While some medical literature in the past reported that seizures could be induced by exercise, there are also more recent reports that exercise can be beneficial to those with epilepsy. Newly emerging recommendations regarding athletes and the risk of head injuries has again raised the possible connection between exercise and seizures. So there are really two issues here: Can exercise be beneficial to those with seizures? Given new recommendations on avoiding the risks of concussions, now identified as traumatic brain injuries, can exercise be dangerous? We asked two experts for their opinions: Nathan B. Fountain, MD, University of Virginia School of Medicine, Department of Neurology and Steven V. Pacia, MD, New York University, Department of Neurology.
What are the risks of exercise in terms of inducing seizures?
Dr. Fountain: It is possible for exercise to precipitate seizures in people with epilepsy, but this is extremely rare. I regularly ask patients what precipitates their seizures and exercise is distinctly uncommon. If exercise is identified as a seizure precipitant then an exercise program can usually be designed that will allow the person to exercise safely and possibly even avoid the factor that exacerbates seizures.
The medical literature only has reports of three patients with exercise-induced seizures. A study of 21 patients participating in a 4-week prospective intensive physical training program did not demonstrate any seizure exacerbation. In 1978, a major epilepsy center reported no cases of recurrent or exacerbated seizures with exercise during 36 years of following 15,000 seizure patients.
Dr. Pacia: It is our belief that a certain subset of patients with seizure disorders are at risk for seizures while exercising. Some have estimated this risk to be 10% of patients, but the exact numbers are unknown.
What do you see as the benefit to exercise?
Dr. Fountain: Exercise, especially aerobic exercise, clearly benefits people with epilepsy because it often reduces seizure frequency, relieves depression, reduces social isolation, and promotes cardiac and general health.
People with epilepsy get even more benefit from exercise than others because people with epilepsy tend to be more sedentary. Several studies have demonstrated the benefits of exercise for people with epilepsy. In one study, 14 women completed a 3-month prospective exercise program and reported a significant reduction in seizure frequency during the period in which they exercised. In another prospective study, 26 children with intractable epilepsy underwent video-EEG monitoring during exercise and more than half showed a significant improvement in their EEG activity. A survey of 74 patients with epilepsy reported that those who exercised had significantly fewer seizures.
Dr. Pacia: Yes, exercise has indisputable health benefits that are as important, or more so. in patients with epilepsy than in the general population. These include stress reduction, as well as positive effects on blood pressure, blood sugar and bone health, among others.
Additionally, some small uncontrolled studies indicate a potential positive effect on seizure frequency for patients with persistent seizures despite proper antiepileptic medication(s) treatment.
Under what circumstances could exercise be dangerous for people with epilepsy?
Dr. Fountain: Exercise itself is rarely dangerous and the benefits usually outweigh the risks, but, of course, everyone should consult their doctor before starting an exercise program. For patients with well controlled seizures, most exercise is not dangerous, although common sense rules should apply to prevent injury from falling during a seizure.
Use of a recumbent exercise bicycle is probably the safest aerobic exercise because the seat is close to the ground so there are few opportunities for injury. However, even contact sports are permissible, such as football, which can be very important to teenage boys. For patients with frequent seizures, more care should be taken to avoid situations where a fall will cause injury. Some types of sports carry a much higher risk of injury because a seizure during them could cause an injury, for example, skydiving, scuba diving, rock climbing, and spelunking. Swimming posses special risks and has its own considerations.
Dr. Pacia: Any exercise where a fall would result in a higher likelihood of injury, for instance a treadmill, or where loss of consciousness would be very dangerous, as in a pool, would be contraindicated in a patient with uncontrolled seizures unless the patient was very closely supervised by properly trained people.
Should people with epilepsy exercise on their own or should they be involved in a controlled or supervised exercise program?
Dr. Fountain: Everyone benefits from a controlled or supervised exercise program, especially patients with epilepsy, because they are often sedentary. Whether people with epilepsy can exercise alone depends on whether they can be alone when they are not exercising. Most people with epilepsy can spend time alone and there is usually not a reason that they can't be alone when they exercise, once it is established that exercise does not exacerbate their seizures. Of course, exercise of all types carries some risk for everyone and is generally safer to perform while others are present.
Each individual must decide what the risks are for each activity and make a conscious decision about whether to take those risks. For example, an established marathon runner who has a seizure is likely to accept the risk of having a seizure alone on the road because running is so important to him or her. Alternatively, it would be unwise for a sedentary person with poorly controlled epilepsy who wants aerobic exercise to start running long distances alone when a recumbent exercise bicycle is available in a supervised setting.
Dr. Pacia: Exercise should be initiated in a supervised setting, preferably ramped up very slowly over weeks to months. In the first few months of an exercise program, low-to–the-ground stationary bikes are preferable to treadmills and weight machines are safer than free weights.
