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Physical Activity and Epilepsy

What Are the Rules?

Joseph I. Sirven, MD; Jay Varrato, DO

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 3 - MARCH 1999


In Brief: Exercise has important benefits for patients who have epilepsy, but several factors must be considered when making activity recommendations. Seizures during sports activity are rare, and exercise may have anti-epileptic effects acutely, but physicians, coaches, and parents should know what to do if a seizure occurs. Many sports activities are permissible as long as patients avoid overexertion, dehydration, and hypoglycemia. Some antiepileptic drugs may adversely affect sports performance, and exercise in turn may reduce serum drug levels by increasing circulating liver enzymes.

Epilepsy affects 1.5 to 3.5 million Americans in any given year (1). Though the disease is relatively common, physicians and patients are often unclear about the relationship between exercise and epilepsy. Striking a safe balance between the disease, its treatment, and appropriate physical activity recommendations can bring patients important health benefits.

Defining Seizures and Epilepsy

A seizure is a sudden involuntary alteration in perception or behavior caused by an abnormal synchronized discharge of cortical neurons in the central nervous system. Epilepsy, on the other hand, refers to chronic recurrent seizures from a primary underlying brain abnormality.

Seizures can be broadly classified into two major categories: partial, involving onset from a discrete area of the brain that may or may not secondarily generalize to the rest of the brain, and primary generalized, involving simultaneous onset from both hemispheres (2).

In an arrangement that parallels the classification of seizures, the International League Against Epilepsy (ILAE) classifies epilepsies as local or generalized (3): Seizures from local epilepsies originate from a discrete cortical site, whereas seizures from generalized epilepsies originate from both cerebral hemispheres.

The ILAE also distinguishes between the idiopathic and symptomatic epilepsies. Those associated with a known or suspected brain disease or lesion are labeled symptomatic. Disorders that must be secondary to an insult but whose cause is unknown are termed cryptogenic and are included in the symptomatic grouping. Epilepsies that are inherited without identifiable pathology are labeled idiopathic. Idiopathic epilepsies often carry a better prognosis than symptomatic disorders.

Clinically, the distinction between partial (or secondarily generalized) seizures and primary generalized seizures is useful because these two types respond differently to medications. Partial seizures can be nearly or completely controlled in 60% of patients with use of carbamazepine, phenytoin, phenobarbital, primidone, or valproic acid (4,5). Valproic acid or ethosuximide controls generalized seizures in 80% of patients who have absence attacks. Valproic acid also controls seizures in 80% of patients who have generalized seizures (6).

What Causes Seizures?

The etiology of seizures and epilepsy is age related. Childhood-onset epilepsy is most often caused by birth and neonatal injuries (58%), followed by central nervous system (CNS) infections (15%) and head trauma (12%), and is caused less often by metabolic derangements, tumors, vascular insults, and genetic predisposition (1). Adult-onset epilepsy is most commonly caused by vascular lesions such as infarcts or hemorrhage (60%), metastatic tumors (10%), and CNS infections (9%), and less often by toxic or metabolic abnormalities such as toxin ingestion or drug withdrawal. Despite careful investigation, the cause remains unknown in a large percentage of affected individuals.

The major concerns regarding epilepsy and sports participation are that a head injury in an epileptic athlete could worsen the condition and that a head injury could trigger seizures in a previously healthy person. Thus, it is important to understand the relationship between head trauma and epilepsy. In general, previously healthy patients who sustain penetrating trauma or a head injury associated with prolonged unconsciousness have a higher risk of developing epilepsy. Authors of a large population-based prospective trial (7) calculated that the relative risk of developing posttraumatic seizures was 4.0 in patients who sustained moderate head trauma (skull fracture or 30 minutes to 24 hours of posttraumatic amnesia or unconsciousness). The relative risk associated with less severe head injuries (less than 30 minutes of posttraumatic amnesia or unconsciousness) was 1.5. The authors also found that the majority of seizures in children occur within 24 hours after the trauma; this effect was not seen in adults. However, an adult seizure within 24 hours of severe or moderate head trauma was likely to presage the development of epilepsy.

Head-injury-related seizures are most likely to happen within 2 years of the incident (8); 50% to 65% of patients will have them within 12 months of injury. Of patients who have seizures, about half will experience a single seizure and 25% will have two or three seizures.

