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MUSCLE CRAMPS

MUSCLE CRAMPS. Dr. MG Roos. HISTORY. 19 yr. female Start with exercise program Muscle cramps Brown belt in karate. MEDICAL HISTORY. DVT at the age 17 Hypertension Dyslipidemia Fam. History father – CAB at the age 46, HT, Chol mother – HT, Chol, DM II,. TREATMENT. Prexum 4mg.

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MUSCLE CRAMPS

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  1. MUSCLE CRAMPS Dr. MG Roos

  2. HISTORY • 19 yr. female • Start with exercise program • Muscle cramps • Brown belt in karate

  3. MEDICAL HISTORY • DVT at the age 17 • Hypertension • Dyslipidemia • Fam. History father – CAB at the age 46, HT, Chol mother – HT, Chol, DM II,

  4. TREATMENT • Prexum 4mg. • Ecotrin 81mg. • Multivitamin • Stopped Crestor

  5. EXAMINATION • BP 130/90 • Neuromuscular = normal • Vascular system = normal • BMI = 34

  6. Special Investigations • Blood tests: FBC/LFT/TFT/UK+E/Ca/Mg/ Phosphate/chol/fasting s-glucose/ fasting insulin/clotting profile • Duplex dopler

  7. Biopsychosocial model • Clinical: Muscle cramps • Personal: She wants to start with an exercise program and loose weight • Contextual: Risk factors / family

  8. MUSCLE CRAMPS • A muscle cramp is an involuntarily and forcibly contracted muscle that does not relax.

  9. MUSCLE CRAMPS • True cramps involve part or all of a single muscle or a group of muscles that generally act together • Tetany all of the nerve cells in the body are activated, which then stimulate the muscles. • Contractures result when the muscles are unable to relax for an even more extended period than a common muscle cramp. • Dystonic cramps muscles are not needed for the intended movement but are stimulated to contract

  10. Aetiology and risk factors True cramps • Exercise associated muscle cramps • Rest cramps: generalised involuntary muscle contractions in non-exercising muscles which are associated with a number of acute or chronic and congenital or acquired medical conditions

  11. Aetiology and risk factors • Rest cramps: in older adults, but may be experienced at any age. • Dehydration • Hypocalcaemia, hypomagnesaemia and hypokalaemia • hypothyroidism, • renal or liver dysfunction • Neuropathic conditions such as amyotrophic lateral sclerosis (ALS), peripheral neuropathies, and cramp-fasciculation syndrome

  12. Aetiology and risk factors Numerous medicines can cause cramps. • Diuretics; furosemide (Lasix), can induce cramps by depleting body fluid and sodium, potassium, calcium, and magnesium. • Anti-cholesterol; statins (Simvastatin) • Alzheimer's disease; donepezil (Aricept) • Myasthenia gravis; neostigmine (Prostigmine) • Osteoporosis in postmenopausal women; raloxifene (Evista) • HT; nifedipine (Adalat) • Asthma; salbutamol (Ventolin)

  13. Aetiology and risk factors • Withdrawal from medications and substances, including alcohol, barbiturates, other sedatives, anti-anxiety agents narcotics, and other drugs. • 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 role of deficiency of these vitamins in causing cramps is unknown. • Poor circulation - claudication

  14. TREATMENT • Rule out all possibilities and Rx • Diet • Medication • Stretching: Data are insufficient to draw any conclusion on the efficacy of calf stretching in reducing the frequency of muscle cramps

  15. Pharmacologic treatment • Quinine – 93 deaths since 1969 • Diltiazem 30mg – reduction in freq/-int • Vit B (Vit B6-30mg) 86% remission • Neurontin – ALS (amyotrophic lat scleroses) no difference • Mg – 90% no difference • ?Baclofen/carbamazepine/trileptal – no clinical trails Katzberg 2009

  16. EXERCISE ASSOCIATED MUSCLE CRAMPS (EAMC)

  17. Definition • EAMC is a syndrome of involuntary painful skeletal muscle spasms that occur during or immediately after physical exercise.

  18. EXERCISE ASSOCIATED MUSCLE CRAMPS (EAMC) • Presents as painful localised muscle cramping that occurs sporadic in different exercising muscle groups —usually calf, hamstring & quadriceps muscles

  19. Not all athletes with muscle cramping suffer from EAMC. • Many underlying medical conditions

  20. EXERCISE ASSOCIATED MUSCLE CRAMPS (EAMC) • EAMC is particularly common in endurance events • aetiology of EAMC in athletes is still not well understood.

