CHAPTER KEY WORDS

• Acute care
  
• Epilepsy
  
• Nonepileptic seizures
  
• Sports participation
  
• Stigma of epilepsy

CHAPTER SCENARIO

Shane is the athletic trainer for a Division II collegiate swimming and diving program. After an early-morning practice, he notices a group of student-athletes circled around a teammate. On initial evaluation, the student-athlete is upright and aware. She is an 18-year old freshman who describes an intense feeling that “elevator music was playing on the pool deck” for an unknown amount of time. This happened as she was sitting on the edge of the pool after practice. She reports that she could hear her teammates talking around her, but she could not recall what they were talking about. After her episode, she describes being slightly dazed and confused and tells her teammates to wait with her while she “gets her head straight.”

After they arrive at the athletic training room, the student-athlete informs Shane that this is not the first time that something like this has happened. There have been 2 other incidents during her high school career following early-morning workouts. She did not report these to anyone because she thought it was due to the time of occurrence and intensity of the workouts.

How would you classify the type of seizure that this student-athlete experienced? Where would you refer this student-athlete? Could this individual be cleared for return-to-sport, and what special considerations would need to be made for this athlete to continue participation in swimming?

SCENARIO RESOLUTION

This epileptic seizure would be classified as a focal onset seizure with impaired awareness. Even though the patient was able to mildly interact with her environment, she was not able to interpret her teammates or the circumstances surrounding her, and she demonstrated mild confusion. The athlete should be seen by her primary care physician or team physician, with referral to a specialist with experience in the treatment of epilepsy. This athlete would be considered for a return-to-sport following these referrals and proper management of her condition with antiepileptic drugs and other treatment measures. Special considerations would have to be made during her swimming events. Swimming is a Group 2 sport that does pose some risk to her if an epileptic event were to occur while she was in the water.

Epileptic seizures are defined as a transient occurrence of signs and/or symptoms due to abnormal, excessive, or synchronous neuronal activities of the brain.1 An imbalance in the signaling between neurotransmitters and/or changes in the structural channels within brain cells can cause symptoms that drastically affect a person’s quality of life. Changes in the normal electrical brain activity of an individual can result in alterations to awareness, perception, behavior, and/or physical movements.² These changes can last from a few seconds to several minutes, depending on the severity of the seizure.

The effects of seizures can cause persistent health-related concerns that have been associated with restrictions in physical activity and sports participation due to fear of causing seizures or increasing the frequency of occurrence.^3,4 Despite medical recommendations encouraging athletic participation for individuals with seizure disorders, studies have demonstrated that those affected are less active and physically fit in comparison to those not affected.^5–8 The stigma around seizures, specifically epilepsy or seizure disorders, has caused individuals to be excluded from sports participation due to “fear, overprotection, and ignorance.”^2,5

When clearing an individual with epilepsy for sports participation, several factors need to be considered, including the type and severity of the seizures, the probability of a seizure occurring and precipitating factors, the usual timing of seizure occurrence, the type of sport participation, and the attitude of the person (and parent/guardian, if warranted) in accepting some level of risk for the athlete’s participation.³ The health care provider for athletes with epilepsy must understand these factors, as well as the risks and benefits of exercise and the current recommendations for the protection and management of individuals with seizure disorders, to promote a positive and safe environment for sports participation.

Epilepsy Epidemiology and Definition

Epilepsy, also known as seizure disorders, is the fourth most-common neurological disorder, affecting more than 50 million people, or 2% of the population, worldwide.⁴ In the United States alone, more than 3.4 million people (3 million adults and 470,000 children), or 1.2% of the population, report active or current epilepsy.⁹ Epilepsy affects people of all ages, races, and ethnicities, especially individuals from the lowest socioeconomical class due to lack of access to a proper management plan.⁹ According to the International League Against Epilepsy (ILAE),¹⁰ an individual is diagnosed with epilepsy if he or she meets any of the following conditions:

• Has had at least 2 unprovoked seizures occurring greater than 24 hours apart.
  
• Has had one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after 2 unprovoked seizures occurring over the next 10 years.
  
• Has had a diagnosis of an epilepsy syndrome.

Phases of Epileptic Seizures

While all epileptic seizures have a beginning, middle, and end, the affected individual will not notice or perceive all phases.¹¹ Common signs and symptoms that can occur throughout the progression of a seizure are shown in Table 10-1.