Exercise-Epilepsy Interactions

Epilepsy patients and their families are commonly concerned about seizures during exercise. Fear often results in overprotection, feelings of isolation, and needless activity restrictions. Thus, an understanding of how exercise affects both epilepsy and its electroencephalographic (EEG) correlates is essential.

Seizures during exercise are rare, but there are a few reports of exercise-induced ictal events. One such report described three patients who had seizures during exercise (9). Two had generalized tonic-clonic seizures, and one had absence seizures. All three patients had normal resting EEGs and showed generalized epileptiform discharges when exercising.

Seizures are most likely to occur after exercise (15 minutes to 3 hours after exercise). In two retrospective reports (10,11), 23% and 65% of children with epilepsy had an increase in epileptiform discharges on EEG immediately after exercise when compared to baseline. Moreover, Kuijer (12) correlated an increase of epileptiform discharges with a decrease in blood pH. This may explain why seizures are more common after exercise; however, confirmation studies are needed. There are no specific treatment strategies to counteract this effect.

Epilepsy may improve with exercise. The literature demonstrates that epileptiform discharges on EEG decrease during exercise (10,11,13). Horyd et al (11) found reduced epileptiform discharges during exercise in 28 of 43 epilepsy patients. Nakken and colleagues (10) recently confirmed this finding in their study of 26 children with epilepsy. The investigators noted that 20 (77%) of the 26 children had fewer epileptiform discharges during 10 minutes of cycle ergometry.

The mechanisms responsible for EEG improvement during exercise are unclear. Several points merit consideration. Hyperventilation is used during EEG recording to increase epileptiform activity. Paradoxically, compensatory hyperventilation during exercise improves the EEG. The underlying pathophysiology explains this apparent discrepancy. Hyperventilation during exercise, a response to increasing oxygen demand, prevents hypercapnia; hyperventilation during sedentary EEG recording causes respiratory alkalosis with resultant cerebral vasoconstriction and hypoxia. Beta endorphin release during exercise may also improve the EEG (14). Lastly, increased attention and awareness required during exercise may confer an antiepileptic effect. Van Linschoten et al (15) speculated that this increased mental concentration may reduce seizure frequency. How increased awareness might protect against seizures is unknown.

Overall fitness and a feeling of well-being have been shown to help reduce seizure frequency. A study by Nakken and colleagues (16) revealed that patients felt better and improved their seizure control with regular exercise. One report suggests that exercise improves self-esteem and social integration regardless of seizure control (17).

How Epilepsy Treatments Affect Exercise

Pharmacologic treatments. Antiepileptic drugs (AEDs) are the most common therapy for epilepsy and seizures, but most have side effects that cause fatigue and lethargy, which are obstacles for some active patients. Other side effects—blurred or double vision, concentration difficulty, and impaired coordination—can also influence performance. Table 1 (not shown) profiles these side effects for numerous AEDs (18). Some medications contribute to poor physical fitness. Valproic acid and lamotrigine may cause weight gain, but a regular exercise program may cancel this effect. Antiepileptic drug selection must consider individual concerns. A drug such as valproic acid may be an appropriate choice for a marathon runner, but not for an ice skater or gymnast.

Physical training appears to affect serum levels of certain AEDs (17,19). Thus, serum AED levels of patients participating in regular exercise programs should be monitored closely, especially in the first few months of training. Additionally, athletes who have epilepsy should avoid anabolic steroids because they may alter AED serum levels (15).

There is no consensus regarding the clinical significance of exercise-induced hepatic enzyme activity. In a Norwegian study (17), 21 adult inpatients who had active epilepsy (at least one seizure per month for the previous year) took part in a 4-week exercise program at a minimum of 60% of their maximal aerobic capacity for 45 minutes a day, 6 days a week. This training program did not significantly change AED levels and did not reduce seizure frequency (17). But until further studies are done, serum levels of liver enzymes should be closely observed.

