Thursday, December 21, 2006

Nocturnal leg cramps


Cortlandt Forum has a nice short article on Nocturnal leg cramps:
By Russel Kirkby, MD, and Brian Alper, MD, MSPH

Description• Involuntary nighttime painful leg muscle contraction that does not relax


ICD-9 codes• 728.85 spasm of muscle • 729.82 cramp of limb

Prevalence• 95% of people sometime in their lives • Especially common in women and elderly
Most commonly affected muscle groups• Calf • Foot

Etiology• Most commonly no cause found• Possible causes (or associated conditions) include —Fluid and electrolyte imbalance: hypocalcemia, hyponatremia, hypomagnesemia, hypokalemia, hyperkalemia, chronic diarrhea, hemodialysis —Endocrine disease: thyroid disease, diabetes mellitus, Addison’s disease — Neuromuscular disease: nerve-root compression, motor-neuron disease, mononeuropathies, polyneuropathies, dystonias —Drugs: calcium channel blockers (nifedipine), diuretics, phenothiazines, fibrates, selective estro- gen receptor modulators (raloxifene), ethanol, morphine withdrawal —Toxins: lead, strychnine, spider bites —Congenital disease: McArdle’s disease, glycogen storage disease, autosomal dominant cramping disease —Peripheral vascular disease —Iron deficiency anemia —Liver cirrhosis, chronic alcoholism, sarcoidosis —HIV myelopathy• Pathophysiology speculative, may include reduced blood flow and oxygen supply
Likely precipitating factors• Activity excessive for condition of muscle• Sleeping prone or supine with toes fully extended • Pregnancy (insufficient calcium intake)• Older age
Complications• Insomnia • Irritability • Anxiety • Depression


Clinical evaluation• History of onset and clues to underlying condition• Drug history crucial• Local exam: arterial pulses, skin, nerves—Pulses and capillary fill (rule out vascular compromise) —Assess skin changes—Sensation/vibration
Differential diagnoses• Intermittent claudication• Peripheral neuritis• Restless legs syndrome• HIV myelopathy• Physiologic cramps due to heat, exercise, excessive activity• Electrolyte abnormalities: hyponatremia, hypokalemia, hypomagnesemia• Polycythemia• Endocrine disease: diabetes, thyroid disease, parathyroid disease, adrenal disease • Muscle diseases: glycogen storage or mitochondrial


Testing (for recurrences or underlying disease)• Electrolytes • Glucose • Blood urea nitrogen, creatinine • Calcium, magnesium, phosphate • Hemoglobin, ferritin • Zinc • Liver function tests • Thyroid function tests• HIV if appropriate• Doppler studies of arteries• Electromyelography


Nonpharmacologic management• Reassurance to exclude causes that might cause patients concern, e.g., vascular disease• Major thrust is to avoid sleep disturbance• Trial of omitting possible causative medication• Other treatments to consider—Local heat —Massage —Osteopathic manipulative therapy (OMT): myofascial release, facilitated positional release


Medications to consider• Quinine sulfate 200-400 mg nightly —Beware long-term use.—Rare but serious side effects described (disseminated intravascular coagulopathy, thrombocytopenia, pancytopenia, hemolytic uremic syndrome) —Consider monitoring complete blood count or platelets.• Other drugs similar to quinine —Hydroquinine 300 mg —Quinidine sulfate 400 mg• Other drugs not similar to quinine—Verapamil 120 mg nightly—Gabapentin (Neurontin) may reduce frequency and severity of muscle cramps.—Magnesium not clearly effective• Benzodiazepines (clonazepam, diazepam) or baclofen—Not traditionally associated with nocturnal cramp therapy but helpful in other spastic muscle conditions, e.g., tetanus, status epilepticus, and back muscle spasm —Address treatment goals of avoiding sleep disturbance.• Gastrocnemius trigger point injection of 1% lidocaine• Randomized n-of-1 trials alternating drug and placebo may determine efficacy of specific drugs for individual patients.

Prevention• Stretching exercises — e.g., nightly or twice daily • 20-minute walk may enhance stretching exercises.
See for www.dynamicmedical.com) references.
Quinine is the most commonly used treatment for this poorly understood condition; however with this medication cinchonism needs to be monitored for.

4 comments:

jr said...

I no longer have Nocturnal leg cramps since I ended a maintenance program for Strongyloides Stercoralis by taking Ivermectin and Thiabendazole daily for about 3 months. I believe the leg cramps are brought on by parasites biting into a nerve. Ivermectin, Thiabendazole, Quinine, Mebendazole, Albendazole and other parasite medications will help. Note that you will find few doctors that will even discuss parasites. People in the US will continue to suffer as long our medical profession continues to ignore the ever-present danger of parasites.
Call me at 918 740 9796 and I will try to answer any questions.

NO LONGER SUFFERING FROM LEG CRAMPS

Anonymous said...

HI people great medication I am young (mid 20s), but after being laid off from my job, the stress left me unable to remain erect with my girlfriend. On top of that, too many hours in the gym left me over-trained. ... between noon and 5pm we had sex 4 times. Took a 2 hour break and then had sex 3 more times that night. Ridiculously hard and I'd be erect again 10 minutes after climax ready to go again. The girlfriend LOVED it and so did I. I have been using a 5mg daily dose for about two months now. I had tried the 15mg single dose with poor results..it took about 18 hours to work and I got many of the side effects in the first couple of hours. The daily dose is great in that it gave me back the spontaneity I had been missing for years. That alone makes it worthwhile. As far as maintaining a long term erection, it works most of the time for a fairly long time. I had a radical prostatectomy which caused my ed and do not use any other drugs. I get occasional short period of side effects, mainly flushing and heartburn, but they only last a few minutes. Viagra Online

Kussy said...

I've been suffering from nocturnal leg cramps (leg cramps at night) for quite a while now. Seriously, very painful.

Kyle Grando said...

woww !! I really enjoyed that. thanks a lot for sharing your stuff..Keep posting!!

LOUISVILLE VACATION PACKAGES