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• The most common treated
conditions treated by
neurologists are:
–1. Headaches
–2. Epilepsy
The Prince
• A different view of epilepsy
– http://www.epilepsycolorado.org/
Epilepsy & Seizures
Cody Butler, SPT
Fall 2009
U of CO Hospital
Objectives
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Define seizures and epilepsy
Discuss the terminology of different types of seizures
Explain risk factors and common triggers for seizures
Discuss ETOH Withdrawal and seizure activity
Explain status epilepticus and the physiological consequences
associated with it
• Understand basic pharmaceutical, medical, and physical
therapy interventions of epilepsy
• Understand reasons for increased seizure activity and
protocols associated with them
• Discuss resources for patients/family diagnosed with epilepsy
Seizures & Epilepsy
• Seizures
– Excessive/synchronous neuronal activity in the brain
– alteration in mental state, tonic/clonic movements,
convulsions, and various other psychic symptoms
– Occur in 4-5% of children1
• Epilepsy
– common chronic neurological disorder
– recurrent, unprovoked seizures
• Seizures can occur in people who do not have
epilepsy
Types of Seizures (terminology)
• Localized within brain
– Partial onset
• Simple
– Consciousness unaffected
• Complex
– Focal onset
• Distributed within brain
– Generalized
• Involve loss of consciousness
• According to body effect
– Absence, myoclonic, clonic, tonic, etc.
Risk Factors for Epilepsy
• Family history of epilepsy
– ↑ risk of 2.5 times2 of developing a seizure
disorder.
• Head injuries
• Brain infections
• Stroke
Common Seizure Triggers
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Sleep deprivation
Stress
Flashing bright lights
Alcohol use
Specific foods
Certain medications
Causes of Seizures without Epilepsy
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Hypoglycemia, hyponatremia, hypoxia
Drug withdrawals
Tumors/abscesses
Drug intoxication
Sleep deprivation
Head Injury
Encephalitis/meningitis
ETOH Withdrawal & Seizures
• Seizures occur in alcoholics
– Long-term kindling effect of recurrent detoxifications
– Short-term effect of ethanol exposure.
• Direct correlation3
– average daily alcohol consumption and seizures
prevalence
• Stronger correlation
– seizure prevalence and the # of times a person
underwent inpatient detoxification
Status Epilepticus
• 1993 Classical Definition1:
– >30 min of:
• Continuous seizure activity
• Repeated seizures without regaining consciousness
• Practical Definition
– >10 min of:
• Continuous/repeated seizures
• Seizures on arrival in ER/hospital or when seen
Physiological Consequences1
of Status Epilepticus
• Hypoxia, Hyperthermia,
Acidosis
• Increased
catecholamine release
• Leukocytosis
• Increased BP and
Pulmonary vascular
pressure
• Pulmonary transvascular fluid flux
• Increased Cerebral
Blood Flow (CBF)
• Increased cerebral
metabolic activity
Pharmaceutical Interventions
• Single Seizures w/ a reversible precipitant4
– Don’t require drug therapy
• Candidates for antiepileptic drug therapy
– Patients with recurrent seizures
– Status epilepticus
– A clear predisposition for seizures
Pharmaceutical Interventions
(continued)
• Seizure disorders
• Increasingly common >60 years of age4
• Can have a significant impact on functional status
• Goal of drug therapy
• Control seizures AND preserve quality of life.
• Use just one agent given in the lowest effective dosage
• Dosage changes guided by clinical response (NOT drug levels)
• All antiepileptic drugs cause different side effects.
• Common drugs in elderly patients
• carbamazepine, valproic acid, oxcarbazepine, gabapentin, and
lamotrigine
Medical/Surgical Interventions2
• Ablative Surgery
– Surgically remove areas of brain that produce seizures are
– Not a replacement for taking medication*.
