AMJ, Vol. 5, N.

2, April, 2007

IMPACT OF STRETCHING EXERCISES PROTOCOL ON REDUCTION

OF MUSCLE CRAMPING DURING HAEMDIALYSIS, AMONG
CHRONIC RENAL FAILURE PATIENTS'
Magda Mohamed 1, Amal Ahmed 2 and Shalabia Abo Zead3
1

Lecturer. Adult Nursing, Faculty of Nursing, Assiut University.

Lecturer. Adult Nursing, Faculty of Nursing, Assiut University.
3
Lecturer. Adult Nursing, Faculty of Nursing, Assiut University.
--------------------------------------------------------------------------------------------SUMMARY
2

Background and Purpose:Haemdialysis patient are susceptible to muscle cramps,

both during dialysis sessions as well as in the interdialytic interval, these cramps
are often very painful, disruptive to dialysis management & adversely affect quality
of life. There no well defined mean of preventing or treating these cramps.
Exercises have been used with apparent success in some patient. Exercises are very
important element in the overall health of people at any age. Stretching exercises
may be the best measure to reduce or prevent cramps from occurring so the
present study was designed to determine the effect of a stretching exercises
protocols on reduction of leg cramp during haemdialysis among chronic renal
failure patients' .Quasi- experiment research design was applied .this study was
conducted in kidney dialysis department of Assuit University hospitals .the
subjects of this study consists of 60 patient with muscle cramps during
hemodialysis. three tools included in the study ,tools of socio demographic data
,tools of patient information about muscle cramps and management & tool of
evaluated patient knowledge & skills after performance exercises .
Results: there was lack of knowledge & skills related to muscle cramps before
nursing instruction protocol. But there was statistical significant difference after
performance of exercises .it was found also that high significance difference
between before and after performance of exercises.
Conclusions: the importance of performance exercises for patient undergoing
dialysis to prevent cramps. there is clearly a need for effective education regarding
recognition ,individual patient need and appropriate intervention strategies in
muscle cramps in dialysis patient and nurses, in partnership with patient ,relatives
and careers and other health professional can help to empower the individual to
mange their cramps .
Key Words: Stretching exercises, Muscle cramps, Dialysis

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Magda Mohamed et al,.

INTRDUCTION
In haemdialysis (HD) patients, painful involuntary muscular contractions,
called cramps & found typically in the lower extremities, are common, but muscles
of the hand, arm, & abdomen may be affected to sever cramping often results in
early termination of dialysis. This cramp is characterized by uncomfortable
sensation usually in the extremities (leg), but this condition is found commonly
amongst end stage renal disease & diabetic patient .for example, uremic, polneuro
pathy, which is the most common neuropathy, is a dysfunction of the peripheral
nervous system induced by uremic symptoms develops as the patient. Most
commonly, HD patients complaint of waking in the night with sever pain due to
cramps, which interferes with functioning in normal life, but may occur at any
time.(1), (2)
Muscle cramps generally result from overexertion & dehydration when you
dont have enough fluid in your system; it leads to an electrolyte imbalance that
causes your muscle to cramp up. Electrolytes are minerals such as sodium,
magnesium, calcium & potassium that help the cells to function normally. The
main electrolytes affecting muscle cramping are potassium, sodium & calcium. (3),
(4)

A muscle cramp or (charley horse) is a transmit, involuntary episode of

painful contraction or tightening of a muscle that comes on suddenly & lasts from a
few seconds to several minutes. The pain localized to one muscle group usually
unilateral & most affect the calf & foot while you are lying in bed or while you are
exercising.(5)
Incidence of leg cramps 20%-62% of people undergoing dialysis reported
leg cramps, symptoms disappear after a kidney transplantation (5) also,
Approximately one third of the patient over 60 years & half of the patient over 80
years suffer from cramp at rest. Forty percent of people with leg cramp have more
than three episodes per week & 6% have episodes at least once every 24 hours(6), (7)
Other study reported that muscle cramps occur in 33% -86% of patients undergoing
haemdialysis (8) Also Anther study in cramp reported an incidence of 7.3 % in
Children older than eight, the incidence increase at 12 Year old and Peaked
at age 16-18. (7)
The nurse plays an extremely important role in teaching the patient with
end stage renal disease .there is a vast amount of information the patient & family
need to understand about renal failure in order to maintain health & avoid
complication associated with renal failure. Because of the extensive teaching
needed by these patients, the community health nurse & dialysis nurse provide on
going education & reinforcement of previous teaching. It is important for primary
care physicians & nursing to educate patient about the non drug management. (9).
Non drug management is the first line treatment for people with leg cramps.
Passive stretching & massage of the affected muscles can relieve an acute

