Leg Cramps; A Discussion on Causes and Cures.

Leg Cramps

A Discussion on Causes and Cures

Author: Mark Parkinson RPh: President AFC CE

Credit Hours 1- Approximate time required: 60 min.

Educational Goal:

To provide insights into the cause and resolution of Muscle Cramps.

Educational Objectives:

1. Present an explanation on what muscle cramps are and what causes them.

2. Describe one possible care plan for leg cramps.

3. Provide insight into possible actions by the doctor.

4. Explain the concept of Homeopathy and list Homeopathic remedies for leg cramps.

Procedure:

1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

Leg Cramps

A Discussion on Causes and Cures

Adult Foster Care Home providers are caring people. They get a lot of pleasure and satisfaction out of helping their residents live a comfortable life. The job also comes with its moments of frustrations. Leg cramps, for example. Cramps aren’t really serious and are usually easily dealt with, but if cramping happens over and over again, it presents a challenge not so easily solved. The frustrating part is trying to solve the problem when you don’t have all the answers. Hopefully by the end of this article you will have some answers and a useable plan of action that will assist you in maintaining a good quality of life for your elderly resident.

What exactly is a muscle cramp anyway?

Muscle cramps or “charley horses” are involuntary severe muscle contractions. They are quite painful and can happen to any skeletal muscle group. Cramping occurs most often at night in the lower legs and feet. Up to 70% of the elderly are painfully afflicted at one time or another. Once you’ve had one, there is no doubt that you don’t want another.

What Causes Leg Cramps?

No one is quite sure the exact mechanism that results in a charley horse. Sometimes the causes can be identified. Other times they just happen for no apparent reason. One thing that science has been able to figure out is that the root of the problem is not in the muscles themselves. It’s in the nerves that control them. Something causes the nerves to fire, causing a strong muscle contraction.

What triggers the nerves to fire?

Normally, nerves under our conscious control only fire when we want them to. As we think about using a muscle, an electro-chemical signal starts to build up. When that signal reaches a certain level the nerves are triggered and off the signal goes. In leg cramps, either the signal is boosted or the trigger threshold is lowered in the nerves that control the afflicted set of muscles. Fortunately, it is only a temporary anomaly that is easily reversed by relaxing the muscle through stretching or massage.

Why do they happen most often at night?

During the day our mind and muscles are alert and have tone. It is thought that as the anomaly starts to develop the body’s systems are able to compensate before a cramp develops. It happens automatically without us knowing about it. At night, when the body is relaxed, the compensating mechanisms are not there to prevent the charley horse.

What are the causes of muscle cramps?

The answer to that question is only partially known. Some causes just continue to remain a mystery. Following are some causes we do know about:

Spinal cord injury or pinched nerve
Spraining or overuse of a muscle
Dehydration
Insufficient blood flow to the muscle group
Medication side effects
Electric shock
Chronic diseases- Addison’s disease, Parkinson’s disease, alcoholism, cirrhosis, hypothyroid, chronic kidney failure, diabetes, peripheral artery disease, deep vein thrombosis
Imbalance of the minerals used by the nerves to fire -Potassium, calcium, sodium and magnesium

There are some behaviors that can contribute to these causes. In the elderly, common contributory behaviors are:

Sitting in one place for a long time without moving.
Always having the feet down
Having the covers too tight in bed (this makes the feet to point down causing the calf and feet muscles to be constricted for too long).

Here is a typical elderly care scenario: Henrietta sits in her chair all day long. She never wants to move a single muscle, even for basic things like getting a drink of water. She takes blood pressure pills and water pills (both can cause cramps). She has poor circulation in her legs. Her nervous system is worn down due to old age and long term diabetes. It’s small wonder that she also complains of reoccurring leg cramps and she is getting real grouchy about it, too.

What are the treatments for Leg Cramps

Muscle cramps are rarely a major health concern. Most of the time, the resident can take care of the problem by himself or herself, by massaging or stretching the offending muscles. Particularly painful occurrences can be helped by applying an ice pack. When the patient has multiple cramping events, it becomes a bit more serious. The more often charley horses occur the lower the quality of life becomes. You, the care provider, can either do nothing (and get increasingly frustrated with each new cramp your resident suffers) or you can have a plan in place that will help you determine when and how much medical intervention is required.

