Prevalence and characteristics of muscle cramps in patients with varicose veins

Intranasal spray of cubosomal Tizanidine Hydrochloride for brain targeting: In-vitro and in-vivo characterization

Tizanidine HCl (TH) is used as first-line therapy for the treatment of muscular spasm. The intranasal cubosomal delivery system of TH for site-specific delivery i.e. CNS was developed. Cubosomes of TH were prepared using Glyceryl monooleate (GMO) as a lipid, poloxamer 407 as stabilizer, and ethanol and polyethylene glycol 200 as co-solvent. Optimized cubosomes of TH were characterized for vesicle size, zeta potential, % drug entrapment, mucin binding efficiency, which found to be 50.22 nm, -6.39 mV, 69.28%, 42.12%. It is also evaluated for CRYO-FESEM, CRYO-TEM, SAXS, residual solvent content, and in-vitro drug release. Ex-vivo permeation was also conducted at 7.4 and it indicates that almost 93.66% drug was diffused from a formulation in 6 hrs. Histopathological study of the optimized TH cubosomes suggests that the prepared formulation is non-toxic to the nasal mucosa. Pharmacokinetic and brain distribution study indicates targeted action of the formulated TH cubosomes.

Lateral Subdermic Venous Plexus Insufficiency: The Association of Varicose Veins with Restless Legs Syndrome and Nocturnal Leg Cramps

PURPOSE

To determine whether nocturnal symptoms of restless legs syndrome (RLS) and muscle cramps in the legs are associated specifically with lateral subdermic venous plexus (LSVP) insufficiency and whether treatment can provide symptomatic relief.

MATERIALS AND METHODS

A retrospective cross-sectional observational study of 506 patients at a single site analyzed whether RLS or nighttime leg cramping symptoms were associated with venous reflux in the LSVP using comprehensive venous ultrasound. The treatment outcomes of ultrasound-guided foam sclerotherapy (USGFS) were followed up for 1 year.

RESULTS

Of 209 patients who reported restless legs symptoms, 179 (85%) demonstrated an abnormal LSVP. A total of 214 patients reported nighttime muscle cramping, of whom 197 (92%) demonstrated an abnormal LSVP. Among 124 patients presenting with both the symptoms, 113 (91%) demonstrated an abnormal LSVP. Conversely, of 83 patients who presented with neither RLS nor nocturnal cramping, 2 (2%) had an abnormal LSVP. Among 242 symptomatic patients with an abnormal LSVP who underwent treatment, the technical success rate was 100%. At 90-day follow-up, 224 patients (93%) reported continued relief, which was maintained at 93% (224/242) at follow-up at 1 year. When substratified, 90 patients presented primarily with RLS or cramping and showed only LSVP reflux, and when treated, all 90 (100%) had significant or complete relief of the symptoms.

CONCLUSIONS

LSVP insufficiency demonstrates an association with symptoms of RLS and nocturnal leg cramps. LSVP treatment using USGFS demonstrated high technical and clinical success rates, with symptomatic relief up to 1 year, most pronounced when the LSVP was the only treated vein.

Non-drug therapies for the secondary prevention of lower limb muscle cramps

BACKGROUND

Lower limb muscle cramps are common and painful. They can limit exercise participation, and reduce quality of sleep, and quality of life. Many interventions are available for lower limb cramps; some are controversial or could cause harm, and often, people experience no benefit from the interventions used. This is an update of a Cochrane Review first published in 2012. We updated the review to incorporate new evidence.

OBJECTIVES

To assess the effects of non-drug, non-invasive therapies for lower limb muscle cramps.

SEARCH METHODS

In August 2018 and May 2020, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of included studies. We imposed no restrictions by language or publication date.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) of non-drug, non-invasive interventions tested over at least four weeks, for lower limb muscle cramps in any group of people, except pregnant women. The primary outcome was cramp frequency. Secondary outcomes were cramp pain severity, cramp duration, health-related quality of life, quality of sleep, participation in activities of daily living, proportion of participants reporting lower limb muscle cramps, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias, and cross-checked data extraction and analyses according to standard Cochrane procedures.