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cramp attack. Passive stretching should be performed with active contraction of the
opposing muscle (e.g. in cramp affecting the calf, dorsiflex the ankle while at
extending the knee). Regular stretching of the calf muscle (three times daily) may
prevent leg cramps. Stretching the calf muscles before going to bed may help some
people. Although there are no controlled trials stretching exercises. Stretching the
calf muscles is recommended as an initial treatment strategy for all people (10), (11),
(12)

other non drug treatment include raising the foot or the head of the bed, &

transcutaneous electrical stimulation of affected muscle, but studies of their of their

efficacy have not been published. Using a pillow to prop the feet up in bed or
hanging the feet over the end of the bed while sleeping in the prone position can
help maintain dorsiflexion & may offer symptom relief (13), (14).
Aim of the study:
The aim of this study is to assess the impact of stretching exercises
protocols on reduction of leg cramp during haemdialysis among chr. RF patients.
Subject & methods
Research design:
Quasi experimental research design was used to conduct this study .
Research setting:
The present study was conducted at "The Kidney Dialysis Unit" of Assiut
University Hospital. The unit is a separate building serving 400 patients at a shift
with a sum of 24 patients (3 shifts). It consists of two floors. The first floor
includes 10 rooms divided as following: one room for ultrasound, on room for
nurses and another for physicians, also there are water treatment rooms, office
room, store room, oxygen therapy room, and room for medications of patients with
chronic renal failure.
Also the first floor has two halls, one of them includes 14 beds and the
other one includes 17 beds for haemodialysis patients using thirty one machines
working for 18 hours. 10 beds serve for peritoneal dialysis patients. This floor
includes an Intensive Care Unit.
The second floor consists of two rooms for staff members, investigation
room, and room for head of the department, and second room for secretary.
Sample:
A sample included 60 adult patient including both sexes, the sample
selected according to the following criteria, age between 18-65years, confirmed
diagnosis of chronic renal failure, conducting haemdialysis & free from other
chronic diseases and orthopedic problems and accepted to participate in the study.
Tools fore data collection:

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Magda Mohamed et al,.

A structured interview was designed and utilized to collect the necessary

data to achieve the study objectives. These tools were tested by piloted study taken
from dialysis unit.
This tool is divided into three parts:
Part I: interviewing questionnaire sheet was included socio-demographic data such
as age, education , marital states, occupation , it also included items related to the
history of dialysis such as duration of dialysis \ hours ,number of dialysis every
week , and duration of disease
Part II: Concerned with information about patient knowledge toward muscle
cramp. Its included: definition of muscle cramp, causes, sites of cramp, types of
pain, duration of pain and method used to reduce cramp (stretching leg exercises)
Part III:
Concerned with exercises used by patient to reduce muscle cramp such as:
knowledge about exercises needed to relieve leg cramp, importance of exercises,
application of exercises every day, and number of cramp after performed exercises
as well as a, observational checklist to assess patient performance related to
performance of stretching leg exercises This tool was used pre-protocol assessment
and post protocol evaluation.
Procedure:
Permission to conduct the study was taken from hospital responsible
authorities after explanation of the aim of the study .Data collection tools were
developed based on review of relevant literature. Pilot study was done to test the
questionnaires content validity. The study was carried 10 patient to ensure the
clarity of the questions .All patient included in the study were informed about the
aim of the study and all of them gave informed consent before engaging in the
study .
Determine the patient readiness to learn and begin interview to collect
socio- demographic data, patient knowledge about disease and how to reduce
cramp.
Nursing instruction was developed on patient need assessment. The content
of the protocol was revised and modified based on the expertise comments .it was
written in Arabic language .the knowledge contained in the protocol covered the
following steps of stretching leg exercises:
During attack:
Perform straighten the leg. Flex the foot up ward the knee or garb the toes and pull
them toward the knee .Apply walking or shaking the affected leg, then elevating it
after dialysis .use warm bath or ice pack, if soreness persists.
During dialysis:
perform active contraction of the opposing muscle (e.g. in cramp affecting
the calf , dorsiflex the ankle whilst extending the knee ).Apply regular stretching
the calf muscle per 1 hour a bout 5 minute exercise. Apply stretching the calf
muscle before going to bed. Use raising the foot or the head of the bed & pillow to
prop the feet up in bed hanging the feet over the end of the bed.
While sleeping in prone position:
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AMJ, Vol. 5, N. 2, April, 2007

