Management of Leg Flexion in Patients with Muscle Spasms or Stiffness
Avoid prolonged positioning of joints at the end range of flexion, particularly full hip, knee, or ankle flexion while sitting, as this can exacerbate muscle overactivity and promote abnormal movement patterns. 1
Key Positioning Principles
What to Avoid
- Do not maintain prolonged positions with joints at end-range flexion (e.g., full hip, knee, or ankle flexion while sitting), as this promotes muscle overactivity, pain, and fatigue 1
- Avoid stretching the hamstring muscle group beyond the comfortable preoperative range, as this may increase risk of sciatic nerve injury 1
- Limit hip flexion to 90° maximum when positioning patients, particularly in lithotomy or seated positions, to reduce risk of both sciatic and femoral neuropathy 1
What to Implement
- Encourage optimal postural alignment at rest and during function with even weight distribution in sitting, transfers, standing, and walking to normalize movement patterns 1
- Support the affected limb when at rest using pillows or furniture to take the weight off the limb when sitting or lying down, reducing muscle overactivity 1
- Promote therapeutic resting postures rather than allowing "nursing" of the affected limb, which can lead to learned non-use 1
Active Management Strategies
Movement-Based Interventions
- Grade activities to progressively increase the time the affected limb is used with normal movement techniques within functional activities 1
- Engage patients in tasks promoting normal movement, good alignment, and even weight-bearing, such as transfers, sit-to-stand, standing, and perch sitting during personal care or kitchen tasks 1
- Implement muscle relaxation strategies including diaphragmatic breathing and progressive muscular relaxation to reduce muscle overactivity 1
Early Mobilization
- Institute active or passive mobilization and muscle training early to prevent muscle deconditioning 1
- Use positioning, splinting (cautiously), passive mobilization, and muscle stretching to preserve joint mobility and skeletal muscle length in patients unable to move spontaneously 1
Critical Pitfalls to Avoid
Splinting Concerns
Avoid routine splinting as it may prevent restoration of normal movement and function. Specific problems include: 1
- Increasing attention and focus to the affected area, potentially exacerbating symptoms
- Increasing accessory muscle use and compensatory movement strategies
- Causing immobilization leading to muscle deconditioning
- Promoting learned non-use
- Increasing pain
- Serial casting for fixed functional dystonia has been associated with worsening symptoms and complex regional pain syndrome 1
Positioning Errors
- Do not extend the hip beyond the normal comfortable range (e.g., hyperlordosis in supine position), as this may increase femoral neuropathy risk 1
- Avoid prolonged pressure on peripheral nerves, particularly the peroneal nerve at the fibular head and radial nerve in the spiral groove 1
Pharmacological Considerations for Specific Conditions
When muscle spasms are severe or refractory to positioning strategies:
- For leg cramps with presyncope symptoms, use physical counterpressure maneuvers (leg crossing with muscle tensing or squatting) while ensuring the patient is in a safe position 2
- For leg cramps associated with liver disease, consider baclofen starting at 10 mg/day with weekly increases up to 30 mg/day 2
- For stiff-person syndrome or similar conditions, drugs enhancing GABA neurotransmission (diazepam, baclofen, vigabatrin) provide relief of muscle rigidity and spasms 3, 4
Monitoring and Adjustment
- Employ anxiety management and distraction techniques when undertaking tasks, as these can be helpful across all symptom types 1
- Consider video recording interventions (with consent) to demonstrate changeability, highlight successes, and serve as reference points for replicating successful strategies 1
- Address associated problems of pain and hypersensitivity as part of the comprehensive management approach 1