MAIN RESULTS

We included three trials, with 201 participants, all 50 years of age and older; none had neurological disease. All trials evaluated a form of stretching for lower limb muscle cramps. A combination of daily calf and hamstring stretching for six weeks may reduce the severity of night-time lower limb muscle cramps (measured on a 10 cm visual analogue scale (VAS) where 0 = no pain and 10 cm = worst pain imaginable) in people aged 55 years and older, compared to no intervention (mean difference (MD) -1.30, 95% confidence interval (CI) -1.74 to -0.86; 1 RCT, 80 participants; low-certainty evidence). The certainty of evidence was very low for cramp frequency (change in number of cramps per night from week zero to week six) comparing the stretching group and the no intervention group (MD -1.2, 95% CI -1.8 to -0.6; 80 participants; very low-certainty evidence). Calf stretching alone for 12 weeks may make little to no difference to the frequency of night-time lower limb muscle cramps in people aged 60 years and older (stretching group median number of cramps in the last four weeks (Md) 4, interquartile range (IQR) 8; N = 48; sham stretching group Md 3, IQR 7.63; N = 46) (U = 973.5, z = -0.995, P = 0.32, r = 0.10; 1 RCT, 94 participants; low-certainty evidence). This trial did not report cramp severity. The evidence is very uncertain about the effects of a combination of daily calf, quadriceps, and hamstring stretching on the frequency and severity of leg cramps in 50- to 60-year-old women with metabolic syndrome (N = 24). It was not possible to fully analyse the frequency data and the scale used to measure cramp severity is not validated. No study reported health-related quality of life, quality of sleep, or participation in activities of daily living. No participant in these three studies reported adverse events. The evidence for adverse events was of moderate certainty as the studies were too small to detect uncommon events. In two of the three studies, outcomes were at risk of recall bias, and tools used to measure outcomes were not validated. Due to limitations in study designs that led to risks of bias, and imprecise findings with wide CIs, we cannot be certain that findings of future studies will be similar to those presented in this review.

AUTHORS' CONCLUSIONS

A combination of daily calf and hamstring stretching for six weeks may reduce the severity of night-time lower limb muscle cramps in people aged 55 years and older, but the effect on cramp frequency is uncertain. Calf stretching alone compared to sham stretching for 12 weeks may make little or no difference to the frequency of night-time lower limb muscle cramps in people aged 60 years and older. The evidence is very uncertain about the effects of a combination of daily calf, quadriceps, and hamstring stretching on the frequency and severity of leg cramps in 50- to 60-year-old women with metabolic syndrome. Overall, use of unvalidated outcome measures and inconsistent diagnostic criteria make it difficult to compare the studies and apply findings to clinical practice. Given the prevalence and impact of lower limb muscle cramps, there is a pressing need to carefully evaluate many of the commonly recommended and emerging non-drug therapies in well-designed RCTs across all types of lower limb muscle cramps. A specific cramp outcome tool should be developed and validated for use in future research.

Investigation of chronic venous insufficiency in patients with sleep disorders due to restless legs syndrome

BACKGROUND

We aimed to investigate of chronic venous insufficiency on patients with sleep disorder due to restless legs syndrome.

METHOD

Five hundred forty-one cases on whom polysomnography was performed due to sleep disorder were evaluated retrospectively. Forty patients with restless legs syndrome were determined. They were examined by history, physical examination, and duplex ultrasonography in terms of chronic venous insufficiency. The sleep stage rates of both groups were compared (that the rate of total sleep time in polysomnography to sleep stages is expressed as minute and percentage has been defined as sleep stage rate).

RESULT

Chronic venous insufficiency was identified in 20 out of 40 patients (group 1; female, 90%). In group 2, there were patients with only restless legs syndrome but with no chronic venous insufficiency (female, 80%). The mean ages of both groups were 56.4 ± 11.8 and 54.3 ± 14.7 years. Stage 1 sleep rate in group 1 was 5% ± 2.7 and in group 2 was 8% ± 3.8 (p = 0.006). Periodic limb movement index (polysomnography finding evaluating involuntary leg movements during sleep) was 11.4 ± 17.5 in group 1, and it was 29.4 ± 37.9 in group 2 (p = 0.006).

CONCLUSION

We recommend that chronic venous insufficiency should be investigated in patients with primary restless legs syndrome diagnosis.

Effect of furosemide on muscle cramps in patients with liver cirrhosis

BACKGROUND AND AIM

Patients with cirrhosis usually experience muscle cramps of varying severity. Although diuretics have been reported to cause muscle cramps, clinical evidence is limited. Also, it has been pointed out that the use of diuretics is associated with the progression of sarcopenia in patients with cirrhosis. We conducted a questionnaire survey to clarify the effects of diuretics and skeletal muscle loss on muscle cramps.