Help maintain the foot dorsiflexion.Support compression hosiery of the foot

Lean forward on to a wall with the soles of your flat on the ground. Every day
teach 10 patient, the patient is divided into 2 session, every session contain 5
patient, patient teaching will individualized, demonstration will be done by the
researcher and redemonstration will be done by the patient under supervision of the
researcher after teaching, duration of every session take 30 minutes.
After performed nursing instruction follow up for one month and evaluation
of the effectiveness of the patient performance by using of assessment duration,
degree of painful, and number of cramp after perform exercises.
Inclusion of subject into the study was done during the period of 4 months
from Augusts to November, 2006
Methods:
- Official per mission to conduct the study was obtained from the responsible
authority of the study setting after the aim of the study was explained.
- The tools were developed by the researchers based on the review of relevant
literature to evaluate the stretching exercises on muscle cramps.
- The tools were tested for content related validity by three experts in the field of
nursing.
- A pilot study was done to test the questionnaires contens, time. The study was
carried to patient to ensure the clarity of the questions.
- The patient who had been restrained was informed about the aim of the study and
ensured about the confidentiality.
- Nursing instruction was developed on patient needs, assessment.
- The expertise comments, it was written in Arabic language. The protocol covered
the following steps of stretching leg exercises.
- Data were collected, during the period from mars, 2006, Mars 2007.
Statistical design:
The collected data were tabulated, categorized & analysis to evaluate the
nursing instructions impact, the statistical was done in relation to the items of
nursing sheet.
Statistical test were used including percentage distribution, means, standard
deviation, chi square & t- test for comparison of distribution & difference measures
of validity, the accepted level of significance was 0.05.

RESULTS
Table (1): Distribution of the studied sample according to their Sociodemographic characteristics (N=100)
Characteristics
Age (years):
18-28

230

No

12

20.00

Magda Mohamed et al,.

29-38
39-48
>48

16
17
15

26.67
28.33
25.00
37-87 11.65

Gender:
Male
Female
Education:
Illiterate
Read & write
Moderate
university
Marital status
Single
Married
Divorce
Accupation:
Prof. work
Non Prof work

46
14

76.67
23.33

9
12
19
20

15.00
20.00
31.67
33.33

25
31
4

41.67
51.67
6.67

23
37

38.33
61.67

Table (1): Display the socio- demographic characteristics of the study sample. The age of the
majority of sample related to age (28.33%) ranged from 39-48 years, with a mean 37.86 11.63.
More than half of the sample 76% were male, the rest of the sample were female (23.33%).
University way prevailing among about (33.33%) of the total sample while (31.67%) moderate, the
rest either illiterate or read & write (15%, 20%) respectively). As regard the occupation, it appears
that, more than half of the patients were non Prof. work (61.67%), the rest of the sample (38.33%)
were Prof. work.

Table (2): Illustrates the distribution of the studied sample according to their
clinical data
Variable
No
%
Duration of disease:
Duration year
16
26.67
Year
29
48.33
More 3 years
15
25.0
Duration of dialysis
1-3 hours
3
5.0
3-5 hours
53
88.33
5-6 hours
4
6.67
Number of dialysis / week
Two
40
66.67
Three
20
33.33
Table (2): This table show that the majority of the sample (48.33%) duration of disease
were 2-3 years while the minor of the sample (25%) were more than three years. Also this
table enumerate that more than half of the patients (88.335) were duration of dialysis 4-5
hr. in relation to number of dialysis per-week, (66.67%) were 2 time per-week while the
rest of study (33.33%) were 3 time/ week.

