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Calf Stretching Prophylaxis for Nocturnal Cramps—Reply

Calf Stretching Prophylaxis for Nocturnal Cramps—Reply In reply Dr Daniell believes that existing data support the efficacy of prophylactic calf stretching to prevent the development of nocturnal leg cramps. This belief rests largely on a 1979 letter to the editor of the New England Journal of Medicine, in which Dr Daniell reported that 44 adults instructed in calf stretching before bed “all reported cure within a week.”1(p216) This trial was uncontrolled and impossible to assess because of the letter's necessary brevity. Dr Daniell is right that his letter is often cited by others as justification to offer prophylactic stretching to patients, but we are unaware of authors who have added experience of their own to support the practice. In 2005, Coppin et al2 reported a peer-reviewed 2 × 2 factorial randomized controlled trial comparing Dr Daniell's stretching regimen to control leg movements that provided minimal stretch to calf and foot muscles. All 191 subjects (from 28 British family practices) were current quinine users who were additionally randomized to continue or discontinue their quinine therapy. This was a pragmatic trial. Subjects continued their assigned interventions for 6 weeks and then chose for themselves to continue those interventions or not for another 6 weeks. At 12 weeks they reported their recollection of the number of cramps over the prior 4 weeks. Not only was there no significant difference in cramp rates related to the stretching recommendation, there was not even a trend to benefit (1.95 more cramps in 4 weeks [95% CI, −3.01 to 6.90] [P = .44]). Two systematic reviews include the study by Coppin et al.2 The first perceived potential bias from limited blinding (though this would presumably favor the intervention) and from potential benefit to the sham exercise.3 The second review did not share these concerns but rated the risk of bias high largely because the intervention was not obligatory during the final 6 weeks of the trial.4 This would bias against a demonstration of efficacy but mirrors patient interactions in the real world. Although there will certainly be clinicians, including Dr Daniell, who believe that calf stretching exercises prevent muscle cramps, currently, the data are simply not there to support the practice. Back to top Article Information Correspondence: Dr Garrison, Therapeutics Initiative, University of British Columbia, 307-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada (scott.garrison@ti.ubc.ca). Financial Disclosure: None reported. References 1. Daniell HW. Simple cure for nocturnal leg cramps. N Engl J Med. 1979;301(4):216449985PubMedGoogle Scholar 2. Coppin RJ, Wicke DM, Little PS. Managing nocturnal leg cramps—calf-stretching exercises and cessation of quinine treatment: a factorial randomised controlled trial. Br J Gen Pract. 2005;55(512):186-19115808033PubMedGoogle Scholar 3. Katzberg HD, Khan AH, So YT. Assessment: symptomatic treatment for muscle cramps (an evidence-based review): report of the therapeutics and technology assessment subcommittee of the American academy of neurology. Neurology. 2010;74(8):691-69620177124PubMedGoogle ScholarCrossref 4. Blyton F, Chuter V, Walter KE, Burns J. Non-drug therapies for lower limb muscle cramps. Cochrane Database Syst Rev. 2012;1:CD00849622258986PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Calf Stretching Prophylaxis for Nocturnal Cramps—Reply

Archives of Internal Medicine , Volume 172 (12) – Jun 25, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.1971
Publisher site
See Article on Publisher Site

Abstract

In reply Dr Daniell believes that existing data support the efficacy of prophylactic calf stretching to prevent the development of nocturnal leg cramps. This belief rests largely on a 1979 letter to the editor of the New England Journal of Medicine, in which Dr Daniell reported that 44 adults instructed in calf stretching before bed “all reported cure within a week.”1(p216) This trial was uncontrolled and impossible to assess because of the letter's necessary brevity. Dr Daniell is right that his letter is often cited by others as justification to offer prophylactic stretching to patients, but we are unaware of authors who have added experience of their own to support the practice. In 2005, Coppin et al2 reported a peer-reviewed 2 × 2 factorial randomized controlled trial comparing Dr Daniell's stretching regimen to control leg movements that provided minimal stretch to calf and foot muscles. All 191 subjects (from 28 British family practices) were current quinine users who were additionally randomized to continue or discontinue their quinine therapy. This was a pragmatic trial. Subjects continued their assigned interventions for 6 weeks and then chose for themselves to continue those interventions or not for another 6 weeks. At 12 weeks they reported their recollection of the number of cramps over the prior 4 weeks. Not only was there no significant difference in cramp rates related to the stretching recommendation, there was not even a trend to benefit (1.95 more cramps in 4 weeks [95% CI, −3.01 to 6.90] [P = .44]). Two systematic reviews include the study by Coppin et al.2 The first perceived potential bias from limited blinding (though this would presumably favor the intervention) and from potential benefit to the sham exercise.3 The second review did not share these concerns but rated the risk of bias high largely because the intervention was not obligatory during the final 6 weeks of the trial.4 This would bias against a demonstration of efficacy but mirrors patient interactions in the real world. Although there will certainly be clinicians, including Dr Daniell, who believe that calf stretching exercises prevent muscle cramps, currently, the data are simply not there to support the practice. Back to top Article Information Correspondence: Dr Garrison, Therapeutics Initiative, University of British Columbia, 307-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada (scott.garrison@ti.ubc.ca). Financial Disclosure: None reported. References 1. Daniell HW. Simple cure for nocturnal leg cramps. N Engl J Med. 1979;301(4):216449985PubMedGoogle Scholar 2. Coppin RJ, Wicke DM, Little PS. Managing nocturnal leg cramps—calf-stretching exercises and cessation of quinine treatment: a factorial randomised controlled trial. Br J Gen Pract. 2005;55(512):186-19115808033PubMedGoogle Scholar 3. Katzberg HD, Khan AH, So YT. Assessment: symptomatic treatment for muscle cramps (an evidence-based review): report of the therapeutics and technology assessment subcommittee of the American academy of neurology. Neurology. 2010;74(8):691-69620177124PubMedGoogle ScholarCrossref 4. Blyton F, Chuter V, Walter KE, Burns J. Non-drug therapies for lower limb muscle cramps. Cochrane Database Syst Rev. 2012;1:CD00849622258986PubMedGoogle Scholar

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jun 25, 2012

Keywords: muscle cramp,night time,stretching exercises

References