Sports Participation in Children with Epilepsy Stefanie Jean-Baptiste Berry, MD Northeast Regional Epilepsy Group Pediatric Neurologist/Epileptologist

Introduction Recurrent unprovoked seizures  epilepsy Recurrent unprovoked seizures  epilepsy Epilepsy is a common disease found in 2% of population, affecting both young and old Epilepsy is a common disease found in 2% of population, affecting both young and old 3 to 6 million Americans with epilepsy 3 to 6 million Americans with epilepsy

Chronic, severity and prognosis is variable Chronic, severity and prognosis is variable 60 – 80% unknown etiology 60 – 80% unknown etiology Up to 80% well controlled on 2 or fewer anti-epileptic medications Up to 80% well controlled on 2 or fewer anti-epileptic medications

Classification of Seizures Seizure types: Seizure types: Generalized Generalized Focal (Partial) Focal (Partial) Focal with secondary generalization Focal with secondary generalization

Generalized Seizures: Generalized Seizures: 1.) Generalized tonic-clonic (grand mal)- Unconscious, whole body shaking; variable duration 1.) Generalized tonic-clonic (grand mal)- Unconscious, whole body shaking; variable duration 2.) Absence (petit mal) – Staring, unawareness, brief (seconds) 2.) Absence (petit mal) – Staring, unawareness, brief (seconds) 3.) Myoclonic – Brief jerk of arm or leg 3.) Myoclonic – Brief jerk of arm or leg 4.) Atonic – Sudden drop 4.) Atonic – Sudden drop

Focal (Partial) Seizures: Focal (Partial) Seizures: 1.) Simple – Consciousness preserved; twitching of one side of face or body, numbness, visual 1.) Simple – Consciousness preserved; twitching of one side of face or body, numbness, visual 2.) Complex – Impaired consciousness; twitching, head/eye deviation etc. 2.) Complex – Impaired consciousness; twitching, head/eye deviation etc.

History of Sports and Epilepsy A stigma associated with epilepsy has prevented involvement in sports and recreational activities for years. A stigma associated with epilepsy has prevented involvement in sports and recreational activities for years. More recently, a more permissive approach has been taken towards children with epilepsy and their participation in sports More recently, a more permissive approach has been taken towards children with epilepsy and their participation in sports New evidence suggests benefit from exercise without increased risk of injury or increased seizures New evidence suggests benefit from exercise without increased risk of injury or increased seizures

Due to stigma associated with epilepsy, those with epilepsy have poorer self-esteem Due to stigma associated with epilepsy, those with epilepsy have poorer self-esteem Restricting child from participating in sports led to isolation from peers and lower self- esteem Restricting child from participating in sports led to isolation from peers and lower self- esteem AAP – risks of sports should be weighed against psychological trauma resulting from unnecessary restriction AAP – risks of sports should be weighed against psychological trauma resulting from unnecessary restriction

1968 – Based on AMA position, physicians recommended restricting the activity of those with epilepsy 1968 – Based on AMA position, physicians recommended restricting the activity of those with epilepsy 1973 – Articles presenting arguments both for and against allowing participation in contact sports 1973 – Articles presenting arguments both for and against allowing participation in contact sports 1983 – AMA and AAP recommended participation in most sports including contact sports (well controlled seizures and proper supervision) 1983 – AMA and AAP recommended participation in most sports including contact sports (well controlled seizures and proper supervision)

Despite progress, most studies show children with epilepsy are 50% less active than those without Despite progress, most studies show children with epilepsy are 50% less active than those without Unnecessary restrictions are set for fear of injury or induction of seizure activity Unnecessary restrictions are set for fear of injury or induction of seizure activity Multiple studies have found that physical exercise actually decreases seizure frequency Multiple studies have found that physical exercise actually decreases seizure frequency

Potential for injury exists but not significant Potential for injury exists but not significant One study showed no difference in the number of accidents that children with epilepsy had during sporting events compared to those without epilepsy One study showed no difference in the number of accidents that children with epilepsy had during sporting events compared to those without epilepsy However, 27% of patients with epilepsy who had seizure with sports sustained injuries related to seizure However, 27% of patients with epilepsy who had seizure with sports sustained injuries related to seizure

