Sports Participation in Children with Epilepsy

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

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

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

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

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

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

7. History of Sports and Epilepsy • 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 • New evidence suggests benefit from exercise without increased risk of injury or increased seizures

8. 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 • AAP – risks of sports should be weighed against psychological trauma resulting from unnecessary restriction

9. 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 • 1983 – AMA and AAP recommended participation in most sports including contact sports (well controlled seizures and proper supervision)

10. 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 • Multiple studies have found that physical exercise actually decreases seizure frequency

11. 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 • However, 27% of patients with epilepsy who had seizure with sports sustained injuries related to seizure

12. 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

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

14. 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 • Studies have shown that physical activity on average reduces seizure frequency and lead to improved cardiovascular and psychological health.

15. Sports restriction may impact child from psychosocial standpoint • 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

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

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

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

19. 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 • ILAE recommends if child has been seizure free > 1 year  most restrictions can be lifted

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

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

22. Contact Sports • 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 • Very few case reports support these notions

23. 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)

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

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

26. Sports from 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

27. Sports from Heights • 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 • Other references allow gymnastics with reasonable precautions/ direct supervision

28. 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 • Hand-gliding, parachuting and free climbing not recommended

29. Motor Sports • Motor sports – some say minimum of 2 years seizure freedom • Possibility for catastrophic injury • 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

32. Summary • 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 • Swimming – direct supervision by an experienced swimmer/ “buddy” system

33. Summary • 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

34. Conclusions • 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 • More harm may be caused by discouraging physical activity

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

36. References • Howard et al. Epilepsy and Sports Participation. Current Sports Medicine Reports 2004. 3:15-19. • 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) • Epilepsy and Sports Participation. Wyoming Epilepsy Association.