Case study IX

1. Case study IX Lizette Luna, SPT Iain Macgregor SPT

2. Case Description • 20 yr old college baseball team manager – Hamish McTavish • Rigid, fell to the ground shaking • Wearing ID bracelet • Team aware of his condition • EMS wascalled • Coach ensured his safety

3. Overview

4. Pathology • Epilepsy A chronic disorder of various causes characterized by recurrent seizures.1 http://www.youtube.com/watch?v=MNQlq004FkE

5. Types of Seizures • Generalized Seizures: no local onset on the brain electroencephalogram (EEG) shows diffuse abnormalities. • Partial Seizures: EEG evidence of local onset • Temporal, frontal, parietal, occipital lobes

6. Types of Seizures Generalized Seizures • Absence seizures • Myoclonic seizures • Tonic-clonic seizures • Atonic seizures • Tonic seizures • Clonic seizures • Atypical absence seizures

7. Types of Seizures Partial Seizures • Simple partial – consciousness not affected; unilateral hemispheric involvement • Complex partial – consciousness affected; bilateral hemispheric involvement • Secondarily generalized – generalized seizure developed from partial seizure

8. Incidence1,2 • Highest amongst patients less than 2 and greater 60 years of age • 200,000 new cases are diagnosed per year • 45,000 new cases for children under 15 years of age per year • Seizures are the most common symptom requiring medical attention in infants • Low death rate • 3% status epilepticus

9. Status Epilepticus1 • An epileptic seizure that lasts more than 30 minutes • Constant or near-constant state of having seizures • Health crisis that requires immediate treatment • Is the leading cause of epilepsy-related death

10. Hamish who? • Given the scenario stated, and your newly refreshed knowledge of epileptic seizures, what type of seizure did Hamish have?

11. Tonic – Clonic Seizures Tonic – muscles become rigid, person could lose consciousness and fall to the ground • “Cry” or “groan” is sometimes heard as air is forced past vocal chords • Cyanotic • Shortest phase, lasts seconds

12. Tonic – Clonic Seizures Clonic – muscles contract & relax rapidly, causing convulsions • Arms & legs will especially jerk • Patients could bite their tongue, cheeks or lips • Saliva, or frothing at the mouth • Tachycardia • Incontinence

13. Tonic – Clonic Seizures www.youtube.com/watch?v=FSkwXUi6ie0

14. Tonic – Clonic Seizures • 1-3 minutes • > 5 minutes, call for medical help • >30 minutes or more than 3 seizures without typical periods in between could indicate status epilepticuswhich is a medical emergency!

15. Back to Hamish again… • Given the fact that EMS was called, and that his team was well aware of his condition, how long could Hamish’s seizure been going on for? • > 5 minutes

16. Tonic – Clonic Seizures • Up to 65 % of patients with epilepsy experience auras before a seizure3 • déjà vu, strange taste, mood changes, headaches, nausea, etc.

17. Auras 3 • "These seizures frighten me. They only last a minute or two but it seems like an eternity. I can often tell Heather's going to have one because she acts cranky and out of sorts. It begins with an unnatural shriek. Then she falls, and every muscle seems to be activated. Her teeth clench. She's pale, and later she turns slightly bluish. Shortly after she falls, her arms and upper body start to jerk, while her legs remain more or less stiff…Finally it stops and she falls into a deep sleep." - mother of child with epilepsy

18. Auras4 • Study by Gupta et al, Journal of Neurology, Neurosurgery, and Psychiatry • Patients with right sided brain lesions > left sided brain lesions • Right lesions = psychic auras, autonomic auras • Left lesions = motor, psychic auras

19. Etiology • Congenital – IVH • Head Trauma (can be prevented) • Hypoxia • Hypoglycemia • Infections • Fever • Tumors • Cerebrovascular disease (older population)

20. Etiology • Usually idiopathic • 25 % of children with epilepsy show evidence of brain damage or trauma4 • 37 % have a genetic predisposition4

21. Etiology • Gene mutations have been identified as causes of inherited epilepsy5 • Study by Hirose et al • Mutations → abnormalities in Na2+, Ca2+, K+ channels in the brain Myoclonic Absence

22. Medications • Valproate • Phenytoin • Divalproex Sodium • Phenobarbital • Primidone • Gabapentin (Neurontin)

23. Common Comorbidities • Neurological disorders, inc CP • Psychological disorders, such as anxiety & depression • Obesity • Rett Syndrome • Mitochondrial disorders

24. APTA Practice Patterns • 5A: Primary Prevention / Risk Reduction for Loss of Balance and Falling • 5B: Impaired Neuromotor Development • 5C: Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Central Nervous System – Congenital Origin or Acquired in Infancy or childhood • 5E: Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the Central Nervous System

25. What can we do? “Physical therapists help people who have disorders of movement or coordination. Most people with epilepsy do not need physical therapy, but some do have limited mobility or other disorders.” - Steven C. Schachter, M.D. Topic Editor, Epilepsy.com

26. What can we do? (cont.) • Essentially, we will be treating patients not for epilepsy, but more likely their comorbidities • Campbell text – no mention of epilepsy per se • Pt & family edu – fall prevention

27. Factors to consider • Some comorbid conditions in epilepsy, such a depression and anxiety, may have a greater influence on subjective health status than does seizure rate. Management strategies employed in the outpatient clinic to maximize overall health outcomes should include screening and treatment for the commonly coexistent conditions in persons with epilepsy.6 • If patient shows signs of depression and anxiety, treat them accordingly