Leg Cramp Prevention Strategy

It is always good to be prepared with a flexible plan. This one has 3 levels of intervention. Each level is determined by the impact the cramps have on the quality of life of the patient.

Mild Impact

Mild impact = infrequent occurrence. The occasional charley horse has no real lasting impact on the patient. Each cramp is remedied in normal fashion as they occur. No future intervention is needed.

Moderate Impact

Moderate impact = frequent occurrence. If there is a high probability of recurring episodes, prevention efforts will be required. The care provider will have to decide how frequently cramping is occurring before intervention is required. Individual patient reactions and the severity of each event have to be taken into consideration. At this level non-pharmaceutical intervention is the most appropriate therapy.

Non-Pharmaceutical Intervention:

Often patient behaviors are the contributing factor causing the recurring cramps. You, the care provider, can find out what they are and assist in altering the behavior.

1) Proper hydration – Ensure the resident has easy access to fluids throughout the day. Flavored or unflavored ice water with a straw should always be close at hand. Watch caffeine consumption, however, because of its diuretic effect.

The body’s thirst impulse can be reduced with age. It’s a good idea to keep an eye on how much your patient is drinking. If the volume is low a gentle reminder may be helpful. The daily amount of liquid is individualistic and should be determined by the doctor.

2) Proper physical activity and blood flow - Elderly patients are naturally more sedentary. Their inactivity often comes with a price tag of poor blood flow to the legs and impinged nerves. You can solve this problem by:

Elevating the legs at regular intervals.
Scheduled courses of exercise walks or stationary bike riding are easy to implement.
Occasional massaging of the leg with lotion promotes blood flow to the area and is good for the skin.
Since most charley horses happen at night, bedtime prevention activities are particularly beneficial.

Place a heating pad on the calf for 10 minutes before bed.
Stretch out the calf and feet muscles when the elder lies down.
Ensure the blankets are loose around the lower legs. Draping the blankets over an elevated foot board might be helpful.

Monitor the frequency of occurrences so you can tell if your efforts are succeeding. If they aren’t having the desired effects then move to the next level.

Sever Impact

Severe impact = regular occurrences or failed non-pharmaceutical therapy. At this level of cramping there are probably larger issues that need to be addressed. It’s time to get a doctor involved with a phone call or a visit. Before you do that, it’s best to be prepared. Here are a few thoughts and methods that will help you get the most benefit out of interactions with the doctor.

Keep in mind that the resident or their family may not be able to communicate the problem correctly.
Doctors are often very busy, so it is best to be concise about what the problem is and what you have done to address it.
If you feel like either you or the doctor doesn’t fully understand the situation, don’t hesitate to ask some questions, just to make sure.
Organize and write down what is going on and what you have done so far. Include frequency of occurrences, all medications and supplements being taken by the resident, what prevention efforts you have done and how long you have done them. The more information the doctor has the better decisions he or she will be able to make. It also makes you look very professional, as well.
If you can’t get through to the doctor and/or have to send your resident to the office, put all the pertinent information in a file folder.
Include in the file a space for the doctor’s response. Let the family know that you want the folder back, complete with the doctor’s response.

I have included an example of what I would do. You may copy this and modify it for your own uses.

______________________________________________________________________________________________________________________________________________

Your Name Care Home

Doctor Visit Information File

Date ________

Patient: Henrietta Smith Age: 86

Medications

1) med 1	3) med 3
2) med 2	4) med 4

Known Conditions

Arthritis, high blood pressure, Diabetes

Reason for visit

Henrietta is suffering from frequent leg cramps that are having a negative effect on her life.

Symptoms

Henrietta’s leg cramps happen exclusively at night. They’ve happened about 3 times per week for the last 2 months, starting 2 months ago.

Relief Efforts:

She gets 4-8 glasses of water a day. She takes regular daily walks of 15-30 min. We massage her legs with lotion each night before she goes to bed. We apply a heat pad for 10 minutes to her calves. We also stretch the calves and feet muscles before sleep.