Those with epilepsy are 4 times more likely to have submersion accidents  drowning or near-drowning Those with epilepsy are 4 times more likely to have submersion accidents  drowning or near-drowning Sports involving heights can increase risk to participant and others Sports involving heights can increase risk to participant and others

Rare cases of exercise-induced seizures Rare cases of exercise-induced seizures One study found 247 out of 400 people with epilepsy could identify precipitant One study found 247 out of 400 people with epilepsy could identify precipitant Only 2 out of 400 identified physical exercise as a precipitant Only 2 out of 400 identified physical exercise as a precipitant

Playing, whether organized sports or in recreational activities, is normal and beneficial part of life Playing, whether organized sports or in recreational activities, is normal and beneficial part of life All benefit socially and physically when play begins at an early age All benefit socially and physically when play begins at an early age Studies have shown that physical activity on average reduces seizure frequency and lead to improved cardiovascular and psychological health. Studies have shown that physical activity on average reduces seizure frequency and lead to improved cardiovascular and psychological health.

Sports restriction may impact child from psychosocial standpoint Sports restriction may impact child from psychosocial standpoint Sedentary lifestyle pose greater health risks than sports participation itself Sedentary lifestyle pose greater health risks than sports participation itself Increased BMI, decreased aerobic endurance, poorer self-esteem and higher levels of anxiety and depression Increased BMI, decreased aerobic endurance, poorer self-esteem and higher levels of anxiety and depression

Prior to Participation General precautions: General precautions: 1. Following methods of conduct and play 2. Utilizing suitable protective equipment 3. Playing responsibly within the rules

Special precautions for children with epilepsy: Special precautions for children with epilepsy: 1. Determine risk for injury and physical impairments 2. Type and timing of seizure (GTC, atonic, absence vs. simple partial) 3. Confirming adequate seizure control with medications 4. Following medication levels and compliance 5. Increased vigilance about proper diet and rest

What is adequate seizure control? What is adequate seizure control? No consensus No consensus Adequate control is largely individualized goal Adequate control is largely individualized goal Complete seizure freedom is every clinician’s goal – but in some patients impractical Complete seizure freedom is every clinician’s goal – but in some patients impractical

Some require multiple medications to control seizures which results in side effects (lethargy and confusion) Some require multiple medications to control seizures which results in side effects (lethargy and confusion) Most patients are able to be controlled on 1 medication  encouraged to participate in sports Most patients are able to be controlled on 1 medication  encouraged to participate in sports ILAE recommends if child has been seizure free > 1 year  most restrictions can be lifted ILAE recommends if child has been seizure free > 1 year  most restrictions can be lifted

Provided seizures are reasonably controlled, most sports are acceptable to play Provided seizures are reasonably controlled, most sports are acceptable to play Some may require additional supervision Some may require additional supervision Adequate seizure control, close monitoring of medication and preparation of family and coaches Adequate seizure control, close monitoring of medication and preparation of family and coaches

Aerobic Sports Aerobic sports (running, track and field or stationary bike conditioning): Aerobic sports (running, track and field or stationary bike conditioning): 1. No specific risks if fluid intake and electrolyte balance are maintained 2. Adequate preparation with diet 3. Can decrease seizure frequency, reduce future health problems, improve body self- image and self-esteem

Contact Sports Children with epilepsy should not be precluded from contact sports (football, hockey, basketball, martial arts) Children with epilepsy should not be precluded from contact sports (football, hockey, basketball, martial arts) Theoretically, trauma from contact sports resulting in recurrent minor head injuries could cause seizures or worsen epilepsy Theoretically, trauma from contact sports resulting in recurrent minor head injuries could cause seizures or worsen epilepsy Very few case reports support these notions Very few case reports support these notions

Contact Sports Many studies show no increased injury risk for children with epilepsy who play contact sports Many studies show no increased injury risk for children with epilepsy who play contact sports Boxing is exception and is prohibited in those with epilepsy (AAN, AMA, and AAP) Boxing is exception and is prohibited in those with epilepsy (AAN, AMA, and AAP)