Surgical treatments. Two emerging therapies in epilepsy—surgery and vagus nerve stimulation—raise unique issues related to exercise. Unilateral temporal lobectomy, in which 4 to 5 cm of temporal tissue is resected, is the most common surgical therapy for partial epilepsy. Corpus callosotomy, surgical severance of the corpus callosum, is a palliative treatment for individuals who have generalized epilepsy. Vagus nerve stimulation is a new procedure in which two spiral electrodes are wrapped around the vagus nerve and connected to an infraclavicular generator pack. The device delivers preprogrammed electrical currents that suppress seizures.

It is unclear what effect these treatments have on active patients. Candidates for such treatments have seizures that are refractory to medication and are likely to be on multiple AEDs. A rule of thumb for patients being considered for or recovering from surgery is to initiate an exercise program gradually and avoid contact sports. Preventing head trauma is essential, particularly for patients who have a history of epilepsy surgery. Likewise, for patients who have had vagus nerve stimulation, neck protection is essential to prevent damage to the generator pack and injury to the nerve.

Sports Participation Recommendations

When making activity participation decisions, the patient and physician need to know common seizure precipitants during exercise. Risk factors include:

  • Excessive fatigue,
  • Sleep deprivation,
  • Hypoxia associated with high-altitude activities,
  • Hyponatremia associated with electrolyte loss,
  • Hypernatremia associated with dehydration,
  • Hyperthermia related to physical exhaustion and heat, and
  • Hypoglycemia associated with poor nutrition before activity.

There is no conclusive evidence that repetitive minor head injuries from contact sports increase seizure frequency. However, helmet use is an important recommendation for athletes who have epilepsy. Other vital safety measures are to maintain adequate hydration, avoid overexertion, and ensure adequate sleep and nutrition.

The most important consideration when making a participation decision is the risk for injury in the patient's particular sport. Athletes who are seizure-free have few, if any, absolute contraindications for specific sports. Patients who have reliable auras and those who have nocturnal seizures may participate in most activities with supervision. However, contact sports, aviation sports, and unsupervised water sports must be avoided. Epilepsy patients who have more frequent or uncontrolled seizures should be more cautious when choosing sports; they require supervision and safety precautions on the playing field. General recommendations for specific sports can be found in table 2. The choice of a sport must be individualized for each patient. Common sense should always prevail, and the decision to pursue a particular activity should be based on discussions between athlete, coach, and physician.


Table 2. Contraindicated Sports for Patients Who Have Epilepsy


All Patients Who Have Epilepsy
Boxing
Full-contact karate
Unsupervised scuba diving
Solo hang gliding
Solo parachuting
Unsupervised mountain climbing

Patients Who Have Uncontrolled Seizures
Aviation sports
Gymnastics (parallel bars, uneven bars)
Horseback riding
Ice hockey, ice skating
Motor sports
Mountain climbing
Scuba diving
Unsupervised downhill skiing
Unsupervised sailing
Unsupervised water sports and swimming
Waterskiing
Wind surfing


When a Seizure Occurs

When a person has a seizure on the playing field, the most important task is to protect him or her from self-injury. This includes helping the patient to the ground and clearing the area of dangerous objects. One should never insert objects into the patient's mouth or attempt to restrain a seizing individual. Seizures are usually self-limiting and typically stop after 2 to 5 minutes.

After seizure, assessment of airway, breathing, and circulation is essential. In the postictal period, most patients exhibit a transient disturbance of mentation, consciousness, or motor or sensory function. If pulse or breathing is absent, cardiopulmonary resuscitation (CPR) should be initiated. The emergency medical system (EMS) should be called when the patient has difficulty breathing, requires CPR, has cluster seizures without returning to baseline, or is confused for more than 30 minutes (table 3). EMS should also be summoned when a patient has a seizure for the first time.


Table 3. Seizure Situations That Require EMS Response


Compromised breathing
Need for cardiopulmonary resuscitation
Cluster seizures with no return to baseline
Confusion lasting longer than 30 minutes
First seizure


Return to Play After Seizure

A common question is how soon a patient can return to play after a seizure. After the first seizure, a thorough neurologic assessment is needed to determine the cause. If the seizure was provoked by an underlying condition such as metabolic derangement, infection, tumor, or abscess, the patient can return to play after treatment.

If seizures are idiopathic, limitations depend on how well seizures are controlled. There is no specific waiting period before return to physical activity. Sound clinical judgment should prevail.

