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Head, Neck, and Spine

Seizure Disorders and Exercise/Sports Participation

Carter, James Milton MD; McGrew, Christopher MD

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Current Sports Medicine Reports: January 2021 - Volume 20 - Issue 1 - p 26-30
doi: 10.1249/JSR.0000000000000799
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Abstract

Introduction

Traditionally, persons with epilepsy (PWE) have been counseled on avoiding participation in sports and physical activity. On the surface, this may seem like a reasonable recommendation to protect both PWE and those around them in the event of a seizure during an inopportune moment. However, this overprotective approach has led to further ignorance and stigma regarding this relatively common condition. Just as no two people in the general population are the same, no two PWE are the same. Thus, universalized recommendations that do not account for the individual person, seizure type, frequency, and control are too restrictive and ultimately, harmful. To limit exercise for PWE is to unnecessarily deny them the physiological and psychological benefits of physical activity that are well established in the literature.

The topic of PWE and exercise/sports participation has been debated extensively with research showing the benefits of physical exercise on seizure frequency and severity. As such, the medical community has altered its approach to recommendations regarding PWE and sports participation/exercise programs. While there are recommended absolute contraindications for PWE in a relatively small number of sports, such as scuba diving or motor sports, PWE can safely participate in the vast majority of sports with the correct counseling and careful observation.

Epidemiology

It is estimated that up to 10% of people worldwide will have one seizure in their lifetime. One seizure does not imply epilepsy, which is defined as having two or more unprovoked seizures. There are around 65 million people worldwide who have epilepsy, making it one of the most common neurological diseases globally. Epilepsy also is a treatable condition. Up to 70% of people living with epilepsy could live seizure-free if properly diagnosed and treated. However, nearly 80% of PWE live in low- and middle-income countries with three quarters of those in low-income countries not receiving adequate treatment (1).

History of Restrictions Levied against PWE

The stigma surrounding epilepsy is deeply rooted in longstanding fear, misunderstanding, and stigmatization. In both India and China, epilepsy is commonly viewed as a reason for prohibiting or annulling marriages. In the United States, until the 1970s, it was legal to deny people with seizures access to theaters, restaurants, recreational centers, and other public buildings (1). As society has slowly come to a better understanding of this disease through scientific research, the physical, emotional, and social impacts of this disease have become more apparent.

In 1968, the American Medical Association (AMA) recommended restricting the physical activity of PWE because of fear of inducing seizure activity or causing injury (2). This was in fact the norm up until the mid-1970s when multiple studies presented arguments for and against participation in contact sports for PWE. For example, Livingston and Berman (3) challenged the AMA, citing lack of medical literature to support their claims that PWE were at increased risk of injury or that repeated head trauma increased the risk of seizures. The AMA Committee on Medical Aspects of Sports changed its stance in 1974, stating that all cases should be judged individually, and participation in contact sports should be permitted if “to do so is considered a major ameliorating factor in the patient's adjustment to school, associates, and the seizure disorder” (4). The American Academy of Pediatrics (AAP) Committee on Children with Handicaps and Committee on Sports Medicine followed suit in 1983, outlining a position that included allowing PWE to play in most sports if seizures were properly controlled and proper supervision was provided (5). The policies of the AMA and AAP have continued to change over time, becoming more liberalized in the process. In 2008, the AAP published a policy statement concluding that children with epilepsy and controlled seizures have no limitations in sporting events. Those with poorly controlled seizures require an individual assessment to prevent injury (6).

More recently, organizations, such as the World Health Organization, the International League Against Epilepsy (ILAE), and the International Bureau for Epilepsy, have led the Global Campaign Against Epilepsy to provide better information and raise awareness about epilepsy and to strengthen public and private efforts to improve care and reduce the disease's impact (1).

The Impact of Exercise/Sports Participation on Epilepsy

The health benefits of regular physical activity for people with seizures have been proven. PWE obtain the same benefits from physical activity as the general population, including reduced risk of obesity, hypertension, diabetes, and coronary artery disease. However, because of lack of information, the importance of physical activity is often ignored in this population by health professionals and PWE alike.

Previous studies have highlighted the negative factors associated with epilepsy and quality of life, including marital status, sex life, drug side effects, and education status (7,8). One study used a questionnaire about quality of life and daily habits of PWE when compared with controls. Of note, they found that patients with epilepsy reported healthier lifestyle habits after diagnosis, including smoking less, lower alcohol consumption, and lower BMI. However, they were more often unemployed and had higher risk of anxiolytic/antidepressant use (9).