The risk for seizures may always be present in a given patient. Duration of exercise, type of exercise, and safety of unsupervised exercise should be determined in the same manner as driving privileges, that is, in close consultation with a neurologist after seizure risk is determined to be reasonably low.
How might exercise affect young athletes under the age of 14 who have had concussions or seizures?
Dr. Fountain: Concussions and seizures are not related; they are two entirely separate things. There are established rules for returning to athletic activity after a concussion because this is a common problem. Similar rules for seizures do not exist, but there are recommendations about sports participation for children with epilepsy.
The common issue is whether children can play contact sports, especially football, if they have seizures. There is no evidence that participation in football or other contact sports exacerbates (or causes) seizures. I have taken care of many high school and college football players with epilepsy who did not have exacerbation of seizures. There are many examples of active NFL players with epilepsy, including the Atlanta Falcons' Jason Snelling and the Pittsburg Steelers' Alan Faneca. Our own review of 157,709 neurology office notes identified only one report of a seizure possibly contributing to injury during football, which is probably an injury rate that is not higher than that for other football players.
Dr. Pacia: The incidence of epilepsy in patients who have suffered a concussion is very low. Most head traumas that lead to seizure disorders result from injuries with prolonged loss of consciousness, intracranial hemorrhage, or coma. Therefore, the vast majority of patients who recover from a concussion without persistent symptoms may exercise without fear of seizures or injury.
What types of exercise are particularly well-suited or poorly suited for people with epilepsy?
Dr. Fountain: Aerobic exercise is well-suited to epilepsy. Walking, jogging, running (especially on an indoor, grass, or supervised track) and stationary bicycling (especially a recumbent bicycle) are particularly safe. There is certainly risk of injury during a fall but this risk is likely to be no different than having a seizure while walking.
Treadmills are generally safe but the emergency stop device must be employed so that if a fall occurs, the track will stop advancing to prevent abrasions. Elliptical or similar devices are probably preferable to treadmills.
Dr. Pacia: I dissuade patients from treadmills unless they have a very low risk of breakthrough seizures.
Are contact sports safe for athletes who have epilepsy?
Dr. Pacia agrees with the findings of a study by Drs. Shaoo and Fountain: Epilepsy in football players and other land-based contact or collision sport athletes: when can they participate, and is there an increased risk? Curr Sports Med Rep 2004; 3(5):284-8 (see abstract below).
About the Experts
Nathan B. Fountain, MD, is Associate Professor of Neurology and since 1998 has been Director of the F.E. Dreifuss Comprehensive Epilepsy Program at the University of Virginia School of Medicine where he completed neurology residency as well as clinical and research epilepsy fellowships. Dr. Fountain's clinical research includes many NIH and industry sponsored early clinical trials (phases II and III) of antiepileptic drugs and devices for the treatment of seizures and epilepsy. He is also pursuing studies of the natural history of changes in seizure frequency and clinical research into the pathophysiology of nonconvulsive status epilepticus. He serves as president of the Epilepsy Foundation of Virginia and on the boards of the National Association of Epilepsy Centers and the Epilepsy Foundation PAB, as well as committees for the American Epilepsy Society and the American Academy of Neurology.
Steven V. Pacia, MD, earned his medical degree in 1987 from the Medical College of Wisconsin and completed his neurology residency and epilepsy fellowship at the Yale School of Medicine. In 1991, he was awarded the Gilbert Glaser Fellowship in Epilepsy and in 1992 was awarded the highly competitive Victor Horsley Research Fellowship from the Epilepsy Foundation of America. In 1993, Dr. Pacia joined the faculty of the Neurology Department at NYU as director of the clinical neurophysiology (EEG) laboratory. In 2002, he became Director of the Clinical Neurophysiology Residency at NYU. In 2004, he was appointed Chief of Neurology at Manhattan's Lenox Hill Hospital and Director of the Comprehensive Epilepsy Center. Dr. Pacia has published numerous peer reviewed articles on the diagnosis and treatment of epilepsy and is co-editor on the best-selling text reviewing alternative treatments for seizures. Dr. Pacia has devoted his career to improving quality of life for patients with seizure disorders.
Abstract of study by Drs. Shaoo and Fountain:
We discuss the impact of epilepsy on the lives of athletes involved in contact sports. Recommendations for epilepsy patients with regard to contact sports have changed over the years from avoidance to encouragement. It is conceivable that exercise could exacerbate seizures either directly, through hyperventilation, or indirectly by alteration of anticonvulsant levels. Seizures could also be injurious in contact sports, and recurrent minor head trauma could worsen epilepsy. However, evidence to the contrary abounds and very few case reports support these notions. Exercise benefits individuals with epilepsy in many ways including improved seizure control, mood, and quality of life. We suggest that athletes with epilepsy be evaluated on an individual basis, and follow sensible guidelines while participating in contact sports. There is no significant evidence to suggest that contact sports are harmful to athletes with epilepsy; however, common sense rules still apply.