Muscle Cramps: a ‘Complication’ of Cirrhosis

View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Crossref REVIEW Muscle cramps: A ‘complication’ of cirrhosis 1 2 1 Paul J Marotta MD FRCPC , Ivo W Graziadei MD , Cameron N Ghent MD FRCPC PJ Marotta, IW Graziadei, CN Ghent. Muscle cramps: A ‘com- Les crampes musculaires comme plication’ of cirrhosis. Can J Gastroenterol 2000;14(Suppl D): 21D-25D. Muscle cramps are a common complaint in clinical complications de la cirrhose practice. They are associated with various metabolic, endocrine, RÉSUMÉ : Dans la pratique clinique, les patients sont nombreux à se neurological and electrolyte abnormalities. A variety of hypothe- plaindre de crampes musculaires. Ces dernières sont associées à diverses ses have been generated to explain the cause of muscle cramping, anomalies métaboliques, endocriniennes, neurologiques et électrolytiques. yet none has been able to support a consistent pathophysiological Plusieurs hypothèses ont été avancées pour expliquer les causes des mechanism. Muscle cramps are painful, involuntary contractions crampes musculaires. Or, personne n’a encore pu en confirmer le of skeletal muscle. They occur frequently in individuals with cir- mécanisme pathophysiologique. Les crampes musculaires sont des rhosis, regardless of the etiology, and are thought to be a symptom contractions involontaires et douloureuses des muscles squelettiques. Elles of cirrhotic-stage liver disease. affectent souvent les sujets cirrhotiques, peu importe l’étiologie de la The pathophysiology of these cramps remains elusive; hence, a cirrhose, et seraient un symptôme de maladie hépatique au stade de la specific therapy has not been identified. Many therapeutic ap- cirrhose. proaches have been offered, yet their efficacy, safety and mecha- La pathophysiologie de ces crampes reste à élucider. Aucun traitement nism of action remain poorly defined. This review defines muscle spécifique n’a donc encore pu être établi. De nombreuses approches cramps and illuminates its prevalence in the cirrhotic individual. thérapeutiques ont été proposées, mais leur efficacité, leur innocuité et leur Current theories relating to the pathogenesis of muscle cramps are mode d’action sont encore relativement imprécis. Cette synthèse définit reviewed, and an overview of the various pharmacological agents les crampes musculaires et met au jour sa prévalence chez l’individu cirrhotique. Les théories actuelles à propos de la pathogenèse des crampes that have had therapeutic success for this distressing and frustrat- musculaires sont passées en revue et on fait le bilan des divers agents ing symptom is provided. pharmacologiques qui ont permis de traiter avec succès ce symptôme Key Words: Cirrhosis; Muscle cramps; Vitamin E frustrant et ennuyeux. DEFINITION nocturnal. The pain is intense yet brief. The pain and the The general term ‘cramp’ has been used to define a variety of contraction resolve spontaneously in seconds to several min- muscle symptoms that involve pain or contraction of a single utes. The calf is the area most commonly affected, but muscle or muscle group. According to the American Asso- cramps in the fingers and hands occur in 30% of patients ciation of Electrodiagnostic Medicine Glossary of Terms (1), (4,5). this broad definition of ‘cramp’ also encompasses a confusing True muscle cramps are painful and electromyographi- array of additional terms such as ‘spasm’, ‘myalgia’ and ‘con- cally exhibit an increased frequency of motor unit action po- tracture’. A more precise definition for ‘muscle cramp’ is re- tentials that spread throughout the muscle group and quired. A working definition was established to help refine produce a sustained muscle contraction. This feature helps the physiological, electromyographic and clinical character- to differentiate various muscle conditions because involun- istics of muscle cramps (2,3). tary muscle contractions are not observed in disorders such A ‘true muscle cramp’ is characterized clinically as an in- as myositis or myalgia, and pain is not a feature of myotonia voluntary, painful, visible or palpable muscle contraction. (6) (Table 1). A muscle ‘contracture’ is also involuntary; The onset is abrupt, generally occurring at rest, and often is however, it is electrically silent (7). Involuntary muscle con- 1Liver Unit, University of Western Ontario, London, Ontario; 2Division of Gastroenterology, University of Innsbruck, Innsbruck, Austria Correspondence and reprints: Dr Paul J Marotta, Medical Director, Liver Transplantation, University Campus, London Health Sciences Centre, 339 Windermere Road, London, Ontario N6A 5A5. Telephone 519-663-3406, fax 519-663-3858, e-mail [email protected] Received for publication October 7, 1998. Accepted April 26, 1999 Can J Gastroenterol Vol 14 