When considering exercise programs, some have raised concerns regarding negative risk factors, including the physical stress of competition, hyperventilation, and alterations in antiepileptic drug (AED) levels among many others (10–12).

There appears to be a link between physical stress and epilepsy, although further studies are needed to assess the exact relationship between the two. The response of the hypothalamic-pituitary-adrenal (HPA) axis to maintain homeostasis when challenged with acute and chronic physical stress may increase seizure frequency. However, this stress on the HPA axis also may in theory secondarily decrease seizure frequency (13).

When considering hyperventilation, absence seizures are known to be triggered by hyperventilation. Hyperventilation also is expected during physical exercise. Thus, one might infer that hyperventilation during exercise may trigger seizure activity. However, hyperventilation at rest leads to hypocapnia and vasoconstriction, which could result in seizure. Hyperventilation with activity is a physiological response to increased metabolic demand and prevents hypercapnia. There is some thought that this also may suppress interictal abnormalities (11,12).

In regard to AEDs, exercise is thought to increase liver-enzyme metabolism. For those AEDs that are metabolized by the liver, exercise could lead to greater drug clearance, thus decreasing serum levels of the drugs and making the participant susceptible to seizure. Some studies have shown no change in metabolic rate of these drugs during exercise, while others have shown slight, statistically irrelevant changes with no effect on seizure frequency (14,15). In general, checking AED levels in physically active PWE is based on an individual clinical assessment.

Interestingly, there also has been research to assess the role of physical exercise programs to prevent epilepsy. It has been suggested that alterations in neurotransmitter systems induced by physical exercises could mediate the inhibitory/excitatory balance in the brain to reduce seizure development and frequency (16).

There also is evidence that early exposure to physical activity can result in a neural reserve that can be used throughout the course of life, suggesting that exercise may improve lifelong brain function and reduce the risk of future brain disorders (17,18). Gomes de Silva et al. (19) examined whether physical exercise exposure during postnatal brain development in rats could modify seizure susceptibility later in life. They exposed rats to daily aerobic exercise for 40 days and found that exercise delayed the onset and reduced the intensity of pilocarpine-induced motor symptoms in midlife rats. Clinically, physical activity is often referenced as a means of reducing the risk of common conditions, such as hypertension, diabetes, and obesity. Research such as this suggests that this same reference could be made in regard to epilepsy and emphasizes the importance of encouraging physical activity at a young age.

Comorbid Conditions

Psychiatric conditions, such as anxiety and depression, are frequent comorbidities associated with epilepsy. Abnormalities in neurotransmitters, such as serotonin, norepinephrine, and dopamine, have been connected to both epilepsy and mood disorders. Participation in a regular exercise program will result in the synthesis and release of dopamine, serotonin, and norepinephrine. This reduces stress and can ultimately provide mood benefits while reducing seizure susceptibility (16,20). Even single sessions of moderate aerobic exercise can provide acute improvements in mood (21). Studies also have shown this benefit in PWE. Nakken et al. (14) found that PWE had an improved mental state, self-esteem, and became more sociable after participation in a 4-week exercise program. In their randomized control study, McAuley and group (22) found improvement in mood and self-esteem in PWE who exercised for 12 weeks when compared with those who did not exercise. Eriksen et al. (23) similarly found that women with medically refractory epilepsy had improved psychosocial functioning and quality of life when involved in a regular exercise program for 15 weeks, although there were no significant changes in anxiety and depression scales.

Obesity is another common comorbidity associated with epilepsy. From a pharmacological standpoint, weight gain is a known side effect of some antiepileptic medications (24). One study showed that children with untreated, newly diagnosed epilepsy presented with a higher body mass index at baseline when compared with children with no epilepsy diagnosis (25). Animal studies also have shown significant increase in body weight in the long term associated with epilepsy (26). Wong and Wirrell (27) compared children with epilepsy to their siblings without epilepsy. There were more overweight cases in teens with epilepsy when compared with controls. This finding also was consistent with reports of decreased physical activity by parents.

Does the Type of Exercise/Sports Participation Matter?

In general, seizures are rarely triggered by physical activity. There has been concern that repeated head injury during contact sports may precipitate seizure. There is no evidence that minor head trauma exacerbates seizures. There have only been a few cases of seizure occurring during contact football that have been identified. It is thought that the mild nature of most head injuries that occur during physical activity is highly unlikely to induce epilepsy (11,28).