28. Psychiatric Considerations8 • Tellez-Zenteno et al, Epilepsia, 2007 • Psychiatric Comorbidity in epilepsy: A population-based analysis • Sample size – 36,984 • Assessed using The Canadian Community Health Survey (CCHS 1.2) • Includes The World Mental Health Composite International Diagnostic Interview • Anxiety disorders and/or suicidal thoughts ascertained from responses • Concludes that individuals with epilepsy were 2.4:1 times more likely to report lifetime anxiety disorders and 2.2:1 times more likely regarding suicidal thoughts

29. Carry on regardless… but what about motor function? • van Empelen et al, 2007 • No deterioration in epilepsy and motor function in children with medically intractable epilepsy ineligible for surgery9 • Longitudinal, prospective study –lasted 2 years • 28 subjects – 14 males, 14 females, • Median age 6 years one month • Measured at baseline, 6 months, 12 months and 24 months

30. Measurements • Pts were measured using the following criteria: • Bayley Scales of Infant development (BSID-II) • Movement Assessment Battery for Children (M-ABC) • GMFCS and GMFM-88 • Pediatric Evaluation of Disability Inventory (PEDI) • Hague Restrictions in Childhood Epilepsy Scale (HARCES) • Hague Seizure Severity Scale (HASS)

31. TaaDaa (Results) • Motor function in children with and without spasticity does not worsen • Functional skills do not deteriorate and caregiver assistance does not increase

32. In the event of a seizure… • Stay calm • Prevent injuryDuring the seizure, you can exercise your common sense by insuring there is nothing within reach that could harm the person if she struck it. • Pay attention to the length of the seizure • Make the person as comfortable as possible • Keep onlookers away

33. Do not hold the person downIf the person having a seizure thrashes around there is no need for you to restrain them. Remember to consider your safety as well • Do not put anything in the person's mouthContrary to popular belief, a person having a seizure is incapable of swallowing their tongue so you can breathe easy in the knowledge that you do not have to stick your fingers into the mouth of someone in this condition. • Do not give the person water, pills, or food until fully alert • If the seizure continues for longer than five minutes, call 911 • Be sensitive and supportive, and ask others to do the same3

34. Or, you could do this… www.youtube.com/watch?v=ibrlbGsPsAc

35. Remember Hamish? • Why was his seizure handled so calmly and efficiently? • ID bracelet! • What can we take from this? • Pt and family edu regarding importance of ID bracelet

36. ID Bracelets Over 95% of EMS personnel check for a medical ID bracelet to assist in their arrival assessment and subsequent differential diagnosis from which hospital staff proceed to treat.10

37. Take home message • Epilepsy related seizures are usually non-fatal • Know general rules for pt safety when seizing (even if you are not sporting an amazing moustache) • Epilepsy alone is usually not cause for PT • Pts with epilepsy have an increased risk for depression and anxiety • Make sure to check ID bracelets

38. References • Goodman CC, Fuller KS, Boissonnault WG. Pathology, Implications for the Physical Therapist. 2nd ed. Philadelphia, PN: Saunders; 2003. • Epilepsy Foundation. Available at: http://www.epilepsyfoundation.org. Accessed March 28, 2009. • Epilepsy.com. Information. Community. Empowerment. Available at: http://www.epilepsy.com. Accessed March 9, 2009. • Gupta AK, Jeavons PM, Hughes RC, Covanis A. Aura in Temporal Lobe Epilepsy: Clinical and Electroencepalographic Correlation. Journal of Neurology, Neurosurgery and Psychiatry. 1983;46:1079-1083. • Benlounis A, Nabbout R, Feingold J, Parmeggiani A, Guerrini R, KaminskaA,Dulac O. Genetic Predisposition to Severe Myoclonic Epilepsy in Infancy. Epilepsia. 2001; 42 (2): 204-209. • Hirose S, Mitsudome A, Okada M, Kaneko S. Genetics of Idiopathic Epilepsies. Epilepsia. 2005; 46: 38-43. • Gilliam FG, Mendiratta A, Pack AM, Bazil CW. Epilepsy and Common Comorbidities: Improving the Outpatient Epilepsy Encounter. • Tellez-Zenteno JF, Patten SB, Jett´ e N, Williams J, Wiebe S. Psychiatric comorbidity in epilepsy: A population-based Analysis.Epilepsia. 2007; 48(12):2336–2344. • Van Empelen R, Helders P, Van Rijen P, Jennekens-Schinkel A, Van Nieuwenhuizen O. No deterioration in epilepsy and motor function in children with medically intractable epilepsy ineligible for surgery. Developmental Medicine & Child Neurology [serial online]. March 2007;49(3):214-218. American Medical ID. Identify yourself for life. http://www.americanmedical-id.com. Accessed April 1, 2009. • Appleton RE, Demmellweek C. Post-traumatic epilepsy in children requiring inpatient rehabilitation following head injury. Journal of Neurology Neurosurgery and Psychiatry. 2002;72:669–672. • Winawer MR, Marini C, Grinton BE, Rabinowitz D, Berkovic SF, Scheffer IE, Ottoman R. Familial Clustering of Seizure Types within the Idiopathic Generalized Epilepsies. Neurology. 2005 ; 65(4): 523–528. • Lisk DR, Greene SH. Drug compliance and seizure control in epileptic children. Postgraduate Medical Journal. 1985; 61,:401-405.

39. References • Oguni H, Symptomatic Epilepsies Imitating Idiopathic GeneralizedEpilepsies.Epilepsia,. 2005; 46(9):84–90. • Camfield CS, Camfield PR , Veugelers PJ. Death in children with epilepsy: a population-based study. Lancet. 2002; 359: 1891–95. • Marini C , King MA, Archer JS, Newton MR , Berkovic SF. Idiopathic generalised epilepsy of adult onset: clinical syndromes and genetics.Journal of Neurology, Neurosurgery and Psychiatry.2003;74:192–196.