METHODS

Overall, we enrolled 152 adults with cirrhosis in this study. Cramp questionnaires were obtained after informed consent. Study variables (demographics, physical findings, serum metabolic panel, and drugs taken that affect muscle cramps) were extracted from medical records. Body composition, including muscle volume, was analyzed using a bioelectrical impedance analysis method, and muscle strength (handgrip) was evaluated at enrollment. Cross-sectional skeletal muscle area was evaluated on computed tomography imaging at the L3 vertebral level to investigate the relationship between muscle cramps and sarcopenia.

RESULTS

The proportion of furosemide administration was higher in patients with cramping compared with those without. On a multivariate logistic regression analysis, furosemide use was a significant factor in the presence of muscle cramps. Furthermore, regarding factors contributing to muscle cramp severity, furosemide use was extracted by multivariate logistic regression analysis. In the presence or severity of muscle cramps, skeletal muscles did not show any significant difference.

CONCLUSIONS

Furosemide use for patients with cirrhosis was considered a risk factor for occurrence and severity of muscle cramps. On the other hand, skeletal muscle mass loss was not associated with muscle cramps.

Criteria in diagnosing nocturnal leg cramps: a systematic review

BACKGROUND

Up to 33% of the general population over 50 years of age are affected by nocturnal leg cramps. Currently there are no generally accepted clinical characteristics, which identify nocturnal leg cramps. This study aims to identify these clinical characteristics and to differentiate between them and the characteristics of restless leg syndrome and periodic limb disorder.

METHOD

A systematic literature study was executed from December 2015 to May 2016. This study comprised of a systematic literature review of randomized clinical trials, observational studies on nocturnal and rest cramps of legs and other muscles, and other systematic and narrative reviews. Two researchers independently extracted literature data and analyzed this using a standardized reviewing protocol. Modified versions of the Cochrane Collaboration tools assessed the risk of bias. A Delphi study was conducted to assess agreement on the characteristics of nocturnal leg cramps.

RESULTS

After systematic and manual searches, eight randomized trials and ten observational studies were included. On the basis of these we identified seven diagnostic characteristics of nocturnal leg cramps: intense pain, period of duration from seconds to maximum 10 minutes, location in calf or foot, location seldom in thigh or hamstrings, persistent subsequent pain, sleep disruption and distress.

CONCLUSION

The seven above characteristics will enhance recognition of the condition, and help clinicians make a clear distinction between NLC and other sleep-related musculoskeletal disorder among older adults.

Prevalence of cramps in patients over the age of 60 in primary care : a cross sectional study

Background

Cramps are involuntary painful muscle contractions that mainly affect older people. Cramps may cause severe pain and sleep disturbance. Little information exists on the prevalence and the main features of cramps in primary care settings. The objective of this study was to estimate the prevalence and the main features of cramps among primary care patients aged 60 years and older.

Methods

We prospectively enrolled 516 patients aged 60 years and older in a cross-sectional study at 25 general practices in Alsace – France between October 2011 and March 2012. Questionnaires were used to obtain information about demographics, cramp presence and main features, medical history, and treatment.

Results

The adjusted prevalence was 46 % (95 % CI: 38–53 %). Thirty-one per cent of the study sample reported being woken up by cramps, 15 % had cramps more than 3 times a month. Logistic regression revealed a slightly higher prevalence in the age group 65–69 years compared to 60–64 years. No significant association was observed between other age groups and prevalence, or between gender and prevalence. The main localization of cramps was in the calves (80 %). The duration since onset was 5 years or more for 58 %.

Conclusions

Cramps are common in primary care, and although only a minority of patients report suffering from cramps more than once a week, many patients report cramp-related sleep disturbance. Further studies are needed to assess risk factors and therapeutic options for patients suffering from cramps in primary care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0509-9) contains supplementary material, which is available to authorized users.

Stretching before sleep reduces the frequency and severity of nocturnal leg cramps in older adults: a randomised trial

QUESTION

In adults who experience nocturnal leg cramps, does stretching of the calf and hamstring muscles each day just before sleep reduce the frequency and severity of the cramps?

DESIGN

A randomised trial with concealed allocation and intention-to-treat analysis.

PARTICIPANTS

Eighty adults aged over 55 years with nocturnal leg cramps who were not being treated with quinine.

INTERVENTION

The experimental group performed stretches of the calf and hamstring muscles nightly, immediately before going to sleep, for six weeks. The control group performed no specific stretching exercises. Both groups continued other usual activities.

OUTCOME MEASURES

Participants recorded the frequency of nocturnal leg cramps in a daily diary. Participants also recorded the severity of the pain associated with nocturnal leg cramps on a 10-cm visual analogue scale. Adverse events were also recorded.

