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Post-Polio Health (ISSN 1066-5331)

Vol. 19, No. 1, Winter 2003

Read selected articles from this issue ...

What Is Cramping Your Style? Straight Answers to Your "Cramped" Questions
Holly H. Wise, PT, PhD, and Kerri Kolehma, MS, MD, Coastal Post-Polio Clinic, Charleston, South Carolina

Editor's Comments

Ocular Health and Pulmonary Assist Machines
Richard E. Hector, MD, FACS, Bradenton, Florida

Wellness and Disability: A report from Rehabilitation Research and Training Center (RRTC) Health and Wellness Consortium at Oregon Health & Science University

Treatment Approach Options
Linda L. Bieniek, CEAP, La Grange, Illinois

Bracing Options: Shadow Bracing System; The Stance Control Orthotic KneeT

Participants Needed: Study on Fear of Falling in Polio Survivors at Gannon University, Erie, Pennsylvania

Potpourri: Guide for Emergency Personnel; Computer/Electronic Accommodation Program (CAP)

Grant Awarded for Scooter


Editor's Comments ...

Joan L. Headley, Executive Director,
Post-Polio Health International (editor@post-polio.org)

It happened again. I received another phone call from a reporter who wanted to know "what polio survivors think." He wanted to know what polio survivors thought about the creation of the poliovirus at SUNY at Stony Brook last year. I held that some polio survivors were surprised, a few were angry, but that the majority was silent on the topic. I further explained that in my experience, polio survivors and their opinions are representative of the population in general.

How do I know? I hear from you. So, let me assure you that the lead article on cramping and overuse is intended to caution polio survivors. I am not saying we should stop "living life."

The articles about bracing are meant to inform you of current options. They are not advertisements and the companies did not pay us to print the information.

I have printed the article about "Disability and Wellness," to reinforce the message that people with disabilities can experience good health. Our organization encourages us, as polio survivors, to focus our energies on what we can do, in conjunction with societal attitudes, our health professionals, families and friends, to be healthy - physically, emotionally, mentally, socially and spiritually.

We offer three pages of Treatment Approach Options for dealing with stress, change, memories, etc. We did not include them because we think post-polio problems are "all in your head." As many of you know, we have committed the last two decades to combating that incorrect message.

We want you to continue living life, and our mission is to offer you information and options.

As an organization, we consider the generous contributions you sent as a stamp of approval for the work we are doing. Although you are not listed, those you chose to honor are. We thank you for your financial support and for letting us know "what you think."


What Is Cramping Your Style? Straight Answers
to Your "Cramped" Questions

Holly H. Wise, PT, PhD, and Kerri A. Kolehma, MS, MD,
Coastal Post-Polio Clinic, Charleston, South Carolina

Tired in the morning? Is it difficult to get comfortable for a good night of sleep? A complaint often reported at the Coastal Post-Polio Clinic in Charleston, South Carolina, is the inability to get to sleep at night due to leg pain, twitching or cramping.

Muscle cramping is a relatively common, painful and bothersome complaint among generally healthy adults, and is more common in women than men. Some studies estimate as many as 50-70% of older adults may experience nocturnal leg and foot cramps (Abdulla, et. al., 1999). Although, leg cramps are a common complaint in older adults, they must be taken seriously when the individual is a polio survivor.

What is a muscle cramp? AKA "stitch," "spasm," "knot," "Charley-horse" or "twitch?"

Muscle cramping involves a physiological disturbance of muscle that produces an involuntary and painful contraction. Cramps typically occur in the calf muscle and are accompanied by sudden excruciating pain and persistent muscle contraction. Occasionally, both legs may be affected by cramping simultaneously. Although cramps often resolve spontaneously within minutes of onset, the episodes may continue for hours or days with no apparent pattern of frequency or duration.

Cramps can occur throughout the day but more often occur at night or when a person is resting. Although it is not known exactly why cramps happen mostly at these times, it is thought that the resting muscle is not being stretched and is therefore more easily excited.

The basis for the theory that cramps occur more at rest, due to the muscle not being stretched, is that passive stretching can relieve muscle cramping. Pain associated with cramping is likely caused by the demand of the overactive muscle exceeding its metabolic supply. This excessive demand results in ischemia, or diminished blood flow, to the muscles, and the accumulation of metabolites (waste products).

Causes of Leg Cramps

Twitching and cramping can be caused by over-activity of nerves and muscles from faulty posture, shortened muscle length and excessive activity or exercise.

Other known causes of muscle cramping include diabetes mellitus, kidney failure, thyroid or neurological disorders, and poor blood flow or peripheral vascular disease. In addition, certain medications and occupational routines can precipitate muscle cramping.

