True cramps, which by definition occur in the absence of fluid or electrolyte imbalance, are more prevalent in patients with well-developed muscles, in the latter stages of pregnancy, and in patients with cirrhosis. The cramps occur when a muscle already in its most shortened natural position contracts further. This rapid firing rate causes the muscle tightness and pain. Electromyographic studies indicate that during ordinary muscle cramps, motor units fire at about 300 per second, far more rapidly than any voluntary contraction. The pain results from a combination of ischemia, accumulation of metabolites, and possible damage to the muscle fibers. Most muscle cramps are thought to be caused by hyperactivity of the peripheral or central nervous system rather than the muscle itself. If there is any uncertainty, a normal electromyogram will rule out any serious disease processes. Fasciculation and cramps without weakness or muscle atrophy are recognized as a benign syndrome. Provide appropriate follow-up to patients who have more than benign self-limited cramps.ĭo not ignore muscle weakness, fasciculations, and wasting, which are signs of lower motor neuron disorders, including amyotrophic lateral sclerosis, polyneuropathy, peripheral nerve injury, and nerve root compression. Although one study failed to find a difference between magnesium and placebo in patients with nocturnal leg cramps, magnesium salts are commonly used to relieve nocturnal leg pain in Europe and Latin America. Oral magnesium (Slo-Mag, Mag 64), qd or bid, can be used to reduce leg cramps in pregnant women, without increasing serum concentrations. A glass of tonic water (a source of quinine) before bed is a less toxic alternative worth trying. Recently, the Food and Drug Administration (FDA) has warned against using quinine for non–FDA-approved symptoms of leg cramps and restless leg syndrome, because of reports of hematologic reactions. However, not all report favorable results, and their use has become somewhat controversial. Most studies show that quinine and its derivatives decrease the incidence, severity, and duration of night cramps. Nocturnal leg cramps have historically been treated with quinine sulfate tablets, 260 to 325 mg taken qhs. Ordinary muscle cramps can be treated immediately with passive or active stretching of the cramped muscle (dorsiflexing the foot for calf cramps). IV fluids with electrolyte replacement will help with heat cramps and alcohol-induced cramps. Hypothyroidism, hyperthyroidism, hyponatremia, hypokalemia, hyperkalemia, hypocalcemia, hypomagnesemia, and respiratory alkalosis (see Chapter 3) can all cause muscle cramping.Īddress any specific cause. Drug-induced cramps can include those from alcohol, lithium, cimetidine, nifedipine, antipsychotic medications (see Chapter 1), clofibrate, and others. Unaccustomed exercise and salt depletion from sweating are common precipitating causes (see Chapter 2). Following this, the muscles may be tender and painful for some time. Most cramps are transient in nature, but they are likely to recur after a severe episode. Other muscle cramps are associated with exercise in the heat, occupations that cause overuse, pregnancy, and drug or alcohol use. Ordinary cramps occur chiefly at rest during the night or after trivial movement but also can occur after forceful muscle contraction. The patient complains of painful, visible, palpable muscle contractions, often affecting the gastrocnemius muscle or small muscles of the foot or hand.
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