RESULTS

All participants completed the study. At six weeks, the frequency of nocturnal leg cramps decreased significantly more in the experimental group, mean difference 1.2 cramps per night (95% CI 0.6 to 1.8). The severity of the nocturnal leg cramps had also decreased significantly more in the experimental group than in the control group, mean difference 1.3 cm (95% CI 0.9 to 1.7) on the 10-cm visual analogue scale.

CONCLUSION

Nightly stretching before going to sleep reduces the frequency and severity of nocturnal leg cramps in older adults.

TRIAL REGISTRATION

NCT01421628.

Non-drug therapies for lower limb muscle cramps

BACKGROUND

About one in every three adults are affected by lower limb muscle cramps. For some people, these cramps reduce quality of life, quality of sleep and participation in activities of daily living. Many interventions are available for lower limb cramps, but some are controversial, no treatment guidelines exist, and often people experience no benefit from the interventions prescribed.

OBJECTIVES

To assess the effects of non-drug, non-invasive treatments for lower limb cramp.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Specialized Register (13 September 2011) using the terms: cramp, spasm, contracture, charley horse and lower limb, lower extremity, foot, calf, leg, thigh, gastrocnemius, hamstring, quadriceps. We also searched CENTRAL (2011, Issue 3), MEDLINE (January 1966 to August 2011) and EMBASE (January 1980 to August 2011) and the reference lists of included studies. There were no language or publication restrictions.

SELECTION CRITERIA

All randomised controlled trials of non-drug, non-invasive interventions trialled over at least four weeks for the prevention of lower limb muscle cramps in any group of people. We excluded, for example, surgery, acupuncture and dry-needling, as invasive interventions. We selected only trials that included at least one of the following outcomes: cramp frequency, cramp severity, health-related quality of life, quality of sleep, participation in activities of daily living and adverse outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed risk of bias and cross checked data extraction and analysis. A third author was to arbitrate in the event of disagreement. We asked the authors of five trials for information to assist with screening studies for eligibility and received four responses.

MAIN RESULTS

One trial was eligible for inclusion.  All participants were age 60 years or over and had received a repeat prescription from their general practitioner of quinine for nighttime cramps in the preceding three months. This review includes data from only those participants who were advised to continue taking quinine. Forty-nine participants were advised to complete lean-to-wall calf muscle stretching held for 10 s three times per day. Forty-eight participants were allocated to a placebo stretching group. After 12 weeks, there was no statistically significant difference in recalled cramp frequency between groups. No "significant" adverse effect was reported. Limitations in the study's design impede interpretation of the results and clinical applicability.

AUTHORS' CONCLUSIONS

There is limited evidence on which to base clinical decisions regarding the use of non-drug therapies for the treatment of lower limb muscle cramp. Serious methodological limitations in the existing evidence hinder clinical application. There is an urgent need to carefully evaluate many of the commonly recommended and emerging non-drug therapies in well designed randomised controlled trials.

Relationship between prolonged standing and symptoms of varicose veins and nocturnal leg cramps among women and men

The relationships between occupational characteristics and symptoms of varicose veins and nocturnal leg cramps and their gender differences were explored in a Korean population. The study population was 2165 workers from various occupations (55.6% female). Multiple logistic regression analyses were conducted to reveal factors related to symptoms of varicose veins and nocturnal leg cramps. The prevalence of varicose veins and nocturnal leg cramps was higher among women than men. The characteristics of standing work were different according to gender. In gender stratified analysis, the odds ratio of varicose veins was significantly high for prolonged standing for male and female workers. However, the odds ratio of nocturnal leg cramps was only significant among prolonged standing male workers. The models including gender, prolonged standing and occupations in this order presented that gender is not significantly associated with varicose veins after occupations were added to the model. Prolonged standing at work may be a more important risk factor for varicose veins and nocturnal leg cramps than biological differences between women and men. Therefore, effective interventions to interrupt or reduce prolonged standing at work should be implemented for the prevention of varicose veins and nocturnal leg cramps.

PRACTITIONER SUMMARY

This paper shows associations between occupational characteristics and symptoms of varicose veins and nocturnal leg cramps and their gender differences. These findings will contribute to knowledge of gender-specific occupational risk factors for symptoms in the distal lower extremities.

