Horrible Muscle Cramps Causes, Cramping Prevention, Treatment ..
Muscle cramps facts
- A muscle cramp is an involuntarily and forcibly
contracted muscle that does not relax.
- Almost everyone experiences a muscle cramp at some
time in their life.
- There are a variety of types and causes of muscle
cramps.
- Numerous medicines can cause muscle cramps.
- Most muscle cramps can be stopped if the muscle can
be stretched.
- Muscle cramps can often be prevented by measures such as
adequate nutrition and hydration, attention to safety when exercising,
and attention to ergonomic factors.
What are muscle cramps?
A muscle cramp is an involuntarily and forcibly contracted muscle that
does not relax. When we use the muscles that can be controlled
voluntarily, such as those of our arms and legs, they alternately
contract and relax as we move our limbs. Muscles that support our head,
neck, and trunk contract similarly in a synchronized fashion to maintain
our posture. A muscle (or even a few fibers of a muscle) that
involuntarily (without consciously willing it) contracts is in a
"spasm." If the spasm is forceful and sustained, it becomes a cramp.
Muscle cramps often cause a visible or palpable hardening of the
involved muscle.
Muscle cramps can last anywhere from a few seconds to a quarter of an
hour or occasionally longer. It is not uncommon for a cramp to recur
multiple times until it finally resolves. The cramp may involve a part
of a muscle, the entire muscle, or several muscles that usually act
together, such as those that flex adjacent fingers. Some cramps involve
the simultaneous contraction of muscles that ordinarily move body parts
in opposite directions.
Muscle cramps are extremely common. Almost everyone (one estimate is
about 95%) experiences a cramp at some time in their life. Muscle cramps
are common in adults and become increasingly frequent with aging.
However, children also experience cramps of muscles.
Any of the muscles that are under our voluntary control (skeletal
muscles) can cramp. Cramps of the extremities, especially the legs
and feet, and most particularly the calf (the classic "charley
horse"), are very common. Involuntary muscles of the various organs
(uterus, blood vessel wall, bowels, bile and urine
passages, bronchial tree, etc.) are also subject to cramps. Cramps
of the involuntary muscles will not be further considered in this
review. This article focuses on cramps of skeletal muscle.
What are the types and causes of muscle cramps?
Skeletal muscle cramps can be categorized into four major types. These
include "true" cramps, tetany, contractures, and dystonic cramps. Cramps
are categorized according to their different causes and the muscle
groups they affect.
True cramps
True cramps involve part or all of a single muscle or a group of muscles that
generally act together, such as the muscles that flex several adjacent fingers.
Most authorities agree that true cramps are caused by hyperexcitability of the
nerves that stimulate the muscles. They are overwhelmingly the most common type
of skeletal muscle cramps. True cramps can occur in a variety of circumstances
as follows.
Injury: Persistent
muscle spasm may occur as a protective
mechanism following an injury, such as a broken bone. In this
instance, the spasm tends to minimize movement and stabilize the area
of injury. Injury of the muscle alone may cause the muscle to spasm.
Vigorous activity: True cramps are commonly associated
with the vigorous use of muscles and muscle
fatigue (in sports or
with unaccustomed activities). Such cramps may come during the
activity or later, sometimes many hours later. Likewise, muscle
fatigue from sitting or lying for an extended period in an awkward
position or any repetitive use can cause cramps. Older adults are
at risk for cramps when performing vigorous or strenuous physical activities.
Rest cramps: Cramps at rest are very common, especially in older
adults, but may be experienced at any age, including childhood. Rest
cramps often occur during the night. While not life threatening, night
cramps (commonly known as nocturnal cramps) can be painful, disruptive
of
sleep,
and they can recur frequently (that is, many times a night, and/or many
nights each week). The actual cause of night cramps is unknown.
Sometimes, such cramps are initiated by making a movement that shortens
the muscle. An example is pointing the toe down while lying in bed,
which shortens the calf muscle, a common site of
muscle cramps.
Dehydration: Sports and other vigorous activities can cause excessive fluid loss from
perspiration. This kind of dehydration increases the likelihood of true
cramps. These cramps are more likely to occur in warm weather and can be an early sign of
heat stroke. Chronic volume depletion of body fluids from diuretics (medicine that
promote urination) and poor fluid intake may act
similarly to predispose to cramps, especially in older people. Sodium depletion has
also been associated with cramps. Loss of sodium, the most abundant
chemical constituent of body fluids outside the cell, is usually a
function of dehydration.
