A Solution to Nocturnal Leg Cramps

4/9/2011: We (Paul and Kitty Antonik Wakfer) are pleased to be able to report to everyone (at least those who read this) that after more than 4 years of increased nocturnal leg cramps, we have discovered a solution that has almost totally eliminated them for Kitty - and likely will do so for some (?many?) others.

Kitty's leg cramp history

Night-time leg cramps have been a painful nuisance to me for more than 25 years, going back at least to my late 30s. Being abruptly awakened from a sound sleep and having to quickly stand up, put weight on the affected leg and either bend my knee or flex my foot - depending on the location - is unpleasant to put it mildly. And the frequency of these cramps increased sometime during the past few years.

I read up on leg cramps back in 2006 (searching general "scholarly" sources) and we reviewed all the known possible causes - though "idiopathic" was and still is the reason provided in journal articles for most occurrences. I get plenty of fluids, my serum electrolytes are well within normal - we did try modifying potassium and sodium salt intakes several times without any clearly reproducible change in the cramp frequency - and my blood pressure is definitely not high. The cramps never happened during the day when I was up and about (except sometimes when I attempted certain purposeful leg stretches), only after I'd laid down to go to sleep and sometimes even before falling asleep. I do know that sometimes extending a foot (pointing my toes) in my sleep or even just to enjoy a stretch while settling down would initiate a cramp in my calf. Also there were times I'd experience a painful twisting-like cramp in one or the other knee (in recent years more often after strenuous dancing); and then there were the rare (thankfully) times of very intense upper thigh cramps that were the ones of longest duration.

The last couple years the cramps seemed to be worse in frequency and intensity, spurring renewed investigation into the problem. Paul reasoned that there was some relationship to my lying down since they never happened while I was sitting in bed reading before he finished his shower and came to bed. Considering the foot extension situation, he rigged up a type of foot of the bed wedge which would keep my feet from being naturally pointed forward by the covers (the covers were directed up over the wedge rather than pushing on my toes) when on my back and also when on my side, if I did not draw my knees toward my chest. Unfortunately this last is when the cramps would occur.... so although it helped somewhat this was not a total solution.

Renewed research, analysis & conclusion

More thought on my cramps came about when we began a review of anatomy and physiology in regards to a rather recent tendency for Paul to retain fluid (edema) in his left leg and particularly after modifications for our "new" standing desks. Blood pressure in one's legs is related to the height difference between the heart and the point of interest in the legs, due to the hydrostatic pressure difference (13.6 mm - about 1/2" of water/blood - equals 1 mm of mercury - measurement for BP). The taller a person is the greater the rise in blood pressure in his/her legs relative to what is measured at the heart (in the arm at the level of the heart). Paul has some mild varicosities in both legs (far worse in his left leg where he had his mysterious leg syndrome for so many years - now over 3 years gone; the last episode in Jan 2008 between visits to the infectious disease specialist whose bill is the subject of Focus article - http://selfsip.org/focus/healthcareexample.html - and containing links to earlier symptom descriptions). The edema is a result of the normal increased blood pressure in the legs when standing coupled with poorly functioning venous leg valves. Wearing support hose has become more of a practice for Paul now that we have our stand-at desks along with both of us moving our legs very frequently - often just walking in place to music as we read or type at our computers.

Thinking about the significant difference in one's legs between standing and reclining, and that difference being the only precipitating factor left that we could think of, Paul suggested that a drop in the blood pressure in my legs when I laid down might precipitate the cramps - the Sherlock Holmes logic: "when you have eliminated the impossible, whatever remains, however improbable, must be the truth". Therefore if my legs were actually at a lower position than my heart, the cramps might not occur or at least less often/severely. With no idea about a mechanism for this in mind, Paul figured that it would likely require a fair blood pressure difference to make any noticeable improvement. So on 3/11 we raised the head of our bed 7", a result of the top frame corners being placed atop each of 2 11-3/4" 6x6 block that we had left from modifying the arrangement of Paul's stand-at desk.

Results & Trial Test

Going to sleep in the bed elevated like this was a bit strange and neither of us slept as soundly as when flat. But the big news was that I experienced NO LEG CRAMPS at all!! That was the first night I could remember in ages not having any leg cramps. We slept this way for 2 more nights and again no leg cramps for me. For Paul, we put some pillows at the foot of his bed to reduce the amount of leg dependence that occurred with that much head elevation, since his leg edema was now not completely disappearing overnight.

Since neither of us found sleeping tilted that much to be really restful, we dropped the tall 6x6s on their sides and added a 4x4, making the total elevation of the head corners at 4" (don't forget that lumber these days is always 1/2" narrower than the nominal size purchased). Even with that very mild elevation of the head of the bed, I still had no leg cramps that night or for the next week. Paul was satisfied that we'd found the solution to my leg cramps and the pillows at the bottom of his side of the bed making a ramp for his legs were tolerable but he was considering sleeping with his head at the foot of the bed....

I thought that before I could reasonably let others know of my "success", I would need to see what would happen if I again slept flat. Well on Monday night, 3/21/2011 we took the blocks out from under the bed corners and let it rest once again on its head end casters. And that night I again had 4 or 5 instances (I lost count in my sleepiness) of leg cramps. I was not at all interested in a second night, so on 3/22 the head of the bed went back up to its extra 4" height.