• Vagus Nerve Stimulation
– Electrical impulses directed into the brain through the
vagus nerve in the neck
– Sent by a surgically implanted electrode
• Ketogenic Diet
– High in fats and low in carbohydrates
– Eliminates seizures entirely in some children
– Not used in adults
U of CO Hospital Seizure Monitors
• Phase I
– Capture brain activity w/ electrodes on scalp
– Electrodes connected to an EEG machine
– Seizure origins are found
• Phase II
– Strip grids & depth electrodes placed directly on
surface of brain
– Provide more accurate information
U of CO Technology
• Video electroencephalogram (EEG)
– Monitors the brain with electrodes
– diagnoses patients with intermittent/infrequent
disturbances
• Positron Emission Tomography (PET)
– Metabolic studies
– Locate areas of the brain that aren’t functioning
normally
• Magnetoencephalography (MEG)
– Measures magnetic brain activity in the brain
PT Interventions
• Exercise recommended5 to all patients
– Should be individualized
– Frequent seizures associated w/ sudden falls should
be restricted in their activity
• 1994 study6
– Active subjects
• Tended to report fewer seizures than inactive subjects
• Depression problems are significantly lower
– Inactive subjects
• Higher % reported experiencing seizures during exercise
PT Interventions (continued)
• 1994 Study7
– 15 women w/ pharmacologically intractable epilepsy
• Aerobic dancing + strength training + stretching
– 60 min, twice weekly, 15 weeks
• Seizure frequency self-recorded before, during,
and after intervention
• Results
– self-reported seizure frequency was significantly
reduced during the intervention period
Exercise-Induced Seizures
• May occur infrequently8
• The patho-physiologic mechanism remains
unclear9
• Are not related to:
– Epilepsy diagnosis
– Type of activity
– Heart Rate
Causes of increased seizure activity
• sleep deprivation
• irregular use of
medication
• Alcohol consumption
• interactions with
certain other medicines
• in photosensitive
people, exposure to
flashing lights/repetitive
patterns
• Brain condition
undergoes changes
• pregnancy
Case Study10
• 27 year old male with uncontrollable seizures
– Age 5: TBI
• 2 weeks later: Drooling and staring episodes
– By age 6: L-sided focal motor seizures began
• Anticonvulsant meds . . . little improvement
– Age 14: R Temporal lobectomy
• Did not reduce seizures
– Age 18: Partial corpus callosotomy (aborted)
• Hemorrhage along sagital sinus
– Next 9 years: anticonvulsant meds (didn’t help)
• Multiple daily seizures + L hemiparesis + impaired cognition
– Age 27: more frequent complex partial seizures
• Right Functional Hemispherectomy
Case Study (continued)
• 9 Post-op PT sessions during acute care
• Outcomes
– Rapid gains
• Surpassed initial PT goals
– At d/c
• Distal left-sided sensori-motor impairments
• Ambulated 400 ft w/ assistance for balance
• Discussion. . . the rapid gains
– Brain injury at young age triggered pre-op function
transfer to unaffected left hemisphere (?)
– Plasticity of the CNS (?)
Resources for patients
• Epilepsy Foundation & Epilepsy Foundation of CO
• Epilepsy Education/Support Group (U of CO)
– For patients, family members and friends
– 3rd Wed. of each month from 7 – 9 p.m.
• Seizure Response Dog
– Trained to summon help or ensure personal safety
when a seizure occurs
– Not suitable for everybody
– A dog may develop a 6th sense of recognizing a
seizure before it occurs (rare phenomenon)
Questions/Comments
References
1. Holt P. Acute Care Symposium: Status Epilepticus and Approach to Childhood Seizures. July 14, 2009.
2. http://www.uch.edu/conditions/brain-nerves/epilepsy/index.aspx. Accessed Sept 15, 2009.
3. Lechtenberg R, Worner T. Total ethanol consumption as a seizure risk factor in alcoholics.
4. Velez L, Selwa L. Seizure Disorders in the Elderly. Am Fam Physician. 2003; 67: 325-32.
5. Nakken K, Bjorholt P, Johannessen S, Lpryning T, Lind E. Effect of physical training on aerobic capacity, seizure
occurrence, and serum level of antiepileptic drugs in adults with epilepsy. Epilepsia. 1990; 3(1): 88-94.
6. Roth D, Goode K, Williams V, Faught E. Physical Exercise, Stressful Life Experience, and Depression in Adults
with Epilepsy. Epilepsia. 1994; 35(6): 1248-1255.
7. Eriksen et al. Physical Exercise in Women with Intractable Epilepsy. Epilepsia. 1994; 35(6): 1256-1264.
8. Korczyn AD. Participation of epileptic patients in sports. J Sports Med. 1979; 19: 195-8.
9. Schmitt B, Thun-Hohenstein L, Vontobel H, Boltshauser E. Seizures induced by physical exercise: report of
two cases. Neuropediatrics. 1994; 25(1): 51-53.
10. Bates A, Zadai C. Acute Care Physical Therapist Evaluation and Intervention for an Adult After Right
Hemispherectomy. Phys Ther. 2003; 83: 567-580.
Thank you everyone.