Studies have shown that aerobic physical activity can decrease seizure frequency. Nakken et al. (15) studied epileptiform EEG discharges in children with intractable partial and generalized epilepsy during exercise. They found that for the majority of tested children, epileptiform EEG discharges decreased during exercise. Furthermore, interictal epileptiform activity on EEGs remained unchanged. Camilo et al. (29) subjected patients with temporal lobe epilepsy to exhaustive exercise with none of the participants experiencing seizures during or after exercise. Some rat studies have even shown that strength training improved seizure frequency (30). Overall, the literature suggests that physical activity, regardless of type or intensity, can be performed by PWE.

Risk of Injury in PWE

The risk of injury during physical activity for PWEs is the often-cited reason that exercise has been traditionally restricted for this population. In general, PWE have higher risk of injuries. Nakken (31) assessed the risk of sustaining seizure-related injuries while exercising in a sample of 204 outpatients with epilepsy compared with age and sex matched controls in the general population. Of the 45% of participants who reported injuries associated with seizures during exercise, 94% had minor injuries consisting mostly of soft tissue injuries. Nakken and Lossius (32) also conducted a prospective study with 62 patients with severe therapy-resistant epilepsy. Only 1.2% of seizures resulted in injury, the most common being head trauma, burns, fractures, and submersion injuries.

The type and severity of seizure is important in assessment of injury risk. Patients with uncontrolled epilepsy, generalized tonic-clonic and atonic seizures are at higher risk of injury both during physical activity and normal daily activities. Even so, research shows the most common type of related injury is related to soft tissue injuries.

Sports-Specific Activity Recommendations

The risk-benefit analysis of whether an athlete with seizures should participate in specific sports or physical activities should be an individualized one. There are multiple factors to consider, including type and severity of seizures, consistency of any prodromal manifestations, history of any seizure-precipitating factors, the likelihood of effective supervision of the athlete, and the willingness of the athlete/guardian to take a reasonable level of risk (33).

PWE and participation in swimming/water sports has been assessed in literature. The risk of drowning during a seizure traditionally led to the recommendations to avoid water sports in PWE. In their population-based cohort study, Diekema et al. (34) analyzed epilepsy as a risk factor for drowning and submersion deaths among children. They found that children with epilepsy had a relative risk of 13.9 for submersion and 13.8 for drowning compared with nonepileptic children. There was a 10-fold increase in risk of drowning and submersion, especially in older children and those without direct supervision. The group ultimately concluded that even though submersion accidents occur in a greater proportion for children with epilepsy, they can swim safely with constant supervision as major injuries and death can be prevented. Bell et al. (35) published a meta-analysis in 2008 on the risk of drowning in PWE, reporting a 15- to 19-fold increased risk of death because of drowning compared with the general population. This risk seemed to be lower in children because they were more likely to be supervised during these activities. General recommendations for persons with controlled epilepsy when swimming or participating in water sports always include swimming with direct supervision of trained professionals, no swimming in unsupervised open waters, and always wearing a life vest when in a boat (36).

Most literature advises against scuba diving. Almeida and group (37) provided more liberal guidelines. They assessed the risk to PWE and diving companions during scuba diving. They concluded that even though the risk of death associated with diving was greater in PWE, if they were seizure free for a minimum of 4 years, the risk of seizure while diving was minimal. It was estimated that for PWE who met this criterion, the chance of a seizure occurring during a 60-min period under normal, nonstressful diving conditions would be less than 1 in 40,000.

The ILAE Task Force on Sports and Epilepsy has provided general guidance regarding sports participation in athletes with seizures, most recently in 2015. The group divided sports into three categories based on potential risk of injury or death should a seizure occur. Group 1 (no significant additional risk) included sports in which the occurrence of seizures poses no additional risk of injury for either PWE or bystanders. This group contains sports, such as collective sports on the ground (baseball, basketball, football, field hockey, etc.), dancing, racquet sports, and most collective contact sports (wrestling, judo, etc.). Group 2 sports are those that involve a moderate risk of physical injury for PWE but no risk for bystanders. Sports, such as swimming, gymnastics, cycling, horse riding, are included in this group. Group 3 sports carry a high risk of injury or death for athletes with seizure disorders as well as bystanders. This group contains sports, such as aviation, diving, climbing, scuba diving, and surfing (33). See the Table for the complete recommended sport grouping by the ILAE.