Prior to the beginning of a seizure, some individuals may experience a prodrome, which involves feelings, sensations, or notable changes in behavior that can precede the seizure by several minutes to several days.¹² The prodrome is not part of the seizure, but it can serve as a warning mechanism to the individual and acute health care provider to take steps to prevent a possible injury.¹¹

The beginning stage of a seizure, known as the aura phase, is marked by the presence of signs and/or symptoms that are often indescribable by the individual, but can be similar each time a seizure manifests.^11,13 Although an aura can occur before changes in awareness, some people do not experience it, and their seizure begins with a total loss of consciousness.¹¹

Epileptic seizures are generally self-limiting and last between 1 and 5 minutes, during which the middle, or ictal, phase correlates with the abnormal electrical activity in the brain that defines a seizure event.^11,14 As the ictal phase and seizure end, the individual will enter a postictal state of reorientation.^15,16 This recovery period occurs between the epileptic seizure and the individual’s return to a normal baseline. This may take a few minutes or several hours and is often characterized by confusion, drowsiness, headache, and nausea.¹⁵ Following his or her return to a normal baseline, an individual can experience muscle fatigue and exhaustion that can last several days.

Triggers and Triggering Precipitants for Epileptic Seizures

During the prodrome phase, changes can occur due to stimulants or factors known as triggers. These are usually identifiable and can be the result of an external stimulant, the individual’s mental process, or both.¹⁷ Common examples of external stimulants include eating (eg, hot and spicy food); seeing flashing lights; touching hot water; experiencing visual, vestibular, auditory and/or tangible stimulants; reading; and listening to music.¹⁷

Changes in cerebral function—including movement, emotion, thoughts, calculations, and cognitive function—can elicit an internal, mental process trigger, as can factors known as triggering precipitants.¹⁷ While not stimulants, triggering precipitants include stress, sleep deprivation, fatigue, alcohol, drug use, and menstrual cycle, which can all also lead to epileptic seizures.17,18 When identified, an individual’s trigger or triggering precipitant can be limited to increase the effectiveness of a management plan for epileptic seizures.

Classification of Epilepsy Type and Severity

In 2017, the ILAE’s Seizure Type Classification Task Force established recommendations for seizure classification.²¹ The operational goal of this group was to define seizure types in a way that was easier to interpret in clinical, teaching, and research settings¹⁰ (Figure 10-1). When describing epileptic seizures, 3 main areas of focus are identified for an accurate classification of type: type of onset or beginning of a seizure, the individual’s level of awareness throughout the seizure, and whether the individual has movement symptoms during the seizure.^22–24

Type of onset identifies where the seizure began in the brain and can be classified as focal, generalized, or unknown.¹⁰ A focal-onset seizure originates within networks limited to one side of the brain. It may be discretely localized or more widely distributed. Focal seizures can originate in subcortical or in deep brain structures.^25,26

Generalized-onset seizures originate at some point within the brain, and rapidly engage in bilaterally distributed networks.^25,26 In other words, a focal-onset seizure affects one hemisphere of the brain, while a generalized-onset seizure affects both.

An unknown-onset seizure is defined when the area of onset is not known or cannot be defined. This distinction is commonly used when the seizure takes place at night or when the individual is alone with no one to witness the event.^10,21,22 As more information is gathered following an unknown seizure, the onset can be redefined to either a focal or generalized onset.¹⁰

Level of awareness during a seizure is important for practical application, as it can directly affect the individual’s safety and the acute health care provider’s response to the seizure. For a focal-onset seizure, awareness is defined as either aware or impaired awareness.^10,21,25 Aware is used if the individual is conscious of him- or herself and the environment during the seizure, while impaired awareness is used if either of these is lost at any point throughout the seizure.¹⁰ It refers specifically to awareness during the seizure, and not an individual’s ability to recall whether a seizure has occurred.²⁵ During a generalized onset seizure, impaired awareness commonly occurs in most cases and is assumed unless otherwise noted by the witness or acute health care provider.²⁵ The level of awareness for an unknown-onset seizure cannot be defined due to the absence of a witness during the event.

