Effects of Exercise (cardiovascular function) on the Development of Epilepsy in Adults. 30 Nov 2012

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1 Effects of Exercise (cardiovascular function) on the Development of Epilepsy in Adults. 30 Nov 2012 Elinor Ben-Menachem, MD, PhD Institute of Clinical Neuroscience and Physiology, Sahlgrenska Academy, University of Goteborg, Sweden American Epilepsy Society Annual Meeting 1

2 Disclosure Name of Commercial Interest UCB Eisai Bial Janssen-Cilag Lundbeck Acta Neurologica Scnadinavica Type of Financial Relationship Research Grant, Consult Research Grant, Consult Research Grant Consult Consult Chief Editor American Epilepsy Society Annual Meeting

3 Learning Objectives 1. Recommendations for the type of exercise most advantageous for patients with epilepsy 2. Understand the factors involved in performing exercise that can have a positive influence on epilepsy 3. Be able to evaluate if exercise can be a positive modulator for your patients with epilepsy. American Epilepsy Society Annual Meeting

4 Purpose Exercise is a neglected area when evaluating epilepsy patients. Exercise is usually addressed when dealing with other conditions but not epilepsy. We will learn how cardiovascular fitness can influence the development of epilepsy and how it can influence prognosis American Epilepsy Society Annual Meeting

5 Reference- Nakken KO et al-epilepsia 1999

6 Ref: Cardiovascular fitness and future risk of epilepsy: a prospective study Nyberg J,, Åberg MAI, Ben-Menachem E Torén K, Nilsson M Kuhn G Currently Submitted Annals of Neurology

7 Exercise and Cardiovascular Fitness GAPS 1. Physicians and nurses do not usually discuss this topic with patients. If so it is only as a general recommendation 2. Tradition, lack of peer reviewed information determines the advise physicians give. 3. There is a lack of prospective studies with appropriate controls 4. Overprotection, social isolation, low self esteem, anxiety and depression are barriers to exercise 5. The resulting gap is that there is little guidance for patients concerning the basic activity of exercise. American Epilepsy Society Annual Meeting

8 Activity Choices for Our Patients? 8

9 Or This- like Marion Clignet 9

10 What Do We Know? Many persons with epilepsy (PWE) are overweight Exercise causes improvements in Parkinson and Alzheimers and Depression Some AEDs cause weight gain PWE are very protected and often do not exercise PWE are like everyone else-getting fatter as they are exposed to the same poor exercise climate and junk food as the rest of the population. American Epilepsy Society Annual Meeting

11 Role of Exercise on Prevention of CNS Diseases The role of exercise in the PREVENTION of EPILEPSY has not been previously explored in humans. A previous study by the Åberg et al has shown that physical exercise is a factor for preventing depression in males Lower cardiovascular fitness at age 18 was associated with an increased risk of future depression, but not bipolar disorder. Hypothesis: Cardiovasvascular fitness could modulate brain plasticity by increasing amounts of circulating growth factors or beta endorphins or some other neuroactive molecule Ref: Åberg M et al. Br J Psyc. June 2012 American Epilepsy Society Annual Meeting

12 Physical Exercise In Outpatients With Epilepsy-KO Nakken-Epilepsia 1999 N=204 patients with active epilepsy-tested with 2 questionnaires. Results: Persons with epilepsy never exercising were higher than the control normal adult population. Persons with epilepsy often exercised in fitness centers and with friends than alone in individual activities 53% and 63% never experienced seizures during or after exercise. 13

13 Nakken (Cont.) Only 2% had genuine exercise induced seizures, mostly with symptomatic localized related epilepsies Most exercise related seizures occurred during strenuous exercise 10% had injuries related to seizures during exercise. 53% claimed no influence of epilepsy, 36% said it was positive and 10% negative. 14

14 Nakken (Cont) Conclusion In majority of patients physical exercise had no adverse effects (90%) 36% said it had a positive influence contributing to better seizure control. Only 10% thought exercise to be a precipitant of seizures 15

15 Cardiovascular Fitness and Future Risk of Epilepsy: a Prospective Study Nyberg J,, Åberg MAI, Ben-Menachem E Torén K, Nilsson M Kuhn G Currently Submitted Annals of Neurology 16

16 Physical Activity Before Developing Epilepsy-Is This Important? To investigate the associations between cardiovascular fitness at age 18 and future risk of epilepsy Population-based, prospective cohort study of Swedish male conscripts (n=1,173,079) born between , Followed for up to 40 years. Data on cardiovascular fitness, as measured by ergometer cycling, were collected during conscription exams and linked with hospital registers to calculate future risk of epilepsy. 17