Body fluid shifts: True cramps also may be experienced in
other conditions that feature an unusual distribution of body
fluids. An example is
cirrhosis of the
liver, which leads to the accumulation of fluid in the
abdominal cavity (
ascites). Similarly, cramps are a relatively
frequent complication of the rapid body fluid changes that occur
during
dialysis for
kidney failure.
Low blood calcium, magnesium: Low blood levels of either
calcium or magnesium directly increase the excitability of both the
nerve endings and the muscles they stimulate. This may be a
predisposing factor for the spontaneous true cramps experienced by
many older adults, as well as for those that are commonly noted
during
pregnancy. Low levels of calcium and magnesium are common in
pregnant women unless these minerals are supplemented in the
diet. Cramps are seen in any circumstance that decreases the
availability of calcium or magnesium in body fluids, such as taking
diuretics,
hyperventilation (overbreathing), excessive
vomiting,
inadequate calcium
and/or magnesium in the diet, inadequate calcium absorption due to
vitamin D deficiency, poor function of the parathyroid glands (tiny
glands in the neck that regulate calcium balance), and
other conditions.
Low potassium:
Low potassium blood levels occasionally cause muscle cramps, although
it is more common for low potassium to be associated with muscle
weakness.
Tetany
In tetany, all of the nerve cells in the body are activated, which
then stimulate the muscles. This reaction causes spasms or cramps
throughout the body. The name tetany is derived from the effect of
the
tetanus toxin on the nerves. However, the name is now commonly
applied to muscle cramping from other conditions, such as low blood
levels of calcium and magnesium. Low calcium and low magnesium,
which increase the activity of nerve tissue nonspecifically, also
can produce tetanic cramps. Often, such cramps are accompanied by
evidence of
hyperactivity
of other nerve functions in addition to
muscle stimulation. For instance, low blood calcium not only causes
spasm of the muscles of the hands and wrists, but it can also cause a
sensation of numbness and tingling around the mouth and other areas.
Sometimes, tetanic cramps are indistinguishable from true cramps. The
accompanying changes of sensation or other nerve functions that occurs
with tetany may not be apparent because the cramp pain is masking or
distracting from it.
Contractures
Contractures result when the muscles are unable to relax for an even more extended period than a common muscle cramp. The
constant spasms are caused by a depletion of
adenosine triphosphate
(ATP), an energy chemical within the cell. This prevents muscle
fiber relaxation. The nerves are inactive in this form of muscle
spasm.
Contractures can result from inherited (for example,
McArdle's disease, which is a defect of
the breakdown of glycogen to sugar within the muscle cell) or
from acquired conditions (for example, hyperthyroid myopathy, which is a muscle disease that is
associated with an overactive thyroid). Cramps of this category are
uncommon.
Dystonic cramps
The final category is dystonic cramps, in which muscles that are not
needed for the intended movement are stimulated to contract. Muscles
that are affected by this type of cramping include those that
ordinarily work in the opposite direction of the intended movement,
and/or others that exaggerate the movement. Some dystonic cramps
usually affect small groups of muscles (eyelids, jaws, neck, larynx,
etc.). The hands and arms may be affected during the performance of
repetitive activities such as those associated with handwriting
(writer's cramp), typing, playing certain musical instruments, and
many others. Each of these repetitive activities may also
produce true cramps from muscle fatigue. Dystonic cramps are not
as common as true cramps.
Do all muscle cramps fit into the above categories?
No. Not all cramps are readily categorized in the preceding manner since these
categories best apply to cramps that make up an individual's major muscle
problem. Many cramps are a relatively minor part of nerve and muscle diseases;
other muscle symptoms are usually more prominent in these diseases. Some
examples include
amyotrophic lateral
sclerosis (Lou Gehrig's disease) with weakness and muscle wasting;
radiculopathy (spinal nerve irritation or compression from various
causes) with pain, distortion or loss of sensation, and/or weakness;
diseases of the peripheral nerves, such as
diabetic neuropathy, with
distorted and diminished sensation and weakness; and a number of
primarily dystonic muscle diseases.
Can medications cause muscle cramps?
Numerous medicines can cause cramps. Potent diuretic medications,
such as
furosemide (Lasix), or the vigorous removal of body fluids,
even with less potent diuretics, can induce cramps by depleting body
fluid and sodium. Simultaneously, diuretics often cause the loss of
potassium, calcium, and magnesium, which can also cause cramps.
Medications such as
donepezil (Aricept, used for
Alzheimer's disease) and neostigmine (Prostigmine and others, used
for
myasthenia gravis) as well as
raloxifene (Evista, used to prevent
osteoporosis in postmenopausal women)
have caused cramps.
