(Editor's Note: This article will provide readers with information on epilepsy and physical activity. Prior to beginning any programme of physical activity or exercise, please consult your doctor.)
Physicians, parents, physical education specialists and therapists are often overly cautious or unduly restrictive in recommending physical activity for children, adolescents and adults with epilepsy. Excellent studies exist which document that people with epilepsy feel better and have better seizure control when they maintain a regular exercise programme. Nonetheless, before embarking upon a new exercise activity, several factors must be considered:
- Benefits of participating in the sport.
- The risk of injury from participating in the sport.
- The frequency and timing of the seizures.
- Medications and potential side effects.
- Enthusiasm of the individual for the sport.
It is gratifying to observe that people with epilepsy are leading much fuller and more active lives than ever before. More precise diagnoses and improved treatment have led to improved seizure control with fewer toxic side effects than in the past.
This richer lifestyle expectation often results in those with epilepsy consulting with medical professionals for advice and guidance concerning physical activity. Medical professionals should not unduly restrict active sports participation. There are data available quantifying the risk of sports participation for the person with epilepsy, though the scope is limited. Therefore, common sense does have to prevail. For the parents of the person with epilepsy, precautionary measures often go far beyond what is reasonable and necessary and can result in an altered self-image and feelings of being different or inferior. This article will provide some practical guidelines for choosing activities.
Benefits of Sports Participation
With few exceptions, regular physical activity is beneficial to the individual, including those with epilepsy. A study undertaken in Norway involved several subjects with epilepsy who reported that they felt better and had better seizure control when they maintained a regular exercise programme. Another study by this group analyzed the pre-hospitalization leisure habits of 44 adult inpatients with active epilepsy, defined as a minimum of 1 seizure a month for the previous year. These authors found that most patients had lived sedentary lives. Social contact was also limited. They were found to have considerably lower maximum oxygen uptake (VO2) than average (75-80% of expected). Physical activity was recommended by the authors to improve quality of life. 21 adult inpatients participated in a 4-week intensive physical training programme for 45 minutes a day, 6 days a week. The maximum VO2 increased an average of 19% and clearly documentable psychological and social benefits were noted. Physical training did not change the average frequency of seizures or the serum concentrations of antiepileptic drugs to a clinically important degree. Four to 8 months after the training programme ended, 70% of the patients were still physically active.
Other studies address the issue of a lowering of self-esteem and self-confidence in the presence of epilepsy. The denial of activities available to others only serves to foster this inequity. The most recent statements by the American Medical Association and the American Academy of Pediatrics also stress the benefits of sports participation, not only the risks.
Risks of Injury from Sports Participation
The types of activities that pose the greatest risk to people who have epilepsy are sports in which there is a danger of falling, contact sports, and water sports.
| Sports To Be Avoided By People With Epilepsy:
flying and parachuting
hang gliding
car racing
mountain and rock climbing
high diving
scuba diving
underwater swimming, especially competitive
Sports Involving Some Risk (should be chosen with consideration of the individual):
archery and pistol shooting
contact sports such as boxing, football
soccer (where heading the ball is required)
competitive cycling for children with frequent absence seizures
swimming
gymnastics (when climbing is involved)
ice skating and skiing
(Adapted from: Frank Cordova "Epilepsy and Sport"
Australian Family Physician 22(4), 558-562, 1993) |
Sports Involving Danger of Falling. Sports in which a dangerous fall could occur if the participant had a seizure without warning should generally be avoided by people who have epilepsy. Activities to be wary of include rope climbing, rock climbing, scuba diving, skydiving, horseback riding, bicycle riding, gymnastics performed on the parallel bars, and jumping and tumbling on a trampoline. Those who are experiencing frequent seizures and would thus be at increased risk of falling should be particularly urged to avoid such activities, as should those who have a definite history of head injury contributing to the onset of seizures, since a fall could cause further injury to the head.
Contact Sports. People who have epilepsy, unless they have a history of head injury or significant structural lesions of the brain (eg. brain tumours), appear to be no more at risk than others when participating in contact sports. In August 1974, the American Medical Association Committee on Medical Aspects of Sports stated, "There is ample evidence to show that patients with epilepsy will not be affected adversely by indulging in any sport, including football, provided the normal safeguards for sports participation are followed, including adequate head protection." Before a final decision is made to participate in a heavy-contact sport, however, the individual's neurologist should be consulted regarding how participation will affect the overall plan of care.
Swimming. Generally, swimming is approved for individuals with epilepsy, as long as there is close supervision. "Always swim with a buddy" is a sensible rule for any swimmer. And for the swimmer who has epilepsy, it's best to swim where there's a Red Cross-certified lifeguard on duty who is fully informed about the swimmer's seizures. (For tips on what to do if someone has a seizure while swimming, see box "First Aid for a Seizure in Water".)
Several studies have looked into the risk of injury during swimming. Although the risk of drowning or serious injury is 4 times that of the general population, the absolute risk remains quite small. A review of those studies would suggest that this risk could be further diminished by strict adherence to water safety rules. It should also be noted that it is the person with active seizures who is at risk, not the individual with well controlled seizures.