Table (3): Distribution of the studied sample according to patient's knowledge and
experiences about muscle cramps & management before nursing
instruction.
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AMJ, Vol. 5, N. 2, April, 2007

Variable
Definition of muscle cramp
Yeas
No
Causes of cramp
Yeas
No
If patients answer yeas
Dialysis
Medication
Nutrition
Times occurs
Before dialysis
During dialysis
After dialysis
Frequency of cramps
One
Two
Three
Types of pain
Mild
Moderate
Severe
Duration of pain
1-5 minute
5-10 minute
Above
Pain leads to sleep disturbance
Yes
No
Relation between cramps & exhaustion
Yes
No
Knowledge about exercises
Yes
No
Practice exercise
Yes
No

No

29
31

48.33
51.67

21
39

35.0
65.0

3
35
1

7.69
89.74
2.56

10
39
11

16.67
65.0
18.33

0
47
13

0.0
78.33
21.67

0
53
7

0.0
88.33
11.67

29
31
0

48.33
51.67
0.0

40.0
20.0

66.67
33.33

5
55

8.33
91.67

4
56

6.67
93.33

4
56

6.67
93.33

Table (3): This table shows the patients' knowledge in relation to muscle cramp
and management. This table revealed that, the majority of patient's a lack of
patient's knowledge as regard def., causes 51-67% end (65%) respectably. As
shown in the table, less the most time of cramps before dialysis (16.67%). While
cramps during dialysis and after dialysis were (65%) and (18.33%) respectively.
Also this table enumerate that the majority of the study sample were (78.33%) and
(88.33%) related to frequency of cramp (two times) and type of pain (moderate)
respectively.
Table (4): Distribution of studied sample according to patient's knowledge and
performance after nursing instruction about stretching leg exercises.
232

Magda Mohamed et al,.

Variable
Knowledge about exercises
Yeas
No
Performance of exercises
Yeas
No
Number
of
performance
this
exercises
One
Tow
Three
Important of exercises
Yeas
No
Present pain after exercises
Yeas
No
Frequency of pain after exercises
No
One
Two-three

No

33
27

55.0
45.0

55
5

90.0
10.0

33
25
2

55.0
41.67
3.33

37
23

61.67
38.33

25
35

41.67
58.33

35
25
0

58.67
41.33
0

Table (4): This table enumerate that present improvement of patient knowledge
about exercises, performance of exercises important of exercises were (55%),
(90%) and (61.67) respectively.

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AMJ, Vol. 5, N. 2, April, 2007

Table (5): Comparison between before and after nursing instruction in related
knowledge and performance of the patients.
Before
After
Variable
X2
No
%
No
%
Knowledge about exercises
Yeas
32.86
No
4
6.67
33
55.0
56
93.33
27
45.0
Performance of exercises
Yeas
4
6.67
55
90.0
86.72
No
56
93.33
5
10.0
Number of performance
this exercises
One
4
6.67
33
55.0
3.11
Tow
0
0.00
25
41.67
Three
0
0.00
2
3.33
Important of exercises
Yeas
4
6.67
37
61.67
40.34
No
56
93.33
23
38.33
Present pain after exercises
Yeas
4.39
No
33
55.00
44
73.33
27
45.00
16
26.67
Frequency of pain after
exercises
One time
47
78.33
37
61.67
3.96
Two-time
13
21.67
23
38.33

to
P
0.01

0.01

0.21

0.01

0.036

0.046

Table (5):This table show that a highly statistical significance difference between before
and after performance leg exercises as regarded exercises, performance of exercises,
important of exercises, present pain after exercises and frequency of pain a statistically
significant difference were evident X2=32,87, P=0.01, X2=86.72, P=0.01, X2=40.34,
P=0.01, X2=4.39, P=0.03, and X2=3.97, P=0.04 respectively.

234

Magda Mohamed et al,.