Tolcapone (Tasmar, used
for
Parkinson's disease) reportedly causes muscle cramps in at least
10% of patients. True cramps have been reported with
nifedipine
(Procardia and others, used for
angina,
high blood pressure and other conditions)
and the
asthma drugs
terbutaline (Brethine) and
albuterol (Proventil,
Ventolin, and others). Some medicines used to
lower
cholesterol, such as
lovastatin
(Mevacor), can also lead to cramps.
Cramps are sometimes noted in addicted individuals during withdrawal
from medications and substances that have sedative effects, including
alcohol, barbiturates and other sedatives, anti-
anxiety agents such
as
benzodiazepines (for example,
diazepam [Valium] and
alprazolam [Xanax]), narcotics, and other
drugs.
Can vitamin deficiencies cause muscle cramps?
Several vitamin deficiency states may directly or indirectly lead to
muscle cramps. These include deficiencies of
thiamine (B1),
pantothenic acid (B5), and
pyridoxine (B6). The
precise role of deficiency of
these vitamins in causing cramps is unknown.
Can poor circulation cause muscle cramps?
Poor circulation to the legs, which results in inadequate oxygen to the
muscle tissue, can cause severe pain in the muscle (sometimes known as
claudication
pain or intermittent claudication) that occurs with walking or
exercise. This commonly occurs in the calf muscles. While the pain feels
virtually identical to that of a severely cramped muscle, the pain does
not seem to be a result of the actual muscle cramping. This pain may be
due to accumulation of lactic acid and other chemicals in the muscle
tissues. It's important to see your doctor if you have pain like this.
What are the symptoms of common muscle cramps?
How muscle cramps
diagnosed?
Characteristically, a cramp is painful, often severely so. Usually,
the sufferer must stop whatever activity is under way and seek relief
from the cramp; the person is unable to use the affected muscle while
it is cramping. Severe cramps may be associated with soreness and
swelling, which can occasionally persist up to several days after the
cramp has subsided. At the time of cramping, the knotted muscle will
bulge, feel very firm, and may be tender.
There are no special tests for cramps. Nevertheless, the diagnosis of
muscle cramps is relatively easy. Most people know what cramps
are and when they have one. If present during a cramp, the doctor,
or any other bystander, can feel the tense, firm bulge of the cramped
muscle.
What is the treatment of skeletal muscle cramps?
Most cramps can be stopped if the muscle can be stretched. For many cramps of
the feet and legs, this stretching can often be accomplished by standing up and
walking
around. For a calf muscle cramp, the person can stand about 2 to 2.5
feet from a wall (possibly farther for a tall person) and lean into the
wall to place the forearms against the wall with the knees and back
straight and the heels in contact with the floor. (It is best to learn
this maneuver at a time when you don't have the cramp.) Another
technique involves flexing the ankle by pulling the toes up toward the
head while still lying in bed with the leg as straight as possible. For
writer's cramp (contractures in the hand), pressing the hand on a wall
with the fingers facing down will stretch the cramping finger flexor
muscles.
Gently massaging the muscle will often help it to relax, as will
applying warmth from a heating pad or hot soak. If the cramp is
associated with fluid loss, as is often the case with vigorous physical
activity, fluid and electrolyte (especially sodium and potassium)
replacement is essential. Medicines
generally are not needed to treat an ordinary cramp that is active since
most cramps subside spontaneously before enough medicine would be
absorbed to even have an effect.
Muscle relaxant medications may be used over the short-term in certain
situations to relax muscle cramps due to an injury or other temporary
event. These medications include
cyclobenzaprine (Flexeril), orphenadrine (Norflex), and
baclofen (Lioresal).
In recent years, injections of therapeutic doses of
botulism toxin (
Botox)
have been used successfully for some dystonic muscle disorders that
are localized to a limited group of muscles. A good response may
last several months or more, and the injection may then be repeated.
The treatment of cramps that are associated with specific medical
conditions generally focuses on treating the underlying condition.
Sometimes, additional medications specifically for cramps are
prescribed with certain of these conditions.
Of course, if cramps are severe, frequent, persistent, respond poorly to
simple treatments, or are not associated with an obvious cause, then
the patient and the doctor need to consider the possibility that more
intensive treatment is indicated or that the cramps are a manifestation
of another disease. As
described above, the possibilities are extremely varied and include
problems with circulation, nerves, metabolism, hormones, medications,
and
nutrition.
It is uncommon for muscle cramps to occur as the result of a medical
condition without other obvious signs that the medical condition is
present.
Cramps are inevitable, but if possible, it would be best to prevent them.
How can muscle cramps be prevented?