The identification of motor (physical) or nonmotor (sensory and emotional) symptoms at the start of the seizure is important to the classification type. If both motor and nonmotor symptoms occur at the beginning, motor signs and symptoms will usually dominate.¹⁰ Common motor symptoms include muscles going limp (atonic); muscles twitching (myoclonus); muscles becoming tense or rigid (tonic); rhythmical full-body jerking motions (clonic); and epileptic spasms.²² Nonmotor symptoms can include sensory or emotional changes as well as changes in the individual’s thought process. A comprehensive list of motor and nonmotor symptoms can be found in Table 10-1. Nonmotor symptoms for generalized or unknown onset seizures are also known as absence seizures. These often present with a sudden cessation of activity and awareness, as well as staring spells with myoclonus twitching of the eyelids.^22,25 Focal-onset seizures can be further defined as seizures changing from a focal beginning to a bilateral (generalized) tonic–clonic seizure due to the regularity of their occurrence among individuals with epilepsy.²⁵

The affected individual commonly assesses the severity of seizures subjectively after all signs and symptoms have subsided to evaluate his or her perception of the physical and emotional response to the seizure.²⁷ The evaluation of severity in individuals with epilepsy is common and is assessed through the use of instruments, including the Seizure Frequency Scoring System, the Veterans Administration Seizure Frequency and Severity Rating Scale, the National Hospital (Chalfont) Seizure Severity Scale, the Occupational Hazard Scale, the Liverpool Seizure Severity Scale, and the Hague Seizure Severity Scale.²⁷ These scales take into account seizure type, duration of event, frequency of the seizures, physical symptoms during the ictal phase, and duration of the postictal recovery period.²⁷ While there is not a universal tool for evaluation of seizure severity, acute health care providers for athletes with epilepsy should maintain at least one instrument to uniformly track the severity of the seizures.

Following the first occurrence of a seizure, the individual should be referred to a primary care physician and a specialist trained in the treatment of epilepsy.23,24,28 The diagnosis of epilepsy or epilepsy syndrome is largely predicated on a comprehensive clinical evaluation, with a thorough medical history from both the affected individual and witnesses to the seizure or seizure events. The clinical history can vary but should include circumstances under which the seizure occurred, timing of the seizure, whether the individual was awake or asleep, whether the individual was standing or sitting, any activity or exercise the individual was doing, possible triggers, precipitating factors, and personal and/or family medical history.^23,24,29 A physical examination should also be performed to address cardiac, neurological, and mental status, and it should include a developmental assessment when deemed appropriate by the specialist.^23,24

While most cases can be diagnosed through a comprehensive medical history and physical exam, some need video recordings of the event and electroencephalography testing to document visible signs and symptoms, as well as abnormalities in the electrical activity of the brain.^23,29,30 A comprehensive evaluation is necessary to identify whether individuals are experiencing epileptic seizures and, if so, to diagnose them for specific type of epilepsy.

Epilepsy syndrome is a composite of signs and symptoms that define a unique epilepsy condition.²⁹ Clinically, this is performed by analyzing the individual’s type of epilepsy, age of onset, and associated comorbidities.³¹ The defining of specific epilepsy syndromes is commonly associated with clinical findings and electroencephalography testing. Examples of epilepsy syndromes include childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, West syndrome, epilepsy with generalized tonic–clonic seizures, idiopathic generalized epilepsy, Panayiotopoulos syndrome, late-onset childhood occipital syndrome, Dravet syndrome, Lennox-Gastaut syndrome, and Landau-Kleffner syndrome.^23,31 Epilepsy syndromes are considered to be resolved for individuals who had an age-dependent epilepsy syndrome but are now past the applicable age for that specific syndrome, as well as those who have remained seizure-free for the past 10 years and without the use of seizure medicines for the past 5 years.¹

While most individuals are diagnosed with epilepsy following large dramatic events, the minor episodes attributed to lesser signs and symptoms often go overlooked. The accurate understanding and identification of minor seizure events could be critical to making an accurate diagnosis of epilepsy.²⁴ Acute health care providers must be cognizant of the identification of signs and symptoms of seizures, regardless of how small or insignificant they might be to the affected individual.