Suppl D November 2000 21D Marotta et al TABLE 1 TABLE 2 Definitions of muscle cramps and cramp-like phenomena Conditions associated with true muscle cramps Term Definition Benign conditions Benign nocturnal muscle cramps in elderly people True muscle cramps An involuntary, painful muscle contraction associated with an increased frequency of Exercise-induced muscle cramps motor unit action potentials Pregnancy-related muscle cramps Muscle contracture An involuntary state of sustained muscle Neurological conditions contraction that has no associated action Motor neuron disease, eg, amyotrophic lateral sclerosis potentials (electrically silent), and the Radiculopathy, eg, spinal stenosis inability of the muscle fibres to undergo relaxation Peripheral neuropathy Miscellaneous conditions Dystonia Simultaneous contraction of both agonist and antagonist muscle groups Hemodialysis Tetany A syndrome of sensory and motor neuron Volume depletion hyperexcitability, with resultant motor Cirrhosis hyperactivity (muscle spasms) and sensory Parenteral nutrition hyperactivity (paresthesia) Adrenal deficiency Malignancy Uremia tractions occur in dystonia, where contraction of agonist and Hyponatremia antagonist muscle groups result in body contortions, and in Drugs (diuretics, morphine, beta-blockers, verapamil) tetany, where the generalized nerve hyperexcitability pro- duces both diffuse motor activity and sensory disturbances (paresthesia). The prevalence of muscle cramps in patients with under- The focus herein is on true muscle cramps and not on lying cirrhosis in the United States had not been determined other cramp-like phenomena. until recently. Abrams et al (16) compared the reports of painful muscle cramps in patients with cirrhosis with that of PREVALENCE two other control groups – patients with chronic liver dis- Many benign and pathological conditions are associated ease without cirrhosis and patients with congestive heart with muscle cramps (Table 2). Regardless of the cause, the failure managed with diuretics. The latter group was in- clinical and electromyographic characteristics are identical, cluded because diuretics have been implicated as a cause of strongly suggesting a common pathophysiology (8-10). muscle cramps (6). In addition, the use of beta-blockers has The prevalence of benign muscle cramps has been diffi- been associated with muscle cramps; hence, patients requir- cult to determine. Lack of a consistent definition, subjec- ing these agents were excluded from the study. In this ques- tiveness of the symptom and selection bias taint the few tionnaire study, 52% of patients with cirrhosis described studies that have been performed. A questionnaire study painful muscle cramps, in contrast to 7.5% and 20% of pa- from the Netherlands found that 8% of an unselected adult tients in the respective control groups. Only 50% of those population reported at least weekly muscle cramps (11). Ob- with cirrhosis were maintained on constant diuretics com- jective studies using electromyography revealed that symp- pared with 90% of the heart failure group, suggesting that tomatic muscle cramps are present in as much as 16% of the the use of diuretics was not the primary cause of the muscle general population (12). cramps. Furthermore, weekly cramps were reported in 22% Through careful observation, it was recognized that pa- of those with cirrhosis and in only 5% of those in the control tients with chronic liver disease suffered from these same groups (P<0.02). muscle cramps. The uniformity of these complaints Chronic, painful muscle cramps are a common symptom prompted further investigation to establish the prevalence of in patients with cirrhosis. The prevalence ranges from 22% cramping in this patient population. Konikoff and Theodor to 88%, reflecting the lack of uniform diagnostic criteria. (13) were the first to report that 88% in a series of 33 patients Clinically relevant muscle cramps should be defined by their with cirrhosis had painful muscle cramps. The symptoms oc- frequency and severity, and hence should occur at least once curred several times per week in more than half of the pa- per week, affect the patient’s quality of life and require anal- tients (13). Chao et al (14) reported a prevalence of muscle gesia. These features occur in 12% to 42% of patients with cramps of 64% in a cohort of Chinese patients with estab- cirrhosis (15-17). The higher prevalence seen in patients lished cirrhosis. A controlled study by Kobayashi et al (15) with cirrhosis compared with those without cirrhosis sug- revealed that 31% of 80 cirrhotic Japanese patients had mus- gests that cirrhosis itself is involved in the pathogenesis. cle cramps at least once per week. This prevalence was sig- nificantly

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