Explanation Is Medicine

Demystifying the relationships between epilepsy, sports, and exercise can provide patients with important benefits. Helping them understand that exercise rarely induces seizures and, in fact, may reduce the frequency of seizures may help alleviate patients' fears. An individualized, commonsense approach to the physical activity recommendation can help fulfill the main goal of epilepsy treatment: to ensure quality of life.

References

  1. Hauser WA, Hesdorffer DC: Epilepsy: Frequency, Causes, and Consequences. New York City, Demos, 1990
  2. Commission on Classification and Terminology of the International League Against Epilepsy: Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia 1981;22(4):489-501
  3. Commission on Classification and Terminology of the International League Against Epilepsy: Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia 1989;30(4):389-399
  4. Mattson RH, Cramer JA, Collins JF, et al: Comparison of carbamazepine, phenobarbital, phenytoin, and primidone in partial and secondarily generalized tonic-clonic seizures. N Engl J Med 1985;313(3):145-151
  5. Mattson RH, Cramer JA, Collins JF: A comparison of valproate with carbamazepine for the treatment of complex partial seizures and secondarily generalized tonic-clonic seizures in adults. The Department of Veterans Affairs Epilepsy Cooperative Study No. 264. N Engl J Med 1992;327(11):765-771
  6. Theodore WH, Porter RJ: Epilepsy: 100 Elementary Principles, ed 3. Philadelphia, WB Saunders, 1995
  7. Annegers JF, Grabow JD, Groover RV, et al: Seizures after head trauma: a population study. Neurology 1980;30(7 pt 1):683-689
  8. Wyllie E: The Treatment of Epilepsy: Principles and Practice, ed 2. Baltimore, Williams & Wilkins, 1997
  9. Ogunyemi AO, Gomez MR, Klass DW: Seizures induced by exercise. Neurology 1988;38(4):633-634
  10. Nakken KO, Loyning A, Loyning T, et al: Does physical exercise influence the occurrence of epileptiform EEG discharges in children? Epilepsia 1997;38(3):279-284 [published erratum in Epilepsia 1997;38(8):956]
  11. Horyd W, Gryziak J, Niedzielska K, et al: [Effect of physical exertion on seizure discharges in the EEG of epilepsy patients]. Neurol Neurochir Pol 1981;15(5-6):545-552
  12. Kuijer A: Epilepsy and exercise: electroencephalographic and biochemical studies, in Penry JK, Wada JA: Advances in Epileptology: The 10th Epilepsy International Symposium, 1978, Vancouver, BC. New York City, Raven Press, 1980
  13. Gotze W, Kubicki S, Munter M, et al: Effect of physical exercise on seizure threshold (investigated by electroencephalographic telemetry). Dis Nerv Syst 1967;28(10):664-667
  14. Albrecht H: Endorphins, sport and epilepsy: getting fit or having one? letter. NZ Med J 1986;99(814):915
  15. van Linschoten R, Backx FJ, Mulder OG, et al: Epilepsy and sports. Sports Med 1990;10(1):9-19
  16. Nakken KO, Loyning T, Tauboll O: [Epilepsy and physical fitness]. Tidsskr Nor Laegeforen 1985;105(16):1136-1138
  17. Nakken KO, Bjorholt PG, Johannessen SI, et al: Effect of physical training on aerobic capacity, seizure occurrence, and serum level of antiepileptic drugs in adults with epilepsy. Epilepsia 1990;31(1):88-94
  18. Liporace JD: Women's issues in epilepsy: menses, childbearing, and more. Postgrad Med 1997;102(1):123-135
  19. Eriksen HR, Ellertsen B, Gronningsaeter H, et al: Physical exercise in women with intractable epilepsy. Epilepsia 1994;35(6):1256-1264

Dr Sirven is a neurologist at the Jefferson Comprehensive Epilepsy Center, an assistant professor in the Department of Neurology, and director of the neurology curriculum at Jefferson Medical College in Philadelphia. Dr Varrato is a resident at Pennsylvania Hospital in Philadelphia. Address correspondence to Joseph I. Sirven, MD, Suite 4150, 111 S 11th St, Philadelphia, PA 19107; e-mail to [email protected].


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