Frequency and Timing of Seizures
An individual who is experiencing frequent seizures which impair consciousness is at increased risk of falling and should choose activities accordingly and practice appropriate safety strategies. If a pattern of seizure activity at clearly predictable times of the day has been documented (eg. only upon awakening or only during sleep), participation in sports at other times is not likely to be a problem.
Medication
People who are about to undertake new physical activities should be reminded that antiepileptic medications can be effective in preventing seizures only if taken exactly as prescribed. Studies to date have not shown a change in drug metabolism or effectiveness during sports participation. However, if a person with epilepsy experiences significant weight loss or gain (as might result from such sports as cross-country running or weight training), the dose of their medication may need to be adjusted. Any change in the dose should, of course, be made under medical supervision.
Enthusiasm of the Individual for the Sport
In some cases, well-meaning but overprotective family members, friends, and social institutions restrict normal activity unnecessarily. Children and adolescents pursue activities to attain peer group acceptance, which is important in establishing self-image. It may be damaging to prevent these young people from participating in a chosen activity. However, realistic limitations should be imposed if they show an interest is a high-risk activity.
Exercise Physiology and Seizure Provocation from Sports Participation
Several factors that can influence or provoke seizures may possibly occur during sports, although any links at this point are largely speculative. Fatigue is one such issue. The stress of competition has been commented on. Hypoxia, hypothermia and hypoglycaemia are other possible considerations. To date, no general studies have show sports participation to provoke seizures, although none of the above factors has been studied in detail.
One factor that is raised frequently, but inappropriately, is that of hyperventilation. Because hyperventilation in the laboratory may provoke epileptiform discharges on the EEG and even seizures, especially absence, some have erroneously believed that increased ventilation during exercise may cause seizures. However, increased ventilation during physical training is a compensatory homeostatic mechanism. It does not lead to seizures.
In reality, seizure-type discharges are decreased during and soon after physical activity. It has been observed that fewer seizures occur during both mental and physical activity compared with periods of rest. The reason for this is thought to be the result of sensory inhibiting effects caused by increased attention and vigilance during physical activity.
Conclusion
The vast majority of individuals with epilepsy should be able to participate fully in sports. Not only should this participation be permitted but in light of existing evidence it should be actively encouraged. Although risks cannot be ignored, neither should the benefits of an active, healthy life.
The temptation to be overprotective with the individual with epilepsy is often overwhelming. Family members, friends, coaches, and physicians should be encouraged to treat the person with epilepsy as a normal human being. The time has come to remove unnecessary obstacles for the millions of people with epilepsy.
(Excerpted from: John R. Gates and Ronald H. Spiegel "Epilepsy, Sports and Exercise" Sports Medicine 15(1): 1-5, 1993 and John R. Gates "Epilepsy and Sports Participation" The Physician and Sports Medicine 19(3): 98-104, 1991)
EPILEPSY AND PHYSICAL ACTIVITY
by K.O. Nakken, M.D.
The National Center for Epilepsy, Sandvika, Norway
At the National Center for Epilepsy in Norway we have for a long time had the impression that children with epilepsy not only are overprotected and understimulated in general, but that many are also shielded from play, sports and other recreational activities in particular. If this impression is correct, this will, of course, have an unfavourable impact on their physical as well as personal development. As adults, many of these patients seem to continue to overprotect themselves. An investigation undertaken at our center confirmed this impression. Forty-four young and adult persons with epilepsy were included in the investigation. Interviews revealed that most of the patients lived an isolated and sedentary life. Their social contact was rather limited, and they were only half as active physically as the average Norwegian population of comparable age and sex. Reasons given for their sedentary lifestyle were many: no interest in physical activity, fatigue resulting from medication, fear of seizures, fear of injuries, lack of company during activity, lack of instructors, and lack of a driver's licence. Their physical capacity was tested based upon maximum oxygen uptake (max VO2) using the bicycle ergometer test. Corresponding to their lifestyle, the maximum VO2 was considerably lower (75%-80%), and the decrease observed in aerobic capacity with increasing age was more pronounced than that of the average Norwegian population.
We have also tested how four weeks of intensive, physical training in 21 young and adult persons with epilepsy influenced aerobic capacity, seizure occurrence and the serum level of their antiepileptic drugs (AED). The training induced a considerable increase in maximum VO2. Seizure type and frequency were not significantly altered, but there were considerable individual variations. Two thirds of the patients had less seizures during the 4 week exercise period compared to two pre-exercise and two post-exercise weeks. Most seizures during the training period occurred when the patients were resting. Only six had seizures during exercise and the occurrence had no related to seizure type, mode of activity or pulse rate. In one patient, we could justify the use of the term "exercise-induced seizures". He was himself well aware of this phenomenon. We believe such patients are exceptional.
The serum levels of the antiepileptic drugs (AED) were not affected by physical training to a clinically significant degree. In an ongoing study at our center, preliminary results seem to indicate that physical activity (cycling on ergometer cycle until exhausted) reduces the occurrence of both partial and generalized epileptic discharges in EEG in children with epilepsy.
