PRINCIPLES OF MANAGEMENT AND INDICATIONS FOR ADMISSION
PRINCIPLES OF MANAGEMENT AND INDICATIONS FOR ADMISSION
Ordinary Cramps.

To relieve an established cramp, one must passively stretch the contracting muscle and gradually contract the apposing one. In some cases, this can be accomplished by simply walking around, which produces a relative dorsiflexion of the foot.
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Massage of the involved muscle sometimes helps. Consciously dorsiflexing at the first sign of a leg or foot cramp might abort it. Prophylactic stretching can also prevent attacks, as might positions in bed that prevent foot dorsiflexion. Swimming-induced cramps can be avoided by sacrificing the ideal plantar-flexed kicking position and maintaining a more neutral foot position.

Patients who suffer from repeated attacks of nocturnal leg cramps seek a reduction in the frequency and severity of episodes. Quinine sulfate has been prescribed for decades for this purpose, but only recently have randomized, double-blind, controlled clinical trials been performed to assess its efficacy, and the number of patients studied remains small. Studies using low-to-moderate dose regimens (200-300 mg qhs) show less benefit than do those using higher doses (200 mg at supper, 300 qhs). This pattern suggests that response rates are related to serum level attained, which can vary greatly with age and preparation used. Risk of serious side effects is quite small but increases with dose and serum level. Cinchonism (nausea, vomiting, tinnitus, hearing loss), visual impairment, and ventricular arrhythmias are the most important of these adverse effects, appearing when serum levels exceed two to five times average serum concentration. An immune thrombocytopenia, occasionally fatal, has also been reported. The small, but real, risk of serious toxicity and the modest drug efficacy should temper one’s uncritical use of quinine for this otherwise benign condition. The drug is available without prescription in low-dose formulations. For those who suffer disabling nocturnal cramps unresponsive to nonpharmacologic measures, a careful trial of quinine may be useful after reviewing risks and benefits with the patient. Starting with small doses (200-300 mg qhs) is best, and platelet count should be monitored periodically. Only if meaningful benefit is obtained should quinine prophylaxis be continued.
Other drugs shown to be of some benefit include methocarbamol and chloroquine. Vitamin E is promoted in health food stores for treatment of nocturnal cramps, but it has been found to be no better than placebo when tested in double-blind, placebo-controlled fashion. It may be found in combination with quinine. The calcium channel blocker verapamil has shown promise in preliminary study.
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Patients with ordinary cramps related to dehydration and sodium depletion respond well to replacement therapy. Those with cramps as a consequence of hemodialysis are best treated with rapid volume expansion (hypertonic dextrose or saline infusion). If hypoglycemia is responsible, then adjustment of insulin regimen is needed . Altering the medication program may be necessary in cases in which beta-agonists or calcium channel blockers are thought to be responsible.
Occupational Cramps are difficult to treat. Rest and occupational aids can be helpful; psychotherapy is not. Minor tranquilizers provide some short-term relief but little sustained benefit. Injection of botulinum toxin has been tried with some success.