Activity: Authorities recommend stretching before and after
exercise or sports, along with an adequate warm-up and cooldown, to
prevent
cramps that are caused by vigorous physical activity. Good hydration
before, during, and after the activity is important, especially if the
duration exceeds one hour, and replacement of lost
electrolytes (especially sodium and potassium, which are major components of perspiration) can also be helpful.
Excessive fatigue, especially in warm weather, should be avoided.
How much should I drink?
Hydration guidelines should be individualized for each person. The goal is to prevent excessive
weight loss (>2% of body weight). You should weigh yourself before and after
exercise
to see how much fluid you lose through sweat. One liter of water weighs
2.25 pounds. Depending on the amount of exercise, temperature and
humidity, body weight, and other factors, you can lose anywhere from
approximately .4 to 1.8 liters per hour.
Pre-exercise hydration (if needed):
1. 0.5 liters per hour for a 180-pound person several hours (three to four hours) prior to exercise.
2. Consuming beverages with sodium and/or small amounts of salted snacks
or sodium-containing foods at meals will help to stimulate thirst and
retain the consumed fluids.
During exercise:
1. Suggested starting points for marathon runners are 0.4 to 0.8 liters per
hour, but again, this should be individualized based on body weight loss.
2. There should be no more than 10% carbohydrate in the beverage, and 7%
has generally been considered close to optimal. Carbohydrate
consumption is generally recommended only after one hour of exertion.
3. Electrolyte repletion (sodium and potassium) can help sustain electrolyte balance during exercise. Particularly when
- there is inadequate access to meals or meals are not eaten,
- physical activity exceeds four hours in duration,
- during the initial days of hot weather.
Under these conditions, adding modest amounts of salt (0.3 g/L to 0.7 g/L) can offset salt loss
in sweat and minimize medical events associated with electrolyte imbalances (for
example, muscle cramps,
hyponatremia).
Post-exercise:
1. Drink approximately 0.5 liters of water for every pound of body weight lost.
2. Consuming beverages and snacks with sodium will help expedite rapid and complete
recovery by stimulating thirst and fluid retention.
Pregnancy: Supplemental calcium and magnesium have each been
shown to help prevent cramps associated with pregnancy. An adequate
intake of both of these minerals during pregnancy is important for
this and other reasons, but supervision by a qualified health care
professional is essential.
Dystonic cramps: Cramps that are induced by repetitive non-vigorous activities can sometimes be prevented or minimized by
careful attention to ergonomic factors such as wrist supports,
avoiding high heels, adjusting chair position, activity breaks, and
using comfortable positions and equipment while performing the
activity. Learning to avoid excessive tension while executing
problem activities can help. However, cramps can remain very
troublesome for activities that are difficult to modify, such as
playing a musical instrument.
Rest cramps: Night cramps and other rest cramps can often be
prevented by regular stretching exercises, particularly if done before
going to bed. Even the simple calf-stretching maneuver (described in the
first paragraph of the section on treatment), if held for 10 to 15
seconds and repeated two or three times just before going to bed, can be
a great help in preventing
nocturnal cramps. The maneuver can be repeated each time you get up to
go to the bathroom during the night and also once or twice during the
day. If nocturnal leg cramps are severe and recurrent, a foot board can
be used to simulate walking even while recumbent and may prevent
awkward positioning of the feet during sleep. Ask your doctor about this
remedy.
Another important aspect of
prevention
of night cramps is adequate calcium and magnesium. Blood levels may not
be sensitive enough to accurately reflect what is happening at the
tissue surfaces where the hyperexcitability of the nerve occurs.
Calcium intake of at least 1 gram daily is reasonable, and 1.5 grams may
be appropriate, particularly for women with
or at risk for osteoporosis. An extra dose of calcium at bedtime may
help prevent cramps.
Supplemental magnesium may be very beneficial for some, particularly
if the person has a magnesium deficiency. However, added magnesium
can be very hazardous for people who have difficulty eliminating
magnesium, as happens with kidney insufficiency. The vigorous use of
diuretics usually increases magnesium loss, and high levels of
calcium intake (and therefore of calcium excretion) tend to increase
magnesium excretion. Magnesium is present in many foods (greens,
grains, meat and fish, bananas, apricots, nuts, and soybeans) and
some laxatives and antacids, but a supplemental dose of 50-100
milligrams of magnesium daily may be appropriate. Splitting the dose
and taking a portion several times during the day minimizes the
tendency to
diarrhea that magnesium can cause.
Vitamin E has also been said to help minimize cramp occurrence.
Scientific studies documenting this effect are lacking, but anecdotal
reports are common. Since vitamin E
is thought to have other beneficial health effects and is not toxic
in usual doses, taking 400 units of vitamin E daily is approved,
recognizing that documentation on its effect on cramps is lacking.
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