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Nocturnal Leg Cramps in Older People J V Butler, E C Mulkerrin, S T O’Keeffe

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Nocturnal Leg Cramps in Older People J V Butler, E C Mulkerrin, S T O’Keeffe 596 Postgrad Med J: first published as 10.1136/pmj.78.924.598 on 1 October 2002. Downloaded from REVIEW Nocturnal leg cramps in older people J V Butler, E C Mulkerrin, S T O’Keeffe ............................................................................................................................. Postgrad Med J 2002;78:596–598 Nocturnal leg cramps are common in older people. motor unit hyperactivity include spinal disinhibi- Such cramps are associated with many common tion, abnormal terminal motor nerve excitability, and enhanced muscle contraction propagation diseases and medications. Physiological methods may through cross activation of adjacent neurons. Pain be useful for preventing cramps in some people, but may occur as a result of accumulation of metabo- there have been no controlled trials of these lites or possibly as a result of focal ischaemia. Muscle cramps are a common consequence of approaches. Quinine is moderately effective in unaccustomed vigorous exercise. Also, peripheral preventing nocturnal leg cramps. However, there are vascular disease is more common in patients with concerns about the risk/benefit ratio with this drug. In cramps than in matched patients without cramps.26 Nevertheless, most nocturnal leg patients with severe symptoms, a trial of 4–6 weeks’ cramps occur independently of arterial treatment with quinine is probably still justified, but the circulation.5 efficacy of treatment should be monitored, for example AETIOLOGY using a sleep and cramp diary. Although nocturnal cramps are idiopathic in .......................................................................... most people, a large number of potential aetio- logical factors have been reported. Medications that have been reported to cause leg cramps ramps are episodes of pain, usually lasting β up to a few minutes, caused by sudden, include diuretics, nifedepine, -agonists, steroids, intense involuntary contractions of mus- morphine, cimetidine, penicillamine, statins, and C lithium.7–9 In one general practice based study, cles or muscle groups. Residual discomfort and tenderness may persist for hours afterwards. 53% of patients taking quinine for cramps were also taking one or more medications that poten- Nocturnal leg cramps, usually involving the calf 10 muscles or the small muscles of the foot, are com- tially cause cramps. Medical conditions associ- mon and troublesome in older people. In a general ated with muscle cramps include uraemia, practice based study of 233 people aged 60 years diabetes,thyroiddisease,hypomagnesaemia,hypo- or more, almost one third had had rest cramps calcaemia, and hypokalaemia. Hence, it is sensible http://pmj.bmj.com/ during the previous two months, including one to check urea, creatinine, potassium, magnesium half of those aged 80 years or more.1 Furthermore, and calcium concentrations, random blood glu- 40% of subjects had cramps more than three cose, and thyroid function tests in patients with times a week, and 6% reported daily rest cramps. cramps. Another study of 350 elderly outpatients found that 50% had rest cramps, with 20% reporting DIFFERENTIAL DIAGNOSIS symptoms for 10 years or more.2 The diagnosis of nocturnal leg cramps is based on a careful history and on the absence of physical Although cramps are generally a benign and on September 30, 2021 by guest. Protected copyright. transient problem, they can cause considerable signs or disease. Conditions that may mimic distress for patients. Management can be diffi- cramps includes simple muscle strain, dystonias, cult, and there has been considerable controversy ischaemic or neuropathic claudication, nerve root about the safety and efficacy of quinine, which is disease, restless leg syndrome, and nocturnal widely used for this condition. myoclonus. Muscle cramps are a feature of many myo- pathic and neuropathic conditions. Cramps due to PATHOPHYSIOLOGY myopathy or neuropathy diseases are not usually The pathophysiology of muscle cramps is still restricted to the nighttime or necessarily to the uncertain. The “squatting” hypothesis suggests legs. Nevertheless, a careful examination of the that the modern habit of sitting at rest or at toilet, neuromuscular system is essential in patients rather than squatting like our ancestors, leads to with troublesome cramps, and investigations See end of article for muscle and tendon shortening and inadequate such as creatine phosphokinase, aldolase, electro- authors’ affiliations stretching and puts the individual at risk for myography, and nerve conduction studies may be ....................... developing leg cramps.3 Neurophysiological and indicated in selected patients. Correspondence to: electromyographic studies suggest that cramps Dr O’Keeffe, Unit 4, Merlin result from spontaneous firing of groups of ante- TREATMENT Park Regional Hospital, Galway, Ireland; rior horn cells followed by contraction of several A thorough explanation with emphasis on the 4 [email protected] motor units at rates of up to 300 per second. This benign nature of the condition is beneficial. Any is considerably more than occurs in voluntary disease that may precipitate cramps should be Submitted muscle contraction. A distal origin in the intra- identified and treated. Cautious withdrawal or 2 November 2001 Accepted 15 May 2002 muscular motor nerve terminals has been substitution of drugs known to cause cramps ....................... suggested.5 Mechanisms that may contribute to should be considered. Patients should be advised www.postgradmedj.com Nocturnal leg cramps in older people 597 Postgrad Med J: first published as 10.1136/pmj.78.924.598 on 1 October 2002. Downloaded from about general measures to improve sleep, such as not going to bed until sleepy, ensuring a comfortable environment for Key points sleep, and avoidance of alcohol and caffeine-containing bever- ages before bed. • Troublesome nocturnal leg cramps are common in older people. • Cramps are associated with many common diseases and PHYSIOLOGICAL MEASURES medications. Physiological methods of terminating and preventing cramp • Physiological methods of preventing cramp have not been deserve a therapeutic trial given that a completely safe and examined in controlled studies. Nevertheless, such methods effective pharmacological remedy remains elusive. deserve a therapeutic trial given that a completely safe and Cramps can be aborted by making use of reciprocal inhibi- effective pharmacological remedy remains elusive. tion reflexes, in which contracting a group of muscles forces • Quinine is moderately effective in preventing nocturnal leg relaxation of the antagonistic group.11 Hence, forcible dorsi- cramps. However, there are significant concerns about the risk/benefit ratio with this drug. flexion of the foot with the knee extended can relieve calf • In patients with severe symptoms, a trial of 4–6 weeks’ cramps. Passive stretch or massage of the affected muscle may treatment with quinine is probably still justified, but patients also help. should be warned of the risks, and the efficacy of treatment Similar approaches have been recommended to prevent should be monitored. cramps, but controlled trials to establish their efficacy are lacking. In an uncontrolled study of 44 patients, passively stretching the calf muscles three times a day for several days dose or after months or years of use. Other rare complications successfully prevented cramp.12 Subjects stood three feet from of quinine include pancytopenia, haemolytic uraemic syn- a wall, leaning against it with arms outstretched and gently drome, and hepatitis.22 23 tilted forward with the heels kept firmly in contact with the Warburton and colleagues noted a significant relationship floor until a non-painful stretch was felt in the calves. This between serum quinine concentrations and relief of leg position is held for 10 seconds and repeated after five second cramps.13 However, toxic levels of quinine give rise to cinchon- intervals three or four times. Raising the head of the bed and ism, a condition manifested by tinnitus, visual disturbances, raising the feet on pillows have both been advocated; neither vertigo, nausea, vomiting, abdominal pain, and deafness. approach has been formally evaluated.313 Severe toxicity can lead to permanent blindness, cardiac arrhythmias, or death. Chronic impairment of auditory, PHARMACOLOGICAL THERAPY vestibular, and visual function have been reported even in Pharmacological treatment of leg cramps may be necessary subjects taking doses of 200 to 300 mg daily.24 The frequency when symptoms are frequent and severe and where the above and severity of adverse effects may be greater in older people measures have failed. since altered pharmacokinetics with age results in a longer half life of quinine.14 Furthermore, the effects of quinine will Quinine add to those of pre-existing sensory defects in older people, Quinine, an alkaloid originally produced from the bark of the while the latter may mask early signs of quinine toxicity. Also, cinchona tree, reduces the excitability of the motor end plate quinine interacts with several widely used drugs in older to nerve stimulation and increases the refractory period of people, such as digoxin. skeletal muscle contraction.14 It has been used to treat leg cramps since 1940, usually as quinine sulphate but sometimes Naftidrofuryl oxalate and orphenadrine citrate http://pmj.bmj.com/ as hydroquinine.15 16 Naftidrofuryl oxalate, a vasodilator, and orphenadrine citrate, Trials examining the efficacy of quinine in nocturnal leg an anticholinergic
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