The word "training" is traditionally associated with drudgery and tough competition. Our task has been to correct this impression among our patients by seeking acceptance for play as a form of training. This is particularly important for patients who previously have been reluctant to take part in physical training for fear of seizures and because of a poor physical condition. At our center, physical training is a compulsory part of the comprehensive care programme. We have three training sessions a week, each of 45 minutes duration. The programme includes ball games, hiking, jogging, skiing, aerobics, and swimming. The preferred type of activity depends on factors like weather, group composition, etc. Great importance is attached to making the training fun and not too competitive. The training sessions are led by physiotherapists and we encourage the rest of the staff to participate, thereby underlining the importance of this kind of therapy. We very rarely experience seizures during the training sessions and we believe Lennox was right when in 1941 he claimed that: "Physical and mental activity seems to be the antagonist of seizures. Enemy Epilepsy prefers to attack when the patient is off-guard, sleeping, resting, or idling."
Depression, anxiety, increased muscular tension, and low self-esteem are often consequences of epilepsy. In addition to improved physical fitness, we think the most important effect of physical training is perhaps psychologically and socially determined. The patients become more outgoing; anxiety, depression and tension are alleviated; the ensuing feeling of well-being and being in charge brings about an enhance self-confidence; and their motivation for physical activity is stimulated.
In our experience, physical fitness makes people with epilepsy more capable in dealing with their disorder and its consequences. When giving advice on questions about physical activity and epilepsy, one should bear in mind that people with epilepsy are a very heterogeneous group. Recommendations must therefore be individualized, taking into consideration factors like: seizure type(s) and frequency; seizure inducing factors; auras; additional disabilities; and the attitude towards, motivation for, and earlier experience with physical activity. Physical activity can hardly represent an important seizure inducing factor in general; most people with epilepsy seem to tolerate physical training quite well. People with uncontrolled seizures should also exercise. Through choosing suitable forms of exercise and wearing special protective gear (e.g. helmet, life jacket, knee protectors), it is possible to reduce the risk of injuries to an acceptable minimum.
Participation in competitive sports should be evaluated on an individual basis with the following questions being considered: Is competition important for the person's self-esteem and social integration? Is competition such a mental strain that it may provoke seizures? What may be learned from earlier experience? What is the risk of having a seizure while participating in the event in question? Advantages must be weighed against disadvantages: a calculated risk of injuries vs. the physical and psychosocial problems due to exclusion and inactivity. Participating in physical activity at home and in school can facilitate a person's integration into society. If this happens, there is an improvement in quality of life, with a mobilization of physical, mental and social resources.
(Reprinted with permission from International Epilepsy News, No. 99, March/April 1990, 4-5)
EPILEPSY RECREATION AND SAFETY ISSUES
An Active Life
Physical activity promotes happiness, satisfaction, self-expression and social interaction. It is a key component in maintaining healthy minds and bodies. A seizure disorder usually does not interfere with the ability to enjoy a wide range of recreational activities. In fact, research has shown that people have fewer seizures if they lead an active life.
For the person whose seizures are not well controlled, the following guidelines will help to ensure that recreational activities are safe and enjoyable.
Bicycle Safety
Head injury is a major risk for all bicyclists. For those without a seizure disorder, a head injury suffered in a bicycling accident could cause epilepsy. For cyclists with epilepsy, a head injury could aggravate a seizure disorder.
A helmet provides valuable protection for the person with epilepsy, should a seizure occur while bicycling. Helmets act as shock absorbers, spreading and absorbing the impact energy when the head hits something. Cyclists need to ensure a helmet fits properly, has a label indicating approval by the Canadian Standards Association (CSA), and that it has never absorbed an impact before. After a bicycling accident, the helmet liner is damaged and the entire helmet must be replaced.
Water Safety
| Swimming. |
Swimming can be a safe and enjoyable activity for children and adults with epilepsy when the following guidelines are followed:
check with your physician before swimming
don't swim if feeling unwell or tired
whenever possible, swim in a pool rather than a river, lake or ocean
always swim with an experienced swimmer
inform lifeguards, camp counsellors, or swimming instructors about your epilepsy
swim when the pool is not busy
ensure that medication has been taken as prescribed
don't dive unless you have been seizure free for several years and your Physician has approved diving |
| First Aid for a Seizure in Water
If a seizure occurs while a person is in the water, follow these procedures:
While in water:
Turn the person face up.
Support the face out of the water.
Tilt head back to keep airway clear.
Get the person out of the water as quickly as possible.
Once out of the water:
Place person on their left side.
Check to see if person is breathing.
If not, begin resuscitation immediately.
Call an ambulance. This is essential.
After the emergency is over:
Anyone who has a seizure in water should be taken to an emergency department for a careful medical checkup, even if the person appears to be fully recovered.
(Adapted with permission of Epilepsy Ontario) |
wear an easily identifiable bathing cap or CSA approved flotation device
| Boating. |
Follow these precautions when enjoying boating activities:
never go out on the water alone
always wear a CSA approved life vest
wear polarized sunglasses if seizures are triggered by flashing light, such as the reflection of sunlight on water
(Excerpted with permission from a brochure by Epilepsy Ontario) |
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