What sports activity is possible?

Patients with epilepsy are less likely to be active in sports compared to healthy individuals, although in general a decrease in seizure frequency during moderate sports activity can be assumed. Seizure provocation by exercise is rare. In animal models, positive effects on epileptogenesis and seizure susceptibility have been shown by influencing neurotransmitter systems and inhibitory neurons, including upregulation of neurotrophic factors. Additionally, psychiatric comorbidities such as depression and anxiety disorders are positively affected. On the other hand, the risk of injury must be considered depending on the type of sport and the individual seizure frequency. An anticonvulsant effect of exercise has not yet been adequately demonstrated in humans.

Approximately one percent of the population suffers from epilepsy; in addition, epileptic seizures are a common complication of neurological diseases [1]. The majority of epilepsy patients exercise less frequently than healthy controls [2–5]. In a large European study, only 30% of epilepsy patients were active in sports, compared to 41% of healthy individuals [6]. It has also been shown that children and adolescents with epilepsy are less likely to exercise and more likely to be obese than their healthy siblings [4]. Objective measures can also be used to demonstrate reduced aerobic and muscular endurance [3] and muscle strength [7] in people with epilepsy. Lack of physical activity, in turn, increases the risk of obesity [3,4] and days of sick leave [8].

The reason for this lack of exercise is probably the fear of patients, their relatives and physicians of an increased risk of injury and seizure induction during sports activities, which makes individual patient counseling necessary in each case.

Anticonvulsant effect of sport

To date, no anticonvulsant effect of physical activity has been demonstrated, but predominantly beneficial effects of exercise on seizure frequency are reported in the literature. In two independent studies of large outpatient epilepsy clinics in Norway and Brazil, over 30% of respondents reported positive effects of regular training on seizure frequency [2,9].

Evidence from animal studies suggests that physical activity may also play a role in the primary prevention of epilepsy. A Swedish population-based study published in 2013 also showed evidence in humans that decreased cardiovascular fitness in 18-year-old male recruits is associated with an increased risk of epilepsy in later adulthood [10]. This allows the hypothesis that an improvement in cardiovascular fitness through exercise could have a protective effect with regard to the development of epilepsy.

The short-term effects of physical activity have been studied in children with focal and generalized epilepsy [11]. During exercise, 77% of the subjects experienced a decrease in epileptiform EEG changes, and this effect regressed in 85% after exercise was stopped.

Physiotherapy and structured exercise programs

There are few prospective study data on the effect of exercise on epilepsy disease. In the majority of these studies, no significant changes in seizure frequency were found, but positive psychosocial effects as well as reductions in sleep problems and fatigue were observed. In the European culture yoga does not belong to the common sports and is rather counted among the relaxation and meditation techniques. When using yoga in epilepsy patients, several studies have demonstrated beneficial effects [12] as well as an increase in quality of life.

Neurobiological effects of exercise on seizure susceptibility.

The exact effects of physical activity on seizure propensity and epileptogenesis are unknown, but some underlying neurobiological mechanisms have been proposed. These conjectures are predominantly based on the pilocarpine model of temporal lobe epilepsy in rats [13,14].

Influence of neurotransmitter systems: In physically active rats, epileptogenesis was protracted [15]. Similar effects were also observed by swimming exercises in the penicillin-induced animal model [16]. In contrast, norepinephrine deficiency may favor epileptogenesis in animal models [17]. Increased catecholamine concentrations were observed during sports training, which is why the assumption of a protective effect of norepinephrine release during sports was made.

Higher neural reserve: early postnatal physical activity was able to slow epileptogenesis and attenuate later motor seizure symptoms in rats [18]. Thus, exercise in adolescence could lead to higher neuronal reserve and protect against later brain diseases.

Neuroprotection: physical training leads to upregulation of neurotrophic factors and thus could lead to increased neuronal resistance to damage [19]. Evidence of increased hippocampal synaptic plasticity was found in trained mice compared to controls [20].