Despite all these efforts the cramps continue. Please advise us what to do to alleviate this problem.

P.S. Would it be appropriate to use an OTC Homeopathic product called Hyland’s Leg Cramps? (More about this remedy will be presented later.)

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Doctor’s Response:

______________________________________________________________________________________________________________________________________________

What will the Doctor do?

Adult Foster Care providers are part of the Health Care continuum. As part of that team it’s good for you to know what the other team members are doing. The doctor will probably review the medications, take a blood sample and do a patient assessment. Considering all the facts, he or she will then choose a therapy.

Review the medications

The doctor will reevaluate the patient’s current medications in light of these new conditions. The doctor may or may not change things.

Note: Every drug has side effects. Choosing a medication for a patient is really a balancing act of benefit vs. risk of injury due to the side effects. A medication may indeed cause muscle cramps, but the benefits far outweigh the cramping. The doctor always has the option of continuing the offending medication and trying to manage the resulting charley horses another way.

Medications that can cause muscle cramps are donepezil (Aricept), raloxifene (Evista), tolcapone (Tasmar), nefedipine (Adalat, Procardia), terbutaline (Brethine), albuterol (Proair, Provental, Ventolin) and statin drugs like lovastatin (Mevacor).

Often, drugs cause muscle cramping indirectly by throwing off the mineral balance of the body. Of major concern are the Diuretics, like furosimide (Lasix) and Hydrocholrothiazide (HCTZ). These water pills can make the body lose a lot of potassium. Low potassium is a known cause of cramping. The doctor will want to see if too much potassium is being lost, which leads to our next point.

Blood samples

The doctor will probably take a blood sample and measure all the important minerals and electrolytes. If deficiencies are seen in the key minerals (potassium, calcium, magnesium, iron), then supplements can be ordered.

Note: Potassium is sometimes written down using its chemical abbreviation, K+.

Health professionals are aware that lack of potassium causes muscle cramps. Patients have also learned this fact, but don’t know all the details, so some myths have arisen.

Myth – Eating bananas will help leg cramps.

Truth – Bananas are a good source of K+, but not that good. I was taught in pharmacy school that you would have to eat 5 feet of banana every day to fulfill the minimum daily requirement. It turns out that orange juice has more potassium than bananas. Also, potato skins and raisins have twice as much as bananas.

Myth – OTC potassium is all you’ll need.

Truth – Overdosing on potassium can lead to some major problems. To prevent this from happening, the FDA has severely restricted the amount of potassium in OTC preparations (potassium picolate). The FDA will only allow between 2% and 4% of the daily requirement in each dose. You would have to ingest a lot of tablets to get what you need.

There are better sources of non-prescription potassium. One can of V-8 vegetable juice has 19% of your daily requirements. Nutritional drinks (Ensure, Boost, etc…) and weight loss drinks (Atkins, Weight Watchers, etc.) also have higher amounts. Reading product labels will enable you to find your own nutritional sources of potassium. There is also a salt substitute product called No-Salt. Instead of sodium chloride (salt), it contains potassium chloride.

Myth – Because you can buy potassium OTC, it’s not dangerous.

Truth – In addition to messing with the brain and nerves, it can also give you a really sour stomach. In the lining of your gut there are tiny glands that pump out stomach acid. They are activated into action by potassium. More potassium in the stomach results in more stomach acid.

Note: If you intend to use No-Salt to reduce sodium intake or increase potassium intake you should monitor for sour stomach reactions in you patients. Ant-acids are a convenient therapy. Don’t forget to chart there use in your PRN drug log.

Physical Assessment

Even though charley horses are not medically significant, they can be an indicator of more serious issues. The presence of continued cramping may lead the doctor to discover a new disease or previously diagnosed condition that is not under control. The doctor will appreciate the detailed information you give him or her.

Choosing a Therapy

Unfortunately, there is no FDA-approved therapy for leg cramps. Quinine has been used in the past, but the FDA has decided that it’s not safe to use. Because of this ruling, Quinine prescriptions have become very limited and are usually not covered by insurances. There are other medications that the doctor can try, like muscle relaxers or gabapentin (Neurontin), but their use is definitely “off label”.