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19 Physical Activity before developing Results: Epilepsy 6796 individuals received specialist outpatient or inpatient treatment for epilepsy during the observation period In fully adjusted models, low cardiovascular fitness at age 18 was associated with increased risk for future epilepsy (HR 1.79, 95%, CI ). In a full-brother model, thereby controlling for familial influences, low cardiovascular fitness remained a significant predictor (HR 1.66, 95%, CI ) but did not account for all the risk. Individuals who had a head injury prior to the epilepsy diagnosis had even stronger associations between cardiovascular fitness at age 18 and future risk of epilepsy (HR 1.88, 95%, CI ).- Fully adjusted models (for calendar year, BMI, region, conscription test centre, parental education) 20

20 Hazard ratios for epilepsy and traumatic head injury in relation to cardiovascular fitness in 18-year-old male conscripts with fully adjusted models (n = ). 21

21 Subanalyses for conscripts (n = ) with one or more brothers: Hazard ratios for epilepsy in relation to cardiovascular fitness at age

22 Physical Activity before developing Epilepsy Take home message: For individuals who had high cardiovascular fitness at age 18 the risk of epilepsy was less during a 40 year period than those who had low cardiovascular fitness at the age of 18.. American Epilepsy Society Annual Meeting

23 Physical Activity before developing Epilepsy Take home message: Individuals who had a head injury prior to the epilepsy diagnosis had even stronger associations between cardiovascular fitness at age 18 and future risk of epilepsy (HR 1.88, 95%, CI ). Risk of traumatic head injury in itself was only very weakly associated with cardiovascular fitness at age 18. American Epilepsy Society Annual Meeting

24 Physical Activity Before Developing Epilepsy-In Other Words Those who had a traumatic head injury before their epilepsy diagnosis had a higher risk of developing epilepsy if they had lower cardiovascular fitness compared to individuals who never had a prior traumatic head injury. This finding could be of clinical value for patients suffering from traumatic head injury in order to try to modify epileptic processes from manifesting in disease later on. American Epilepsy Society Annual Meeting

25 Physical Activity Before Developing Epilepsy This study found significant associations between physical fitness early in life and risk of epilepsy later in adulthood confirming previous results from animal models Physical activity may act as a positive diseasemodifying behaviour for preventing or delaying the development of epilepsy. American Epilepsy Society Annual Meeting

26 R. M. Arida et al. Epilepsia, 51(Suppl. 3): 76 79,

27 Impact Fitness on Clinical Care and Practice Exercise has positive impact on general health and quality of life and does not generally act as a seizureinducing factor ( Roth DL et al Epilepsia. ;35:1248, Steinhoff BJ et al Epilepsia ;37:1221). In fact, aerobic physical exercise programs in patients with epilepsy can reduce frequency of seizures (Eriksen HR et al Epilepsia :1256) Exercise can contribute to better seizure control (Nakken KO. Physical exercise in outpatients with epilepsy. Epilepsia. 1999;40:643) Scheme Provided by J. Engel, UCLA, 2012 excluding fitness 28

28 Conclusion Patients who already have epilepsy can benefit from exercise. Only few will have a seizure during exercise There is a possible preventive effect of cardiovascular exercise on seizure susceptibility and development of epilepsy in humans Physical education is important in children and adolescents even as a possible modulating factor in prevention of epilepsy. 29

29 Why Not? 30

30 Reserve slides 31

31 Numbers and proportions developing epilepsy during the observation period shown by level of cardiovascular fitness at age 18. Cardiovascular fitness Cardiovascular fitness Number with epilepsy 1 (Low) (1.11%) 2 (Low) (1.09 %) 3 (Low) (1.08 %) 4 (Medium) (0.85 %) 5 (Medium) (0.76 %) 6 (Medium) (0.46 %) 7 (High) (0.54 %) 8 (High) (0.43 %) 9 (High) (0.46 %) All levels

32 Subanalyses for conscripts with or without a traumatic head injury prior to the epilepsy diagnose: Hazard ratios for epilepsy in relation to cardiovascular fitness at age 18 with fully adjusted models (n = ). 34

Staging of Seizures According to Current Classification Systems December 10, 2013

Staging of Seizures According to Current Classification Systems December 10, 2013 Elinor Ben-Menachem, M.D.,Ph.D, Instituet of Clinical Neuroscience and Physiology, Sahlgren Academy, Goteborg University,