Varicose veins: a qualitative study to explore expectations and reasons for seeking treatment

BACKGROUND

Patients experience a wide range of symptoms from varicose veins and are seeking treatment from health care providers. However, there is little data on the relative effectiveness of the treatments available. Patients are therefore often confronted with a choice regarding treatment that they are ill-equipped to make. This lack of certainty and the resultant potential for variability in treatment decisions can mean that patients have expectations that are unrealistic or unfulfilled.

AIMS AND OBJECTIVES

The aim of our study was to explore patients' expectations and reasons for seeking treatment for varicose veins. Additional aims included the exploration of symptoms associated with varicose veins and their impact on quality of life.

DESIGN

Qualitative study conducted in a large NHS Trust.

METHODS

A total of 16 patients, who had been referred to a specialist vascular service for the treatment of varicose veins, were recruited. Semi-structured interviews were used to explore the patients' reasons for seeking treatment. Framework analysis was used to analyse the data from the anonymized transcripts.

RESULTS

Participants attributed a wide range of symptoms to their varicose veins, and were actively seeking treatment with the expectation that they would gain symptom relief. The symptoms attributed to their varicose veins had a significant negative impact on their quality of life and lifestyle. Improving the cosmetic appearance of their legs was seen as a secondary benefit.

CONCLUSIONS

The perceived symptoms of varicose veins can impact on lifestyle and quality of life. Patients seek treatment with the expectation of treatment outcomes that are not supported by robust clinical evidence. Appropriate education and management of such expectations are an essential step in caring for this group of patients.

RELEVANCE TO CLINICAL PRACTICE

Nurses are caring for patients with varicose veins in a range of clinical settings. When caring and providing information for this group of patients, nurses need to be aware of the impact of varicose vein symptoms and to understanding that patients may have unrealistic expectations or invalid reasons for seeking treatment.

Muscular cramps: proposals for a new classification

Muscle cramps are involuntary, painful, sudden contractions of the skeletal muscles. They are present in normal subjects under certain conditions (during a strong voluntary contraction, sleep, sports, pregnancy) and in several pathologies such as myopathies, neuropathies, motoneuron diseases, metabolic disorders, hydroelectrolyte imbalances or endocrine pathologies. There has been considerable uncertainty in the literature regarding the classification and nomenclature of muscle cramps, both because the term "cramp" is used to indicate a variety of clinical features of muscles, leading to its use as an imprecise "umbrella" term that includes stiffness, contractures and local pain, and because the spectrum of the diseases in which it appears is wide. The purpose of the present study is to propose a simple classification to provide a framework to better recognize the full spectrum of phenomenology of muscle cramps.

Symptoms in individuals with small cutaneous veins

The clinical relevance of small cutaneous veins (SCV) is still being discussed. In the Duesseldorf/Essen civil servants study, the prevalence of SCV and the individual symptoms and age-dependent changes were analysed. This cross-sectional study recruited 9935 employees; 9100 could be finally evaluated for this analysis. All volunteers were asked to fill out the questionnaire and were clinically examined. Primarily the clinical findings were documented, adapted to the Basel Study and later modified according to the CEAP classification: (a) class 0 - no visible or palpable clinical signs of venous disease, (b) class 1 - small cutaneous veins, (c) class 1 - reticular veins, (d) class 2 - varicose veins. In all, 64% of the volunteers had no signs of venous disease (class 0: age 41+/-10 years); 10% had small cutaneous veins (class 1: age 44+/-10 years). SCV was more frequent in females (25%) than in males (6%). Only 5% of those with SCV had already consulted a physician. A striking result was that individuals with SCV generally complained about more leg symptoms, of which 'leg swelling' and 'muscle cramps during the night' were the most frequent. 'Continual leg swelling' was reported by 24% of individuals with SCV as opposed to 10% of those without. 'Leg cramps' and 'restless legs' also were more often documented in individuals with SCV (29% vs 22% and 10% vs 7%). These findings were all statistically significant (p<0.001). After adjusting for age and sex, though, there were few or no differences between groups (leg swelling: odds ratio (OR) 1.3; 95% confidence interval (95% CI) 1.1-1.6 and cramps: OR 1.1; 95% CI 0.9-1.3). A gender separate estimation of the rates showed that females suffer more often from any symptom. Regarding 'leg cramps', 'restless legs' and 'itching', the OR were not different for females and males. For 'leg swelling' the age-adjusted OR were significant for women (OR 1.4; 95% Cl 1.1-1.7) compared with men (OR 1.1; 95% Cl 0.7-2). Individuals with SCV seem to have more symptoms compared with healthy people. However, this analysis shows that age and sex are the most relevant explanations for these symptoms.