Recurrent cramps without a known cause are called idiopathic cramps. These cramps are suspected to be the result of disruptions or imbalances of unknown origins anywhere in the central and peripheral nervous systems and may explain the wide range of conditions in which the cramping occurs (Bentley, 1996).

Seeking Answers

A thorough history and possibly a referral for screening labs will help determine the causes for leg pain and cramping. Polio survivors can provide a description of their muscle cramps, identification of the time and place when they occur, and an activity log of the 24-48 hours preceding the episode(s). For example, if after a vigorous exercise session or a particularly long walk, a polio survivor's muscles are noticeably twitching, aching or painful, then the activity probably exceeded the strength of the muscle.

In addition, the physical examination should include:

Prevention and Treatment of Leg Cramps

The treatment approach for non-idiopathic cramps - cramps in which the underlying cause is known - is to treat the underlying cause. The only proven strategy for the prevention and treatment of exercise-induced muscle cramps is the avoidance or reduction of activities that cause cramping.

Strategies to reduce muscle overuse may include lifestyle changes, such as weight reduction, use of assistive and orthotic devices, and the adoption of energy conservation techniques. Other strategies include advice from a physical therapist to create efficient mobility patterns and to intentionally pace day-to-day physical activities. These approaches are designed to allow for sufficient rest of over-used muscles and to eliminate muscle twitching, cramping and pain.

As with the general population, nocturnal muscle cramping in polio survivors may also be idiopathic in nature and not just related to overuse of muscles affected by polio or the other known causes listed above. The first line of treatment is to stretch the leg muscles before sleep, avoid caffeine in the evening, and eat foods high in potassium (bananas, orange juice, etc.).

To accomplish self-stretching, polio survivors can put their foot flat on the floor and slowly put weight on the foot. This action stretches out the calf muscle, which can also be done in bed by "pointing your toes towards your nose" until the cramping stops. Applying heat and massaging the cramped muscles can provide relief, as can wearing night splints that help prevent muscle shortening. Individualized intervention sessions with a physical therapist and/or referral to a certified orthotist are usually required to correct muscle imbalance and faulty posture.

Although no treatment is conclusively effective, many people achieve temporary relief of symptoms with one or more of these treatments. Success would include the reduction in the intensity of cramping episodes, number of cramps per episode, and/or in the number of nights free of cramps.

What about quinine? Any new treatments?

The standard pharmacological treatment that has been used for over 50 years is 300 mg quinine taken at night. The outcomes are substandard with about 40% of individuals getting relief (Diener, et. al., 2002). The medicine must be taken for one month to truly tell if it is going to work, and does have side effects: ringing in the ear (tinnitus), dizziness, blurry vision and headaches.

Newer treatments include vitamin E or calcium gluconate, both of which are available over the counter. The beneficial effects of these non-prescription treatments on nocturnal cramping have not been studied in detail.

IMPORTANT WARNING:

Quinine should not be used to treat or prevent nighttime leg cramps. Quinine has not been shown to be effective for this purpose, and may cause serious or life-threatening side effects, including severe bleeding problems, kidney damage, irregular heartbeat, and severe allergic reactions.

Your doctor or pharmacist will give you the manufacturer's patient information sheet (Medication Guide) when you begin treatment with quinine and each time you refill your prescription. Read the information carefully and ask your doctor or pharmacist if you have any questions. You can also visit the Food and Drug Administration (FDA) website to obtain the Medication Guide.

 
References and Resources

Abdulla, A.J.J., Jones, P.W., & Pearce, V.R. (1999). Leg cramps in the elderly: Prevalence, drug and disease associations. International Journal of Clinical Practice, 53, 494-496.

Bentley, S. (1996). Exercise induced muscle cramp - Proposed mechanisms and management. Sports Medicine, 21(6), 409-420.

Diener, H.C., Dethlefsen, U., Dethlefsen-Gruber, S., & Verbeek, P. (2002). Effectiveness of quinine in treating muscle cramps: A double-blind, placebo-controlled, parallel-group, multicentre trial. International Journal of Clinical Practice, 56(4), 243-246.

Drug Information Handbook. (1999). Hudson, OH: Lexi-comp Inc., 875-876.

Guide to Physical Therapist Practice. 2nd edition. (2001). Alexandria, VA: American Physical Therapy Association.

Kanaan, N., & Sawaya, R. (2001). Nocturnal leg cramps – clinically mysterious and painful – but manageable. Geriatrics, 56, 34-42.

Principles of Ambulatory Medicine. 4th edition. (1995). Baltimore, MD: Williams & Wilkins, 1255-1256.

Riley, J.D., & Antony, S.J. (1995). Leg cramps: Differential diagnosis and management. American Family Physician, 52, 1794-1798.

Yunus, M.B., & Aldag, J.C. (1996). Restless legs syndrome and leg cramps in Fibromyalgia syndrome: A controlled study. British Medical Journal, 312, 1339.

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