Last year we published a randomised trial demonstrating that stretching before sleep reduces the frequency and severity of nocturnal leg cramps in older adults (Hallegraeff et al 2012). The results of that study align perfectly with the uncontrolled study of Daniell (1979). In a recent letter to this journal, Daniell and Pentrack (2013) proposed an alternative stretching procedure for preventing nocturnal leg cramps. Some major differences can be identified between their new stretching procedure and the procedure used in our study.
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In 2012, our randomised trial demonstrated that stretching before sleep reduces the frequency and severity of nocturnal leg cramps in older adults.1 These episodic cramp attacks are characteristic: painful, sustained, involuntary muscle contractions of the calf muscles, hamstrings or feet. The sharp and intense pain may last from seconds to several minutes, accompanied by firm and tender muscles, and in some cases, with plantar flexion of feet and toes.2–5 In his letter, Garrison argues that prophylactic stretching is unlikely to prevent nocturnal leg cramps.
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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.
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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.
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The objective of this thesis is to make a first step towards prevention of the progression of chronic venous disease and the development of a first venous leg ulcer in chronic venous disease patients. The aim is to identify chronic venous disease patients at risk of developing more severe clinical stages, provide insight in the lifestyle related risk factors, and provide an overview of current chronic venous disease care in the Netherlands.
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Phantom limb pain following amputation is highly prevalent as it affects up to 80% of amputees. Many amputees suffer from phantom limb pain for many years and experience major limitations in daily routines and quality of life. Conventional pharmacological interventions often have negative side-effects and evidence regarding their long-term efficacy is low. Central malplasticity such as the invasion of areas neighbouring the cortical representation of the amputated limb contributes to the occurrence and maintenance of phantom limb pain. In this context, alternative, non-pharmacological interventions such as mirror therapy that are thought to target these central mechanisms have gained increasing attention in the treatment of phantom limb pain. However, a standardized evidence-based treatment protocol for mirror therapy in patients with phantom limb pain is lacking, and evidence for its effectiveness is still low. Furthermore, given the chronic nature of phantom limb pain and suggested central malplasticity, published studies proposed that patients should self-deliver mirror therapy over several weeks to months to achieve sustainable effects. To achieve this training intensity, patients need to perform self-delivered exercises on a regular basis, which could be facilitated though the use of information and communication technology such as telerehabilitation. However, little is known about potential benefits of using telerehabilitation in patients with phantom limb pain, and controlled clinical trials investigating effects are lacking. The present thesis presents the findings from the ‘PAtient Centered Telerehabilitation’ (PACT) project, which was conducted in three consecutive phases: 1) creating a theoretical foundation; 2) modelling the intervention; and 3) evaluating the intervention in clinical practice. The objectives formulated for the three phases of the PACT project were: 1) to conduct a systematic review of the literature regarding important clinical aspects of mirror therapy. It focused on the evidence of applying mirror therapy in patients with stroke, complex regional pain syndrome and phantom limb pain. 2) to design and develop a clinical framework and a user-centred telerehabilitation for mirror therapy in patients with phantom limb pain following lower limb amputation. 3) to evaluate the effects of the clinical framework for mirror therapy and the additional effects of the teletreatment in patients with phantom limb pain. It also investigated whether the interventions were delivered by patients and therapists as intended.
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Objective reduction of physical activity (PA) during pregnancy is common but undesirable, as it is associated with negative outcomes, including excessive gestational weight gain. Our objective was to explore changes in five types of activity that occurred during pregnancy and the behavioural determinants of the reported changes in PA. Design we performed a secondary analysis of a cross sectional survey that was constructed using the ASE-Model – an approach to identifying the factors that drive behaviour change that focuses on Attitude, Social influence, and self-Efficacy. Participants 455 healthy pregnant women of all gestational ages, receiving prenatal care from midwifery practices in the Netherlands. Findings more than half of our respondents reported a reduction in their PA during pregnancy. The largest reduction occurred in sports and brief rigorous activities, but other types of PA were reduced as well. Reduction of PA was more likely in women who considered themselves as active before pregnancy, women who experienced pregnancy-related barriers, women who were advised to reduce their PA, and multiparous women. Fewer than 5% increased their PA. Motivation to engage in PA was positively associated with enjoying PA. Key conclusions and implications for practice all pregnant women should be informed about the positive effects of staying active and should be encouraged to engage in, or to continue, moderately intensive activities like walking, biking or swimming. Our findings concerning the predictors of PA reduction can be used to develop an evidence-based intervention aimed at encouraging healthy PA during pregnancy.
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