Pop Quiz

1. Pop Quiz • The most common treated conditions treated by neurologists are: • 1. Headaches • 2. Epilepsy

2. The Prince • A different view of epilepsy • http://www.epilepsycolorado.org/

3. Epilepsy & Seizures Cody Butler, SPT Fall 2009 U of CO Hospital

4. Objectives • 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

5. 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

6. 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.

7. Risk Factors for Epilepsy • Family history of epilepsy • ↑ risk of 2.5 times2of developing a seizure disorder. • Head injuries • Brain infections • Stroke

8. Common Seizure Triggers • Sleep deprivation • Stress • Flashing bright lights • Alcohol use • Specific foods • Certain medications

9. Causes of Seizures without Epilepsy • Hypoglycemia, hyponatremia, hypoxia • Drug withdrawals • Tumors/abscesses • Drug intoxication • Sleep deprivation • Head Injury • Encephalitis/meningitis

10. 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

11. 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

12. Physiological Consequences1 of Status Epilepticus • Hypoxia, Hyperthermia, Acidosis • Increased catecholamine release • Leukocytosis • Increased BP and Pulmonary vascular pressure • Pulmonary trans-vascular fluid flux • Increased Cerebral Blood Flow (CBF) • Increased cerebral metabolic activity

13. 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

14. 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

15. 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

16. 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

17. 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

18. PT Interventions • Exercise recommended5to 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

19. 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

20. Exercise-Induced Seizures • May occur infrequently8 • The patho-physiologic mechanism remains unclear9 • Are not related to: • Epilepsy diagnosis • Type of activity • Heart Rate

21. 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

22. 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

23. 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 (?)

24. 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)

25. Questions/Comments

26. 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.

27. Thank you everyone.