Table (7): This table distribute that the relation between number of dialysis per
week in relation to present of cramps, type of pain and frequency of cramps.
Number of dialysis per week
Variable
X2
P
Two time (40)
Three (20)
No
%
No
%
Present pain
Yeas
24
40.00
5
8.33
8.12
0.004
No
16
26.67
15
25.00
Type of pain
Moderate
34
56.67
19
31.67
6.95
0.008
Severe
6
10.00
1
1.67
Frequency of pain
One time
19
31.67
12
20.00
6.85
0.033
Two time
21
35.00
8
13.33
Table (7): This stable show that statistical significance different in all variable items in
relation to number of dialysis.

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AMJ, Vol. 5, N. 2, April, 2007

Table (6): Co-relation between socio demographic data & knowledge about exercises, performance, number of
performance, importance of exercises and present of pain
Variable

Age
- 30
- 40
- >40
Probability
Sex
Mal
Female
Probability
Education
Read & write
Moderate
University

Inform
nation about
exercises
Yes
No

Performance
this exercises

Number of performance

Importance
Yes

No

One

11
6
23
9
9
23
0.36 ns

17
22
21

0
0
0

9
11
13

7
10
8
0.82 ns

1
1
0

10
7
12
10
15
6
0.5 ns

13
4
15
7
16
5
0.799 ns

10
7
15
7
12
9
0.73 ns

27
19
6
8
0.3 ns

46
14

0
0

25
8

20
5
0.62 ns

1
1

25
12

21
2

36
10
8
6
0.12 ns

28
18
9
5
0.82 ns

21

10

11

19

Above 2

No

0.35*
0

12

Yes

No

Number of
pain occurs

Yes

Two

Present of
pain

11

One

two

10

17
14
19
0
7
11
1
13
6
17
2
15
4
15
6
20
0
7
12
1
12
8
17
3
11
9
Probability
0.413 ns
0.009**
0.33 ns
0.001**
0.31 ns
Ns= non significance difference **= high significant difference P<0.005% * significant different at the P <0.05%

236

Magda Mohamed et al,.

Table (6): This table show that correlation between age, sex and education in relation to exercises important,
performance and pain accurse. It was found that was statistical significance difference between sex and important of
exercises (0.035), also this table show that a highly statistical significance difference between education and number
of performance, and number of pain accrue (0.009) and 0.001 respectively. It was noticed also that there was non
statistically significance difference between age & item mention.
Table (8): The distribution of the study sample according to the duration of disease in relation
frequency of pain
Duration of disease
Variable
One year (16)
2-3 yeas (29)
> 3 years (15)
N
%
N
%
N
%
Present pain
Yes
9
15.00
14
23.33
6
10.00
No
7
11.67
15
25.00
9
15.00
Type of pain
Moderate
13
21.67
25
41.67
15
25.00
Severe
3
5.00
4
6.67
0
0.00
Frequency of pain
Onetime
12
20.00
12
20.00
7
11.67
Two times
4
6.67
17
28.33
8
13.33

to present, type and

X2

0.18

0.67

2.88

0.24

4.86

0.3

Table (8): This table show that no statistical significance different in all variable in relation to duration of disease.

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AMJ, Vol. 5, N. 2, April, 2007

Table (9): The distribution of studied sample according to relation between duration of dialysis and present type and
frequency of pain.
Duration of dialysis
Variable
1-3 hrs/w (3)
4-5 hrs/w (53)
>5 h/grs/w(4)
X2
P
N
%
N
%
N
%
Present pain
Yes
2
3.33
27
45.00
0
0.00
4.29
0.12
No
1
1.67
26
43.33
4
6.67
Type of pain
Moderate
2
3.33
47
78.33
4
6.67
1.9
0.39
Severe
1
1.67
6
10.00
0
0.00
Frequency of pain
Onetime
3
5.00
27
45.00
1
1.67
3.95
0.41
Two times
0
0.00
26
43.33
3
5.00
Table (9): Demonstrated that was no statistical significant difference between duration of dialysis and present, type
and frequency of pain.

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Magda Mohamed et al,.