Because there are no FDA-approved therapies, all sorts of remedies have popped up. Everything from putting a bar of soap under the covers to extra vitamin supplements. No one really knows how or even if they work. None of these so-called cures has any scientific basis, except one. Homeopathy.

Disclaimer – This author is not proposing you rush out and get some homeopathic remedies for leg cramps. This is a pharmaceutical therapy and has to be reviewed and approved by the doctor before its use. Since there are so few good alternatives out there, I will tell you about it.

What is Homeopathy?

Homeopathy is not herbs or naturopathy. It is a medical discipline that has been around for more than 2 centuries. It approaches the practice of medicating in a totally different way. Regular medical disciplines (allopathic) rely on direct intervention on body systems. For example, large doses of drugs are used to either destroy a pathogen (antibiotics) or reduce symptoms directly (anti-inflammatory, antidepressants). Naturopathic medicine does the same thing, except with herbs instead of drugs.

The Homeopathic approach is different. It tries to solve the problem by stimulating the body into certain responses. Then the body cures itself through these responses. In leg cramps, Homeopathic medicine is given in hopes that it will stimulate a “resolve the cramping” response before there is a cramp to fix, thereby reducing the problem before it happens again.

Homeopathic doses are very small compared to regular medicines. Homeopathy has been described as “tricking the body to respond”. Practitioners claim that even though the doses are very small, they are very potent because of the way they are prepared. Smaller doses also produce the benefit of reduced side effects, thus creating a safe, easy-to-use product. This has led the FDA to allow several potent remedies to be marketed over the counter.

Homeopathy is considered an alternative medicine. For a doctor schooled in allopathic approaches, it wouldn’t be a first choice of therapy. They are just not familiar with this approach and are concerned by the tiny amount of drugs used. In order for it to be considered for therapy, it will most likely have to be brought to their attention by you (see sample Doctor Visit Information File, above).

Homeopathic Medicines for Leg Cramps

There are three OTC Homeopathic formulations for the doctor to consider. Hyland Leg Cramps, Hyland Leg Cramps with Quinine and Hyland Leg Cramps PM. The company claims there are no side effects and that they are safe to use with other medications. If the doctor decides to use this medicine, it should be under the same Adult Foster Care rules as the resident’s other medications.

Conclusion

Charley horses are never fun to experience. If they occur on a regular basis, it can be an indicator of a more serious problem. The care provider should have a plan in place to deal with the condition if it arises. That plan should be flexible enough to consider the frequency of occurrence, effective communication with the doctor, non-pharmacological and pharmacological remedies. Even though there is not an FDA-approved therapy for leg cramps, the caregiver does have several options at their disposal.

References:

1. Molly Punzo, MD, Assessment and Management of Leg Cramps: A Homeopathic Approach. March 15 2010. Power-pak C.E. UAN: 0430-0000-10-009-H01-P; 0430-0000-10-009-H01-T

2. Night Leg Cramps- Mayo Clinic.com

www.mayoclinic.com/health/night-leg-cramps/MY00410

3. Nighttime Legcramps: What causes muscle spasms and Late-Night Leg Cramps?

www.webmd.com/sleep.../nighttime-leg-cramps-topic-overview

4. Muscle Cramp Causes, Cramping Prevention and Treatment

ttp://www.medicinenet.com/muscle_cramps/article.htm

5. Jonatham Cluett MD, Leg Cramp, Orthopedics, About.com

http://orthopedics.about.com/cs/sprainsstrains/a/legcramp.htm

6. Joe Graden, Leg Cramps: Home Remedies and Treatments YouTube video

http://www.youtube.com/watch?v=zVzbIC_zG-s

7. Leg Pain- Leg Cramps- Causes- Symptoms- Diagnosis- Treatment. About.com http://arthritis.about.com/od/legpain/Leg_Pain_Causes_Symptoms_Diagnosis_Treatment_Pain_Relief.htm

8. Hyland Homeopathic- Leg cramps with Quinine