  21. Aetiology of EAMC • The first reports of muscle cramping related to physical activity were from labourers working on steamships and in mines in hot, humid conditions more than 100 years ago. • In these early reports it was noted not only that muscle cramping occurred in the heat but also that cramps were accompanied by profuse sweating. • These early anecdotal observations led to the development of the traditional ‘‘electrolyte depletion’’ and ‘‘dehydration’’ hypotheses for the aetiology of EAMC.

  22. Hypothesis • Dehydration and electrolyte depletion are often considered together (and recently together with muscle fatigue) as the ‘‘triad’’ causing EAMC. • The key components of this hypothesis are that electrolyte depletion through excessive sweat (sodium) loss together with dehydration causes EAMC.

  23. Evidence against Electrolyte & Dehydration Hypothesis • No difference between pre- and post race serum electrolytes Drew N, MPhil Sports Medicine dissertation, University of Cape Town, 2006). Schwellnus 2010

  24. Electrolytes & Localised symptoms • Both electrolyte depletion and dehydration are systemic abnormalities, and therefore would result in systemic symptoms • However, in EAMC, the symptoms classically are local and are confined to the working muscle groups.

  25. Thus, the available evidence to date does not support the hypotheses that electrolyte depletion or dehydration cause EAMC • Therefore an alternative hypothesis for the aetiology of EAMC has to be considered.

  26. NEW HYPOTHESIS • ‘muscle fatigue’ • suggested that the development of ‘neuromuscular fatigue’ leads to abnormal neuromuscular control.

  27. Muscle fatigue • Altered neuromuscular control • Muscle cramps

  28. MUSCLE FATIQUE

  29. Muscle fatigue • Altered neuromuscular control • Muscle cramps

  30. Altered Neuromuscular Control • Fatigue increases the muscle spindle afferent activity • and decreases the Golgi tendon organ afferent activity • which may result in altered neuromuscular control

  31. Muscle fatigue • Altered neuromuscular control • Muscle cramps

  32. Mechanisms by which fatiguingmuscular exercise causes muscle cramping • 1. Repeated stimulation of the 1a afferents through electrical stimulation or using the tendon tap (activating the 1a afferents) can induce cramping.

  33. Mechanism by which fatiguingmuscular exercise causes muscle cramping • 2. Tension in Golgi tendon when stretched afferent reflex inhibitory input in a-motor neuron • This is a plausible mechanism to explain why stretching is the most effective treatment of cramping • This mechanism offers further support for the hypothesis that abnormal neuromuscular control is associated with EAMC.

  34. Altered Neuromuscular Control • Altered neuromuscular control • may result in increased alpha motor neuron activity. • Increased muscle cell membrane activity • Therefore, as progressive muscle fatigue develops, there may be an increased risk of developing EAMC.

  35. Altered Neuromuscular Control

  36. Schwellnus. Br J Sports Med 2009;43:401-408 doi:10.1136/bjsm.2008.050401

  37. TREATMENT AIM • Reduce muscle spindle and motor neuron activity by reflex inhibition and afferent stimulation

  38. PREVENTION • No proven strategies • Regular muscle stretching before and after exercise • Correction of muscle balance and posture • Adequate conditioning for an activity • Mental preparation for the competition • Avoidance of provocative drugs

  39. OTHER STRATEGIES • Incorporating plyometrics or eccentric muscle strengthening into training programs • Maintaining adequate carbohydrate reserves during competition • Treating myofascial trigger points

  40. CONCLUSION • Disabling • Not all athletes with muscle cramping suffer from EAMC. • Treat co-morbid conditions • Multidisciplinary approach

  41. References • M P Schwellnus. Cause of Exercise Associated Muscle Cramps (EAMC) -- altered neuromuscular control, dehydration or electrolyte depletion? Br J Sports Med 2009;43:401–408 • Martin P Schwellnus, Nichola Drew and Malcolm Collins Increased running speed and previous cramps rather than dehydration or serum sodium changes predict exercise-associated muscle cramping: a prospective cohort study in 210Ironman triathletes Br J Sports Med published online December 9, 2010 • Hans D. Katzberg, MD Ahmir H. Khan, MD Yuen T. So, MD, PhDAssessment: Symptomatic treatment for muscle cramps (an evidence-based review) Am Ac of Neurology 2010;74: 691-696

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