Epilepsy Treatment

The goal for treatment of epileptic seizures should be to control or stop the seizures, as well as their side effects.³² While seizures may be difficult to control, it is imperative that each individual has a treatment plan personally tailored to his or her needs. Treatment plans should only be initiated by a specialist trained in the treatment of epilepsy, along with the individual’s primary care physician.^24,28 Most treatment plans will incorporate several aspects that can include antiepileptic drugs, psychological interventions, dietary therapy, neuromodulation, and surgery. The acute health care provider must ensure that each individual has an identified treatment plan to control or stop epileptic seizures, as prescribed by a specialist in the treatment of epilepsy.

Antiepileptic drugs, prescribed to prevent the recurrence of seizures, form the standard treatment of care for individuals with epilepsy.^23,24 About 65% to 70% of adults and adolescents with epileptic seizures can be successfully controlled with the initially prescribed antiepileptic drug, while an additional 15% to 20% will attain effective control with subsequent antiepileptic drug prescriptions.^32,33 The choice of specific antiepileptic drugs is affected by the classification of seizure type, the individual’s age, comorbidities, comedications, lifestyle, possible pregnancy, type of epilepsy syndrome, and preferences of the person and family members as appropriate.^23,24,28 Antiepileptic drugs make up a diverse group of medications with different properties and mechanisms of action that contribute to their therapeutic effects.^34,35 While it is beyond the scope of this publication to differentiate between them, commonly prescribed antiepileptic drugs are listed in Table 10-2.

It is recommended that antiepileptic drugs be chosen on the basis of the epilepsy syndrome, or, if not clear at presentation, then on the type of epileptic seizure.^23,24 The acute health care provider for athletes with epilepsy should be diligent in identifying any possible adverse effects or changes in behavior of their athletes while they are on prescribed antiepileptic drugs.²³ While antiepileptic drugs have been successful in treating individuals with epilepsy, 25% to 35% of individuals will not be able to control their seizures with medication.^36,37 Other therapies should be considered if the epilepsy is not controlled with only medication within 2 years, management has been unsuccessful following administration of 2 antiepileptic drugs, the individual is experiencing adverse side effects from the medication, a psychological and/or psychiatric comorbidity has been diagnosed; or diagnostic doubt exists regarding the type of epilepsy or epilepsy syndrome.

Psychological interventions should be considered for use in conjunction with antiepileptic drugs, but not as an alternative to the medication.²⁴ Cognitive dysfunction and psychiatric comorbidities have been shown to be more prevalent in individuals with epilepsy than among the general population.^40–42 If left untreated, psychological and psychiatric conditions have a greater negative effect on the individual’s quality of life than the seizure-related signs and symptoms.^40,41,43 Relaxation techniques, cognitive behavior therapy, and biofeedback have been shown to improve the quality of life for some individuals, but have not been proven to decrease the frequency of seizures. In adolescents, specific attention should be shown to their relationships with friends, teammates, and families.²⁴ Acute health care providers are commonly the first line of defense in reporting changes in behavior among their athletes.

Dietary therapy has been shown to be effective in the treatment of some individuals with refractory, or uncontrolled, seizures, usually along with antiepileptic drug administration. Specifically, the ketogenic diet has shown an ability to maintain the presence of ketone bodies (compounds produced during the metabolism of fats) in circulation, which have an antiepileptic effect, although the exact mechanism is not clearly defined.^31,36 This specialized diet contains a 4:1 ratio of fats to carbohydrates, with the amount of protein regulated so that about 90% of calories are derived from consumption of fats.36 This diet should be prescribed and monitored by a specialist in epilepsy, along with a nutritionist. While this approach has demonstrated clinically meaningful improvements, compliance with administration of this highly unusual diet can be challenging.^31,36,37 The modified Atkins diet is a high-fat, low-carbohydrate option that has had similar effects to the ketogenic diet, but it is far less restrictive, which can make it easier for an athlete to maintain compliance.³⁷ While long-term adherence to both diets can be challenging, especially in athletes, the effects can be felt in a short amount of time and have been shown to be successful in individuals with refractory seizures.^31,37

BOX 10-3. CANNABIDIOL OIL

Cannabidiol oil is a constituent of the cannabis plant that does not elicit euphoria and may significantly decrease the frequency of seizures in individuals with epilepsy. While it is not considered a widely used therapy, it is a topic that needs to be monitored by acute health care providers for athletes with epilepsy.^46–48

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