Final Bed Arrangement

Paul with all time highest total score Cooperative ScrabblePaul with all time highest total score Cooperative ScrabbleTo make the sleeping arrangement better so as to promote fluid drainage in Paul's legs while he sleeps and because he is more comfortable in a flat position rather than V-shaped with his legs up, I also changed the top sheeting so that we each have separate single top sheets and separate blankets. His were arranged with his head at the "foot" of the bed (about 5" lower than the very head of the bed, because the foot caster pivot point is a ways "up" from the foot of the bed). The photo I took of us lying in our respective positions gives an idea of how it looks, along with the close-up of the block arrangement.

The angle is relatively slight - only 4" in 64" length of bed - but it is oh so effective in virtually eliminating my leg cramps. Not having the cramps has made for a truly restful night's sleep - even if we don't know exactly the full mechanism behind it. (Awaking with the need to urinate - caused by my intentionally drinking a full mug of tea along with my night pills as one of my means of reducing any tendency to UTI (urinary tract infection) - is gentle and does not happen more than once.)

Nocturnal Leg Cramps in Mainstream Medicine

Interestingly, but after doing all of the above, I found "Nocturnal Leg Cramps", a review paper by Monderer, Wu and Thorpy in the January 2010 issue of Current Neurology and Neuroscience Reports (PMID20423227). Under Treatment, is the statement, "Other nonpharmacologic measures that have been proposed include raising the head of the bed and raising the feet on pillows, although neither of these methods has been evaluated formally." A great deal of attention is given prior to this regarding evaluation and even more afterward to pharmacological treatments. The conclusion of the paper is short and begins:

"Nocturnal leg cramps are a common problem that may adversely affect sleep. Although most cases are idiopathic, nocturnal cramps may be associated with a wide range of underlying conditions, many of which are treatable. Although benign and possibly worthwhile for some, nonpharmacologic methods of preventing leg cramps have not been proven effective for most people."

Note the logic disconnect between the first statement regarding raising the head of the bed (or raising the feet on pillows) with "neither of these methods has been evaluated formally" and the conclusion that "nonpharmacologic methods of preventing leg cramps have not been proven effective for most people." The authors appear to be equating "unproven" with "unevaluated", whereas the attributes of proven/unproven should not even apply until experimentation has been done. The bias towards pharmacologic treatment is obvious with the last sentence in the Conclusion: "Additional, larger studies are needed to identify a medication that is both safe and effective in treating and preventing nocturnal leg cramps."

It appears to me that the authors of this paper are not interested in anything but phamacologic treatments. And given the fact that pharmaceutical companies fund much of the health related research, it can be seen that none of them would fund anything that is not related to a drug. However maybe an adjustable bed manufacturer would recognize a market potential for a bed with hydraulics at the foot and head of a bed to enable easy raising/lowering of either end depending on the customer's needs. (From my search recently online I do not see this feature, but mostly various back curvature/raising arrangements, some with ability to notch up the knees, that enables the user to sit up in bed, supposedly for respiratory/gastric reflux reasons and/or simply to read or watch TV.) A well-designed study on the actual effects in the population with leg cramps of raising the bed head should produce good data. Tempur-Pedic, Legget and Platt, Sleep-Comfort and Select Comfort (our adjustably inflatable bed in AZ), etc - are you listening?!!

Beauty of restful sleep

So now it's been over 4 weeks since we first elevated the bed head, and 3 weeks since the one night of again flat with much cramp-interrupted sleep. The occasional cramp occurs when I have been sleeping in a definite fetal position (mostly done if I am cold and indicates to me need for a/additional blanket) or have done a strong toe-pointing stretch, but both instances have truly been rare, compared to previously. I am convinced that the described slight decrease of my legs from a horizontal position equal to the level of my heart has relieved me of what had become a very bothersome and potentially health damaging situation due to decrease in restful sleep.

BTW Paul no longer sleeps with his head at the foot of the bed. After the purchase of several good quality (just below) knee-high support hose, which he has taken to wearing daily, he can sleep with his feet slightly lower and still have edema-free feet and legs in the morning. This is very good since Paul was not sleeping as well "upside-down" and neither of us liked this arrangement much for togetherness - too much like single beds :)

6/9/2011 UPDATE: The above was written before our return to Ontario at the end of April for the 6 months we spend there (Paul's legal residence) each year. Kitty was concerned that arranging our bed as done above in Arizona would be problematic since it is only a double bed and the room is much smaller. Therefore no changes were made and she simply waited to see what would happen. At this writing she has had only a few nights with leg cramps and only once were they severe enough to cause her a poor night's sleep. She has noticed that the severity of cramps appears to coincide with strenuous leg activity (at least in Ontario), like the night after timed step climbing was done. Paul's adjustment of potassium supplementation in Kitty's meal cocktail as a method to prevent/ameliorate these cramps continues to be a challenge since at-home blood electrolyte measurement is not available. Unless the situation worsens, the bed in Ontario will remain flat.

10/5/11 UPDATE: After the middle of June, when night leg cramps for Kitty became annoying, she and Paul raised the head of the bed at the cottage similarly as is the arrangement for the larger Arizona bed. Since then leg cramps have been infrequent for Kitty and both she and Paul do not find the head elevation to inhibit their sleeping. Interestingly though is that during the one week we spent at the end of July in Michigan in a motel with a level bed, Kitty did not experience any nocturnal leg cramps.


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