Epilepsy Essentials: Physical Activity and Epilepsy

People with epilepsy often have sedentary lifestyles and also have a higher prevalence of obesity than the general population.¹ Historically, there has been a cautious and even overprotective mindset toward people with epilepsy by their loved ones, caregivers, and health care professionals that adversely influenced the levels of physical activity in this population.² Among the guiding tenets of medicine emphasized in the Hippocratic Oath is to “first, do no harm,” from the Latin phrase, “primum non nocere,” which has doubtlessly contributed to past recommendations for people with epilepsy to avoid physical activity. In 1968, the American Medical Association (AMA) recommended restriction of contact sports for people with epilepsy to avoid injury or the possibility of inducing seizures.³ By 1974, the AMA position was modified to allow people with epilepsy to participate in contact sports with the caveat that “each participant should be judged on an individual basis.”⁴ Over the last few decades, a shift has continued toward encouraging people with epilepsy to pursue physical activity and sports.⁵ In 2016, the International League Against Epilepsy (ILAE) published a report from the ILAE Task Force on Sports and Epilepsy that advocated for the participation of people with epilepsy in sports in the context of an individualized risk assessment.⁶ Despite this change, multiple recent reviews suggest people with epilepsy remain less active than their peers.^7-10

Safety and Benefits of Physical Activity

People with epilepsy and their families often limit their physical activity because of safety concerns (eg, fear of injury if a seizure were to occur during physical activity or increased risk of seizure because of physical activity).⁵ These apprehensions are largely unfounded. Although there have been reports of seizures induced by physical activity in people with epilepsy,¹¹ this appears to be the exception rather than the rule.^12-15 In a study of 400 people with epilepsy, only 2 individuals had seizures induced by exercise.¹² The ILAE has published a risk stratification of sports for people with epilepsy, including sports that carry no significant additional risk of injury for people with epilepsy or bystanders.⁶ There have also been reports of physical activity reducing both seizure frequency and interictal epileptiform discharges in people with epilepsy and even proposals that exercise should be included as a complementary treatment for epilepsy.^13-15

Improved mood and sleep are among the many positive effects of physical activity.¹⁶ In people with epilepsy, who are known to have a higher risk of depression¹⁷ and cognitive difficulties, physical activity has been associated with a higher quality of life and improved cognition.^18-20 Recent meta-analysis suggests the prevalence of comorbid anxiety and depression in people with epilepsy is 20.2% and 22.9%.²¹ Armed with this knowledge, we can do more for people with epilepsy by encouraging physical activity and educating our patients on how to exercise safely. Prescribing exercise could certainly serve as a low-cost treatment option to address multiple challenges faced by this population.

Increasing Physical Activity

The most commonly tested method of increasing physical activity in people with epilepsy is required, regular physical activity over an intervention period,^2,22-24 with reported positive outcomes. Any physician, however, can attest to the challenges of convincing their patients to start a structured exercise program. Other methods studied include behavioral counseling,²⁵ exercise education and goal setting,²⁶ and even epilepsy surgery,²⁷ none of which affected the level of physical activity for participants. In today’s high-tech environment, a natural next question is how we can use technology to make physical activity more enticing to people with epilepsy in a way that can be feasibly incorporated into a busy clinician’s daily practice. Wearable physical activity trackers have been shown to increase physical activity in people with chronic lung disease or heart disease and may be an effective tool to encourage increased physical activity in people with epilepsy.^28,29

With a grant from the Texas Neurological Society, a randomized controlled clinical trial has been launched to further investigate the use of activity trackers in people with epilepsy at the University of Texas Health Science Center at Houston (UTHealth). The objective is to evaluate standard-of-care exercise education alone vs with a wearable physical activity tracker in people with epilepsy. Outcome measures will include level of physical activity, depression, anxiety, quality of life, sleep, and seizure frequency. Participants in the activity tracker group will also have their daily step count, daily distance, and daily active minutes monitored.

Summary

Among health care professionals, physical activity has gone from being a perceived risk to a perceived benefit for people with epilepsy. Studies have shown that for people with epilepsy specifically, increased physical activity improves symptoms of depression, quality of life, and cognition. Although physical activity may often be recommended to and even desired by people with epilepsy, data suggest they are more sedentary than the general population. Increasing physical activity can be challenging for patients and clinicians alike. Physical activity trackers have been shown useful for increasing activity in people with other chronic conditions and may be beneficial for our patients with epilepsy as well.