Table - Categorization of sports by level of risk of injury or death for PWE, or for bystanders, should a seizure occur during the event.
Group 1 Sports (No Significant Additional Risks) Group 2 Sports (Moderate Risks to the PWE but Not Bystanders) Group 3 Sports (High Risk for PWE, and for Some Sports, Also for Bystanders)
Athletics (except for sports listed under group 2) Alpine skiing Aviation
Bowling Archery Climbing
Most collective contact sports (judo, wrestling, etc.) Athletics (pole vault) Diving (platform, springboard)
Collective sports on the ground (baseball, basketball, cricket, field hockey, football, rugby, volleyball, etc.) Biathlon, triathlon, modern pentathlon Horse racing (competitive)
Cross-country skiing Canoeing Motor sports
Curling Collective contact sports involving potentially serious injury (e.g., boxing, karate, etc.) Parachuting (and similar sports)
Dancing Cycling Rodeo
Golf Fencing Scuba diving
Racquet sports (squash, table tennis, tennis, etc.) Gymnastics Ski jumping
Horse riding (e.g., Olympic equestrian events — dressages, eventing, show jumping) Solitary sailing
Ice hockey Surfing, windsurfing
Shooting
Skateboarding
Skating
Snowboarding
Swimming
Water skiing
Weightlifting

The ILAE also offered suggestions for a series of individual conditions. For persons with one or more acute symptomatic seizures related to a transient factor that temporarily lowers the seizure threshold, the risk of further seizures would be relatively low with resolution of the causative factor. The task force suggests that these individuals be permitted to compete immediately in Group 1 sports. They also may compete in Group 2 and 3 sports at a neurologist’s discretion.

For people with a single unprovoked seizure, these individuals should be able to compete immediately in Group 1 sports after medical evaluation. After 12 months without another seizure, these individuals should be allowed to compete in Group 2 and 3 sports or sooner based on medical evaluation of each individual case.

The group also made recommendations for PWE with sleep-related seizures only, those continuing to have seizures without or with impaired awareness, and those undergoing medication withdrawal.

After 12 months of seizure freedom, PWEs may compete in all sports. The ILAE defines epilepsy resolution as seizure freedom for the last 10 years and off AEDs for at least the last 5 years. These persons also should be allowed to participate in all sports.

Concussive Convulsions

Although not a seizure phenomenon, concussive convulsions are occurrences that can mimic seizure activity and warrant a brief mention. Concussive convulsions are defined as an initial period of brief tonic stiffening followed by myoclonic jerks. The motor occurrences are usually bilateral but often asymmetrical. They occur within seconds of impact and last for a short period of time, often only seconds with some cases lasting up to 3 min. The mechanism for concussive convulsions has not been extensively explained. A common hypothesis of the general pathophysiology likely involves a brief, immediate cortical loss of cortical inhibitory function with possible reflex brainstem release similar to convulsive syncope (38). These episodes are not associated with structural or permanent brain injury and are a nonepileptic. Nicholas et al. (39) performed a systematic review of literature regarding sport-related concussive convulsions, noting low incidences of imaging studies with positive findings, EEGs with abnormal findings, long-term sequelae, and AEDs required for pharmacologic control. Based on these findings, the authors suggested that the presence of concussive convulsion in the absence of clinical red flags should not be the sole indication for additional work-up. The development of a seizure disorder post concussive convulsion also seemed very rare, suggesting extended follow-up does not appear to be necessary. These findings are in line with the most recent consensus statement regarding sports related concussion released by the Concussion in Sport Group, which indicated that convulsions require no specific management beyond the standard treatment of the underlying concussion (40).

Conclusions

PWE have traditionally been restricted from participation in certain sports and physical activities. Often these restrictions were based on overcautious opinions rather than scientific evidence. As such, PWE have not been able to enjoy the physical and psychosocial benefits of living a physically active lifestyle, including increased self-esteem and improvement in general health. Many studies have demonstrated that PWE can participate in the majority of sports and physical activities with minimal risk to themselves or others. Physical activity is a vital component to a high quality of life; epilepsy is not a reason to restrict physical activity but rather to encourage it. The medical community should continue to advocate for PWE to afford them the same lifelong benefits of exercise available to the general population.

The authors declare no conflict of interest and do not have any financial disclosures.

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