Inhibitory interneurons: animal models showed an increase in hippocampal inhibitory interneurons, which may have an anticonvulsant effect [21].

Psychological effects

Depression and anxiety disorders are common comorbidities in people with epilepsy. The treatment of these important complaints is of central importance for epilepsy sufferers. Thus, physical training had a positive impact in patients with depressive disorder, as shown in a meta-analysis of 32 studies [22]. Similarly, another meta-analysis demonstrated positive effects on symptoms of anxiety disorder [23]. The positive effect of exercise on psychiatric comorbidities has also been demonstrated in people with epilepsy.

Sport risk

Despite the known beneficial effects of exercise in people with chronic diseases, patients with epilepsy have long been discouraged from exercising. As late as 1968, the American Medical Association (AMA) had recommended abstinence from sports for epilepsy patients [24]. This opinion was relaxed in light of new findings until 1974, when the possibility of participation in contact sports was also granted [25].

Essentially, the presumed sports-related risk relates to seizure provocation by sports activity and increased risk of injury if epileptic seizures occur. This continues to be reflected in the uncertainty of patients and physicians despite some educational work in recent years. For example, Steinhoff et al. [3] reported a fear of sports-associated seizures in 41% of epilepsy patients and seizure-associated injuries in 40%.

Seizure provocation through sports

Triggering of epileptic seizures during exercise has been postulated to be caused by severe fatigue, sleep deprivation, dehydration, electrolyte loss, hypothermia, or hypoglycemia [26]. Indeed, such changes may lead to provocation of epileptic seizures, but this seems to be the case only in rare extreme situations. Several clinical studies have failed to establish a relationship between physical exertion and the occurrence of epileptic seizures [27–30]. In addition, a reduction in interictal epileptiform discharges and desynchronization during exercise have been observed in several electroencephalographic studies [11,31,32]. Hypercapnia, stress reduction, or increased GABA activity during exercise have been discussed as underlying seizure-protective mechanisms. In addition, the increased alertness and vigilance immediately during exercise could be protective [33].

Nevertheless, there is no question that certain patients suffer more epileptic seizures during physical exertion. In these patients, an EEG recording under ergometric stress demonstrated an increase in interictal epileptiform activity [27,34]. Thus, EEG ergometry could provide a simple diagnostic tool to detect those epilepsy patients who are prone to sports-associated seizures. Accordingly, the individual consultation will then be able to take place.

Risk of injury

The overall risk of injury in patients with epilepsy, although only slightly increased compared to the healthy population, is definitely increased (17 vs. 12% in 12 months), as shown in a prospective European study [35]. However, the risk of severe or repeated traumatic brain injury is increased by more than 50% [36]. The proportion of sports-associated injuries, on the other hand, is up to three times lower in epilepsy patients than in healthy individuals [25], which is probably related to greater precautions and the lower level of sports activity in epilepsy patients.

Certain physical activities carry greater risks of injury than others. Swimming accidents are the most common sport-associated cause of death in patients with epilepsy [37]. Adults with epilepsy have a fourfold increased risk of drowning, and children have as much as a seven- to fourteenfold increased relative risk [38]. Sports activities at high altitudes or high speeds carry an epilepsy-independent risk of potentially serious injury to participants and spectators.

Sporting activity should be encouraged as a matter of principle. Many sports are possible for people with epilepsy [39]. The individual case requires an individual clarification with consideration of the type of sport, seizure type and seizure frequency as well as drug treatment. Table 1 shows an overview of risk assessment for individual sports.

With seizure freedom lasting for a year or more, almost all sports can be played. Epilepsies that are not accompanied by impaired consciousness are also usually unproblematic. Significantly more limitations are present in seizures associated with impaired consciousness and transition to generalized tonic-clonic seizures. If there are time-of-day differences in the occurrence of seizures, it is important to avoid particularly high-risk times of day. Special care should be taken when switching or discontinuing medications.

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