Epidemiology and Nomenclature

Epilepsy affects approximately 2% of the population. In three-quarters of these cases, the diagnosis is made before the age of 21 years. Thus, epilepsy is a relatively common condition that may affect individuals during the years of sport participation.

Epilepsy is a neurological disorder of the brain characterized by recurrent (more than two) seizures. It has been estimated that approximately 10-30% of the population will have a seizure at some time in their lives. However, neither single episodes of seizures during adolescence or adult life, nor febrile convulsions in infancy, constitute a diagnosis of epilepsy.

The terms 'seizure ', 'epilepsy',  'convulsion' and 'fit' are often used interchangeably. The term 'seizure' will refer to an epileptic seizure and the term 'convulsion' will be used to describe the movements during an episode without implying a specific etiology.

Pathology

A seizure usually occurs suddenly and is the result of an abnormal electrical discharge within the brain. In the vast majority of cases, the cause of the electrical disturbance in the brain is unknown. In a small percentage of cases, either specific genetic inheritance or structural anatomical abnormalities can induce seizures. Cortical scars related to head injuries , stroke and other intracranial injuries may also cause seizures. During the seizure there may be an initial prodromal  stage ('aura'), followed rapidly by disturbances in movement and alterations in consciousness.

Epilepsy can be classified by criteria developed the International League Against Epilepsy (ILAE), This classification utilizes the electro clinical features of the seizure to make a syndromal or etiological diagnosis, which then has important implications for management. In the broadest sense, the ILAE classification breaks seizures into generalized or focal (depending on the origin of the seizure), and complex or partial (depending upon whether consciousness is preserved during the episode). Outside of neurological practise, the specific epilepsy subtype may be difficult to quantify and subjects are often simply reported to have a generalised seizure. This type of seizure was previously known as 'grand mal' but this term has fallen out of favor and should be avoided.

Generalized tonic-clonic seizure

In the generalized tonic-clonic seizure, the patient usually falls to the ground and goes through a 'tonic' phase of muscle stiffness followed by a 'clonic 'phase of muscle twitches prior to resolution of the attack. After the attack, the patient is usually sleepy, confused and may have a headache. The average length of the seizure is usually no more than 30 seconds, although most people who have witnessed someone having a feel that the attack seems to last much longer.

Convulsions that are not due to epilepsy

In addition to the true epilepsy seizures described above, there are other situations where convulsions may occur. These may superficially resemble epilepsy although the etiology of such syndromes is distinct different. These have the potential to cause confusion for non-neurologists and the eyewitness history usually provides the basis of the diagnosis. The two commonest situations are listed below:

1. Concussive convulsions, where a convulsion may be a manifestation of the concussive impact. Although usually brief and limited to tonic posturing, it may occasionally result in a prolonged convulsion over several minutes. These are being phenomena and require no specific management beyond that of the underlying concussion .

1. Convulsive syncope, where convulsive movements (including generalized movements, tongue biting and incontinence) occur in the setting of a syncopal faint.

In both situations the convulsive movements result from reflex phenomena, not epileptic discharge.

Diagnosis of epilepsy

The diagnosis of epilepsy relies primarily upon the clinical history and on the nature of the electro-encephalogram (EEG) changes. The most important and useful diagnostic consideration is history from an eyewitness who has seen and can describe the attack, particularly the onset and offset of the seizure. Any patient observed to have a seizure should be referred to a neurologist for assessment.

Treatment

The role of specific treatment in patients with a single seizure or recurrent seizures (epilepsy) requires an understanding of the nature of the seizure disorder and its natural history as well as individual patient consideration. In some situations, drug treatment should begin after a single seizure. Consideration of lifestyle factors in the overall management is paramount. Specific factors that may lower seizure threshold include sleep deprivation, alcohol and use of recreational drugs. Patients must be specifically counseled about such lifestyle issues when they begin pharmacological therapy.

More than half the individuals taking antiepileptic medication for idiopathic generalized epilepsy can expect to be seizure-free with minimal restriction on their lifestyle. Approximately one-third may have only an occasional seizure, which usually does not greatly limit their lifestyle. The other 20% will have seizures frequently enough to restrict their lifestyle to some extent.

The medications used in the treatment of epilepsy may cause a number of side-effects, including tiredness, poor concentration, impairment of coordination and cognitive impairment. In some cases, medication (e.g. phenytoin) toxicity may result in permanent neurological symptoms.

Exercise Prescription

Regular physical activity is advocated for individuals with epilepsy. In general, people with epilepsy report better seizure control when exercising regularly. Occasionally, some individuals will have more seizures with exercise, and hence every case must be treated individually. Persons with epilepsy have no higher injury rate in sport than those without epilepsy and sport participation does not affect serum drug levels.

In a sample of over 200 patients with epilepsy in Norway, exercise patterns were similar to that of the average population. In the majority of the patients, physical exercise had no adverse effects and over a third of patients claimed that regular exercise contributed to better seizure control. In 10% of patients, exercise appeared to be a seizure precipitant and this applied particularly to those with symptomatic partial epilepsy (i.e. underlying structural brain lesion). The risk of sustaining serious seizure-related injuries while exercising in this population was modest.

There are a number of important considerations when counseling the individual who has epilepsy and wishes to exercise. Patients having frequent seizures must be discouraged from activities such as scuba diving, horseback riding or rock climbing. Sports where any impairment in split-second neuromuscular timing is dangerous (e.g. motor racing or downhill ski racing) should also be avoided. Patients with epilepsy will not be affected adversely by participating in contact sport provided the normal safeguards for participation are followed.

The frequency of seizures is important when considering activities such as swimming, where the potential for serious injury exists if a seizure were to occur. Generally, swimming is allowed under supervision (e.g. with a 'buddy'). Swimming with a companion is a sensible rule for all swimmers, not just those with epilepsy.

The physical and psychological wellbeing of the individual also requires attention. In children particularly adolescents, participation in activities is important in establishing a good self-image and gaining peer group acceptance. Therefore, it is important to allow the child with epilepsy to pursue many activities. Absolute and relative contraindications to sporting activities.

Conclusion

Overall, people with epilepsy are able to participate sport with few limitations. Occasionally, it is appropriate to restrict certain physical activities. A with epilepsy must meet certain  legal obligations when driving a car. The individual with epilepsy take his or her medication correctly and ensure well-balanced eating and sleeping schedule. Family friends, team mates and coaches must be aware of the epilepsy and understand what to do in the event of a seizure. All these factors will contribute to removing unnecessary barriers to a normal active lifestyle in those with epilepsy.