if done before going to bed. Even

the simple calf stretching maneuver (described in the first paragraph of the

section on treatment), if held for 10 to 15 seconds, and repeated two or

three times just before going to bed will often be a great help in preventing

cramps, usually within a week or two. The maneuver can be repeated each time

the person gets up to go to the bathroom during the night, and also during

the day once or twice. It may also help to avoid flexing the foot and

pointing one’s toes while in bed. If nocturnal leg cramps are severe and

recurrent, a foot board allows the sufferer to simulate walking even while

recumbent, and may prevent awkward positioning of the feet during sleep.

Another important aspect of prevention of night cramps is adequate calcium

and magnesium. Blood levels may not be sufficiently sensitive to accurately

reflect what is actually happening at the tissue surfaces where the

hyperexcitability of the nerve is occurs. Calcium intake of at least 1 gram

daily is reasonable, and 1.5 grams may be appropriate, particularly for women

with osteoporosis. An extra dose of calcium at bedtime may help prevent

cramps.

Supplemental magnesium may be very beneficial for some, particularly if the

person has a magnesium deficiency. However, added magnesium can be very

hazardous for persons who have difficulty eliminating magnesium, as happens

with kidney insufficiency. The vigorous use of diuretics usually increases

magnesium loss, and high levels of calcium intake (and therefore of calcium

excretion) tend to increase magnesium excretion. Magnesium is present in many

foods (greens, grains, meat and fish, bananas, apricots, nuts, and soybeans)

and some laxatives and antacids, but a supplemental dose of 50 to 100

milligrams of magnesium daily may be appropriate. Splitting the dose and

taking a portion several times during the day minimizes the tendency to

diarrhea that magnesium can cause.

Vitamin E has also been said to help minimize cramp occurrence. Scientific

studies documenting this effect are lacking, but anecdotal reports are common

and sometimes quite enthusiastic. Since vitamin E is thought to have other

beneficial health effects and is not toxic in usual doses, taking 400 units

of vitamin E daily is approved, recognizing that documentation on its effect

on cramps is lacking.

Are there particular concerns for older adults?

Older adults should have periodic magnesium blood levels taken if they use

supplemental magnesium. Even a mild and otherwise not apparent degree of

kidney dysfunction, which is often seen in this age group, may lead to toxic

levels of magnesium with modest doses.

Recent studies have indicated that vitamin D (a vitamin required for the

normal absorption of calcium from food) deficiency is common in some elderly

individuals. Consequently, vitamin D replacement is important for these

people, taking appropriate care to avoid excessive vitamin D levels, as these

are toxic. An intake of 800 units of vitamin D daily is likely to be fully

adequate; at least 400 units daily is generally recommended.

While the more potent diuretics are associated with an increased loss of

calcium and magnesium, hydrochlorthiazide (HYDRODIURIL) and related diuretics

are associated with calcium and magnesium retention. Diuretics are commonly

used for the treatment of hypertension and heart failure. If cramps (or

osteoporosis) are also a problem, the patient and doctor may consider using

hydrochlorthiazide or another thiazide type of diuretic if otherwise feasible

and appropriate.

Diuretics also cause sodium depletion and most also cause potassium

depletion. Many patients who use diuretics are also on sodium restricted

diets. Careful attention to the effects of diuretics on sodium and potassium,

and replacement of these elements as needed, is always appropriate, even more

so if cramps are also a problem.

Older adults often do not hydrate themselves adequately, partly because the

sense of thirst diminishes with age.

This situation is exaggerated in those who are treated with diuretics. For

some, simply increasing fluid intake to the generally recommended six to

eight glasses a day will improve the cramps. However, drinks with caffeine

should not be counted since they act on the kidneys to increase fluid loss.

Individuals who are on restricted fluid intake should consult their doctor on

this issue and must not ignore their recommended fluid intake limits.

For older people, it is uncommon to determine an exact cause for night

cramps. The best prevention involves implementing the following measures:

stretching regularly, adequate fluid intake, appropriate calcium and vitamin

D intake, supplemental vitamin E, and possibly -- with physician consultation

-- supplemental magnesium intake.

Are there medications to prevent muscle cramps?

In recent times, the only medication that has been widely used to prevent,

and sometimes also to treat, cramps is quinine. Quinine acts by decreasing

the excitability of the muscles. It has also been shown to be effective in

many, but not all, scientific studies. However, quinine also causes birth

defects and miscarriages. It has also occasionally caused hypersensitivity

reactions and a deficiency of platelets, which are the blood components

responsible for clotting. Either of these reactions can be fatal. Quinine is

also associated with a cluster of symptoms called cinchonism (nausea,

vomiting, headaches, and deafness). Additionally, vision and heart

irregularities can occur. Consequently, quinine is now available in the

United States only by prescription. The conventional dose of quinine sulfate

for cramp prevention is 325 milligrams once nightly. For individuals who

tolerate it and use the drug properly, quinine remains the most effective and

safe medication available. If the self-care preventive measures noted above

do not work, a nightly dose of quinine would currently be the next step most

physicians would recommend.

What is the prognosis of recurrent muscle cramps?

Although cramps can be a great nuisance, they are a benign condition. Their

importance is limited to the discomfort and inconvenience they cause, or to

the diseases associated with them. Careful attention to the preceding

recommendations will greatly diminish the problem of cramps for most

individuals. Those with persistent or severe muscle cramps should seek

medical attention.

Reference:

1. McGee SR. Muscle Cramps. Arch Intern Med, 1990;159:511-518.

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