DISCUSSION
Muscle cramps are involuntary painful sudden contraction of the skeletal
muscle. They are present in normal subject under certain condition such as
myopathies, neuropathies, & hydro-electrolyte imbalance Praise L, (15) & crowing
B (16) to prevent this cramps from occurring, night stretching exercises may be best
measure Walgreen a (17). So the aim of this study is to determine the effect of a
stretching exercises protocols on reduction of leg cramp during haemdialysis
among patient with renal failure.
The present study revealed that mean age of the patient was 37.87 +11.65.
these result were is agree with American academy of family physician (18) reported
that exact prevalence is uncertain limited studies have indicated that 2 15 % of
population may experience muscle cramp symptom .this wide range of result may
be due to different in study methodologies although the prevalence of muscle
cramp increases with age .it has a variable age of onset & can occur in children.
other study done by Butler et al (19) who found that leg cramps are common in older
people. Also Picchietti (20) who found that , the muscle cramps especially leg
cramps occur at all ages but peak at different times. the are particularly common in
adolescence ,during pregnancy ,& in older age, affecting up to 70% of adults over
50% at some point. While more than half of the patient were males, these result is
disagree with (21) reported that, males & females are equally affected & it occurs in
more people as they get older. Other study done by Abdullah A (5) the prevalence
of leg cramps was 50% cramps were commoner in female (56%) than in male
(40%).
As regard patient, education, in the present study, the majority of them
university education, this level of education help to understanding purpose of the
study. As regard duration of disease in the present study range between one year to
4 years 48.4%. On the other hand duration of disease is another important factors
concerning complication & to improve awareness & knowledge since Heiba (22)
found that with long duration of disease there was a slight increase in knowledge &
the practice.
As regard duration of dialysis in the present study table (2) revealed that,
most patient still under dialysis from 4-5 hours 88.9% & tow time dialysis every
week 66.6 %. On the other hand duration of dialysis is another important factors
concerning complication. Johnson (23) supported that, within a year after starting
dialysis the patient complained of pain in the feet. Also Young, G (24) who found
that, muscle cells are made up of 80% fluids, so they need to be replenished
constantly. So rest, cold therapy, stretching & exercises help to strengthen the
muscles. Also Twardowski, (25) stated that ,when chronic haemdialysis session
were first developed in the Seattle in the (1960) they were long procedures that
caused few intra- or inter- dialectic symptoms. over the next several decades, the
overwhelming number of patient requiring haemdialysis created both financial &
logistical incentives to shorten dialysis sessions to as little as 2 hours per
treatment. Three times per week. Shorter treatment spread rapidly, especially in the
united states. Rapid ultrafilteration leads to symptoms such as sever muscle
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AMJ, Vol. 5, N. 2, April, 2007

cramps, nausea & vomiting, headache, fatigue, hypotension during dialysis, patient
who receive these short treatment remain fluid overload & their blood pressure
control is poor. So the frequency & length of dialysis treatment should be adjusted
such as that patient does not suffer from symptom caused by rapid ultra filtration.
On the other hand patient knowledge in relation to muscle cramp &
management in out line in table (3). This table revealed that lack of knowledge &
skill as regard muscle cramp, sites, relation between over exertion & muscle cramp
& exercises before nursing instruction.
As regard when cramp occur, most patient answer during dialysis & occur
one times per day, 65 %, 78.3 % respectively .this supported with Walgreens (26)
leg cramps occurs 20%-62% of people undergoing dialysis reported leg cramps
symptoms disappear after a kidney transplantation, As regards sites of cramp
occurs, this study revealed to that the majority of patient no information about sites
73.33 & minority of patient 26.67 % answer in the leg 37. 5%, trunk 25.0% & 37.5
5 in arm. This study on line with Voon (27) who repotted that cramps are most
commonly experienced in leg.
According to types of pain this study revealed that the majority of patient
complaint mild pain 88.33% duration of pain range between 5-10 minutes 51.67%
this result agree with Young (24) reported that ,pain severity & duration varies from
seconds to many minutes ,& the muscle may remain tender for up to 24 hours after
the acute pain.
As regard time of pain occur in this study the majority of patient, the pain
increased at night 90%. This result agreement with Ondo (28) reported that leg
cramp symptoms are generally worse in the evening & at night & less severe in the
morning. Leg cramp must be distinguished from sleep related leg condition such
as nocturnal leg cramps .Also Salih (6) & kanaan & sawaya (4) reported that leg
cramps commonly happen at night where the plantar flexed foot places the calf &
ventral foot muscle in the most shortened & vulnerable position .
As regarding relation between cramps & sleep disturbance, this study
revealed to that the majority of patient 66.67 % answer the cramp leads to sleep
disturbance ,this agreement with Culebras. A (1) who found that, when leg cramp
appears before going to sleep, it may interfere with falling asleep & leads to a sleep
deficit. Other study done by Walgreens.com (26) said that, cramps that awaken
people during sleep are very common & they are not part of periodic limb
movement disorder .they can be very painful may cause jump out of the bed in the
middle of the night. They typically affect a specific area of the calf of the foot.
As regard relation between cramps & over exertion, this study revealed to the
majority of the patient no information about them 91% 6 ,this result disagree with
Chokroverty (29) said that over exertion, standing on concrete for long period or
prolonged sitting (especially with the legs contorted) may contribute to nighttime
cramps. Also Claman (30) said that, when playing sports, muscle fatigue as well as
vigorous use of the muscle can cause cramping. These cramps can occur either
during & after the activity. Older individuals are at a higher risk for cramping while
doing any type of intense physical activities.
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As regarding information about non drug management .this study revealed