Water Sports Swimming and water sports- excellent way to improve cardiovascular health and maintain muscle strength and tone Swimming and water sports- excellent way to improve cardiovascular health and maintain muscle strength and tone Direct visual supervision should always be present Direct visual supervision should always be present Supervising person should have adequate training in rescue and resuscitation Supervising person should have adequate training in rescue and resuscitation Avoid swimming in open water Avoid swimming in open water Swimming should be avoided in those with frequent seizures Swimming should be avoided in those with frequent seizures

Water Sports Boating with floatation device is ok Boating with floatation device is ok Scuba diving is prohibited Scuba diving is prohibited X

Sports from Heights Gymnastics involves increased risk due to certain skills performed at greater heights Gymnastics involves increased risk due to certain skills performed at greater heights Ok for children with well-controlled seizures and if observed by coaches aware of their condition Ok for children with well-controlled seizures and if observed by coaches aware of their condition

Sports from Heights Some references do not recommend gymnastics especially balance beam and uneven bars Some references do not recommend gymnastics especially balance beam and uneven bars Having seizure during these events can result in fall and cervical spine injury Having seizure during these events can result in fall and cervical spine injury Other references allow gymnastics with reasonable precautions/ direct supervision Other references allow gymnastics with reasonable precautions/ direct supervision

Sports from Heights Horseback riding and harnessed rock climbing – only if seizures well controlled and with person who can provide first aid and contact emergency personnel Horseback riding and harnessed rock climbing – only if seizures well controlled and with person who can provide first aid and contact emergency personnel Hand-gliding, parachuting and free climbing not recommended Hand-gliding, parachuting and free climbing not recommended

Motor Sports Motor sports – some say minimum of 2 years seizure freedom Motor sports – some say minimum of 2 years seizure freedom Possibility for catastrophic injury Possibility for catastrophic injury An accident at the speeds attained in motor sports is danger to driver, other drivers and spectators An accident at the speeds attained in motor sports is danger to driver, other drivers and spectators Most feel that motor sports should be avoided Most feel that motor sports should be avoided

Summary Aerobic sports such as running track and cross-country skiing – no special precautions Aerobic sports such as running track and cross-country skiing – no special precautions Contact and collision sports such as basketball and football – usual precautions (e.g. helmet) and direct supervision Contact and collision sports such as basketball and football – usual precautions (e.g. helmet) and direct supervision Swimming – direct supervision by an experienced swimmer/ “buddy” system Swimming – direct supervision by an experienced swimmer/ “buddy” system

Summary Sports such as hand-gliding, scuba diving and mountain climbing not recommend due to risk of severe injury or death if seizure occurs Sports such as hand-gliding, scuba diving and mountain climbing not recommend due to risk of severe injury or death if seizure occurs Boxing is prohibited since head trauma can precipitate seizures Boxing is prohibited since head trauma can precipitate seizures

Conclusions Participation in sports and physical activity is important way to maintain physical and psychological health Participation in sports and physical activity is important way to maintain physical and psychological health Children with epilepsy should not be excluded from participation in sports Children with epilepsy should not be excluded from participation in sports More harm may be caused by discouraging physical activity More harm may be caused by discouraging physical activity

Sports involving heights and speeds are not recommended Sports involving heights and speeds are not recommended Majority of sports are safe and will potentially reduce seizure frequency and improve quality of life Majority of sports are safe and will potentially reduce seizure frequency and improve quality of life

References Howard et al. Epilepsy and Sports Participation. Current Sports Medicine Reports : Howard et al. Epilepsy and Sports Participation. Current Sports Medicine Reports : Miele Vincent J.. Participation in Contact or Collision Sports in Athletes With Epilepsy, Genetic Risk Factors, Structural Brain Lesions, or History of Craniotomy. Neurosurg Focus. 2006;21(4). Miele Vincent J.. Participation in Contact or Collision Sports in Athletes With Epilepsy, Genetic Risk Factors, Structural Brain Lesions, or History of Craniotomy. Neurosurg Focus. 2006;21(4). Fountain NB, May AC. Epilepsy and athletics. Clin Sports Med 2003;22(3) Fountain NB, May AC. Epilepsy and athletics. Clin Sports Med 2003;22(3) Epilepsy and Sports Participation. Wyoming Epilepsy Association. Epilepsy and Sports Participation. Wyoming Epilepsy Association.