Muscle Spasm or Cramp
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Muscle spasm or cramp is a painful muscular contraction lasting generally from a few seconds to minutes, but some may persist for many hours. Cramp most often occurs in a single muscle of the foot or calf. Cramps are thought to be due to hyper-excitability of the intramuscular portion of the motor nerve. Muscle cramps may be followed by residual tenderness. They can occur spontaneously, after minor muscle movement or after forceful contraction.
- Appropriate assessment to identify cause and severity of symptoms
- Cramps can be idiopathic e.g. occurring after or during exercise e.g. nocturnal cramps
- In the Palliative Care setting cramps are often pathological.
Pathological causes of cramp include:
Metabolic dysfunction
- Acute dehydration e.g. due to diarrhoea, vomiting or sweating
- Hypocalcaemia
- Hypomagnesaemia
- Uraemia
Neuromuscular problems
- Nerve root damage or compression e.g. caused by tumour or radiotherapy
- Part of a para-neoplastic syndrome
- Peripheral neuropathy
- Painful bone metastases or pathological fractures (often associated with muscle spasm which serves to protect and splint the area)
- Meningeal metastases
- Disease or damage to the brain or spinal cord can cause spasticity in the limbs which may be associated with painful muscle spasms.
Note: In patients with advanced cancer cramps in the upper arm/s should alert the healthcare provider to a possible underlying neurological cause.
Drugs
- Diuretics with fluid loss
- Prednisone
- Amitriptyline
- B stimulants e.g. salbutamol
- Medroxyprogesterone
- Amphotericin
- Cimetidine
- Chemotherapeutics e.g vincristine, cisplatin
Emotional causes
Explanation to patient and family
Explain to the patient and the family that cramp is a universal experience, but common in the Palliative Care setting and is treatable. Discuss probable underlying causes and contributing factors to the cramp/spasm and treatment options.
Correct reversible factors
- Correct metabolic abnormality
- If possible stop or reduce dose of drug/s contributing to the cramps
- If there is an associated neurological condition, treatment should be aimed at the underlying cause e.g. nerve compression. If possible treat nerve infiltration or compression.
- Treat any associated bone metastases e.g. radiation therapy
- Reverse any dehydration and manage any cause of acute fluid loss
- Correct electrolyte imbalances
Non-pharmacological interventions
- Forced dorsiflexion of the foot for 5-10 seconds stretches both the calf and foot muscles. This can be repeated as needed
- If possible the patient should try to stretch their own muscles against a wall or using a “theraband”. Stretch the affected muscle regularly (both passive and active stretching) once or twice a day
- Massage and relaxation therapy
- Refer to physiotherapist if necessary
Pharmacological interventions
First line therapy
- Diazepam 5-10 mg nocte for nocturnal or resistant cramp
- Baclofen 10-20 mg bd-tds
- Phenytoin or carbamazepine
Second line therapy
- Dantrolene 25 mg od – 100 mg qid. Start at 25 mg od and increase by 25 mg increments to max 100 mg qid. This can be used in conjunction with diazepam or baclofen. It acts peripherally and so causes less drowsiness.
- Quinine sulphate 200-300 mg nocte for nocturnal foot and calf cramps
- Corticosteriods may be useful for neuropathic syndromes
- Other options include: Calcium channel blockers e.g. diltiazem, Vit B Complex, diphenhydramine
Involvement of the interdisciplinary team
- Cramp can be exacerbated or caused by anxiety. If diazepam alone does not reduce anxiety, refer for counselling.
- Consider breathing relaxation and retraining if hyperventilating
- Physiotherapy for myofacial trigger release