that the majority of patient 93.4 % no any information about management .this may
be due to one or more of the following reasons lack of training program, limited
qualification of the nurse & lack of patient knowledge may be one of the reason
cramp occurs. Also it was found that all patient knowledge was related to the
management, pre program, prior program implementation. So the pre-test used as
the starting point for reorganizing the content of the theoretically course as it
identify learning & planning needs.
To prepare health education message, assessment has to be done this include
assessment of their knowledge & practice in relation to muscle cramp management
& asking them what they need to know about their disease.
Result of the post nursing instruction revealed that patient is interesting in
knowing the items that deal with the management of their disease.
The result of the study revealed that, improvement of patient knowledge &
practice as regard exercises need, performance of exercises, number of
performance, important of exercises, present pain after exercises & number of pain
occurs after exercises (table 4).
Results of present study revealed that, high significant difference between
before & after nursing instruction as regard exercises 8.3% & 55.0% respectively
P<0.001 %, as regard important of exercises, performance of exercises,& number
of pain occurs after exercises ,these result supported with Corwin-Brown (31)
found that, advice only stretching exercises for leg cramps, stretching exercises for
the calf muscle will prevent cramps in many people .on the other hand exercises
earlier in the day may be one of the best way to achieve health sleep. Also, other
study done by Corwin Brown (31) Stretching a cramped muscle out can help to
temporarily relieve a muscle cramps, use a slow, sustained stretch, rather than
quick & forceful ones. in some events, where resources & time are limited,
stretching may be the only thing you are able to do. This significant difference
related to clarity of the material, using simple language & relevance items of the
nursing instruction content to the practice. Also high receptivity of the patient, their
interest & their need to increase adaptation with their condition.
Results of present study showed that, significance different in relation
between sex &important of exercises, also, high significance difference in relation
between education & number of performance, &pain present after exercises.
Daniell (32) agree with their result stretching of the calf muscle (three times daily)
may prevent leg cramps.
As regard duration of disease in relation to present type and frequency of
pain. This table show that no statistical significance different in all variable in
relation to duration disease. Johnson MJ, (23) reported that within a year after
starting dialysis the patients complained of chest pain and pain in the feet, and
skeletal radiologic survey showed generalized demineralization and fractures of
fifth through the eight ribs.
CONCLUSION
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The study concluded that there lack of knowledge & skills related to muscle
cramps before nursing instruction protocol. But there was statistical significant
difference after performance of exercises. It was found also that high significance
difference between before & after performance of exercises. So the study
recommended that the importance of performance of stretching exercises for
patient before dialysis to prevent cramps. there is clearly a need for effective
education regarding recognition ,individual patient need & appropriate intervention
strategies in muscle cramps in dialysis patient & nurses, in partnership with patient
,relatives & careers & other health professional can help to empower the individual
to mange their cramps
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