Sports and epilepsy: A comprehensive review in the Japanese context
Abstract
Abstract:Introduction: Epilepsy, affecting 1% of the global population, is a neuropsychiatric disease often co-occurring with psychiatric disorders. It is characterized by recurrent “epileptic seizures” caused by abnormal electrical activity in the brain, which poses risks during exercise and damages athletic identity. In Japan, psychiatrists perform essential roles in the treatment of patients with epilepsy. Methods: This review examines and addresses the challenges and opportunities for individuals with epilepsy in athletic endeavors. Results: Historically, misconceptions regarding seizure triggers, societal stigma, and overprotective attitudes have limited physical activity among individuals with epilepsy, resulting in obesity and reduced wellbeing. However, exercise does not typically induce seizures. Recent research suggests that exercise benefits seizure control, quality of life, and comorbidities among individuals with epilepsy. Sports participation risks were categorized into three groups using tailored guidelines provided by the International League Against Epilepsy (ILAE). Water-based sports require controlled environments, monitoring, and distinctive attire due to the risk of drowning. In contact sports, precautions are required to address seizures prior to physical contact. Guidelines for children with epilepsy in school events emphasize inclusion, as restrictions may lead to social and developmental challenges. Few prominent athletes who openly disclosed their epilepsy diagnoses. Conclusion: Physical activity offers benefits to individuals with epilepsy, necessitating a re-evaluation of exercise restrictions. Guidelines and seizure type considerations are essential. Athletes’ openness about epilepsy enhances awareness and support, contributing to the overall well-being of this population. Dipruption of epilepsy on competitive mindset might extend to Athletic Identity (AI).
Introduction
Persons with epilepsy (PWEs) have previously faced several restrictions with regard to physical activity and sports engagement. However, in recent years, there has been growing recognition of the potential positive effects of exercise and sports on epilepsy management. Additionally, concerns regarding the perceived risk of injury during sporting activities for PWEs may have been overstated. This narrative review aimed to elucidate the interplay between epilepsy and sports while examining the participation of individuals with epilepsy in athletic pursuits. There is sparse evidence in the field of sports and epilepsy. Therefore, this review’s comprehensiveness could be restricted.
What is epilepsy?
Epilepsy, a prevalent neuropsychiatric disorder, affects approximately 1% of the global population [1]. Psychiatry plays a pivotal role in epilepsy care due to the frequent comorbidity of psychiatric conditions [2, 3]. In Japan, psychiatrists perform an essential role in the care and treatment of patients with epilepsy. Epilepsy is characterized by the occurrence of “epileptic seizures,” which stem from sudden and excessive electrical activity within the brain. According to the International League Against Epilepsy (ILAE), epilepsy is defined as a cerebral ailment encompassing one of the following criteria: (1) at least two unprovoked (or reflex) seizures occurring >24 h apart; (2) one unprovoked (or reflex) seizure and a probability of further seizures, similar to the general recurrence risk (at least 60%), after two unprovoked seizures, occurring over the next 10 years; (3) diagnosis of epilepsy syndrome [4]. Epilepsy can manifest across all age groups and exhibits a bimodal incidence pattern, with peaks in childhood and later in life [5]. This disorder is remarkably diverse and presents with an array of epileptic seizure types. Some seizures cause sudden loss of consciousness or cessation of movement, which can lead to accidents or risk to life if seizures occur during exercise, especially swimming.
Physical exercise restriction in PWEs
Historically, PWEs have faced unwarranted limitations when engaging in physical exercises and sports activities. These restrictions have arisen from exaggerated concerns regarding the risk of seizure-related injuries, overprotective attitudes, societal stigma, and lack of understanding [6, 7]. For instance, concerns about triggering epileptic seizures by exercising and the risk of accidents often lead to restriction of exercise in PWEs. However, it is pertinent to note that antiepileptic drugs successfully control seizures in approximately 70% of PWEs [8] and exercise does not appear to serve as a seizure trigger, as shown below. Given the favorable treatment outcomes, it is conceivable that these exercise restrictions were overly applied to PWEs. In childhood, when epilepsy is more likely to manifest, restricted participation in physical education classes can inadvertently contribute to scholastic difficulties and hinder physical development. Conversely, in old age, lack of exercise can predispose individuals to frailty, elevating the risk of fractures and physical decline resulting from falls. The imposition of exercise restrictions has a detrimental impact on the quality of life of patients with PWEs.
Because of these restrictions, PWEs engage in physical activity significantly less frequently than the general population [9, 10], leading to higher rates of obesity and diminished physical and mental well-being [11, 12]. These trends underscore the fact that individuals with epilepsy tend to have less active lifestyles and consequently grapple with compromised health. Nonetheless, in recent years, the potential therapeutic benefits of exercise and sports for PWEs have garnered increasing recognition, challenging the perceived risk of trauma and other injuries during sporting activities. A comprehensive study exploring the relationship between exercise, seizure control, quality of life, depression, anxiety, and side effects of antiepileptic drugs in PWEs revealed superior outcomes in the active exercise group [13]. This suggests that a higher level of physical activity may positively correlate with the overall medical status of individuals with epilepsy. The significance of physical activity as a determinant of the holistic health of PWEs has garnered support from a mounting body of research. Consequently, it is imperative to remove undue restrictions on physical activity and institute societal changes that foster the inclusion of PWEs in sports activities.
Effects of sports on PWEs
PWEs exercise less frequently compared to the general population, often experiencing a higher likelihood of obesity and lower levels of physical and mental well-being, indicating a proclivity toward inactivity and diminished health [11, 12, 14]. Conversely, empirical investigations have shown that active participation in exercise improves epileptic seizure control, enhances the quality of life, reduces depression and anxiety, and mitigates the side effects of antiepileptic drugs in PWEs [15]. These findings suggest that exercise had an overall positive influence on this demographic.
Effects on epileptic seizures
The antiepileptic benefits of exercise have been recurrently demonstrated in animal models, strongly suggesting the capacity of exercise to suppress epileptic seizures [16, 17]. Among PWEs, self-reported reductions in seizure frequency attributable to daily exercise have been reported in 36% of individuals [9]. In addition, a reduction in epileptic discharge associated with exercise has been observed, particularly in cases of juvenile myoclonic epilepsy [18]. Although the data on the impact of exercise programs on people with epilepsy reported in the literature are still limited, it is noteworthy that a study by Eriksen et al. (1994) [19] reported a decreased number of seizures in individuals with epilepsy who participated in a 15-week aerobic physical training program. This study highlights the potential benefits of structured exercise for people with epilepsy. Moreover, numerous forms of epilepsy are associated with sleep and often manifest as seizures during sleep cycles [3]. Notably, sleep deprivation is a potent trigger in most types of epilepsy. Consequently, the improvement of sleep quality through exercise may exert an antiepileptic effect.
In the context of exercise’s anti-epileptic effects, aerobic exercise has been the most extensively studied. Multiple studies have consistently reported the beneficial impact of aerobic exercise in reducing seizures [10, 17, 19]. Nevertheless, it is noteworthy that one randomized controlled trial investigating the effects of moderate cardiovascular exercise did not find a significant reduction in seizure frequency [20]. Additionally, yoga has demonstrated beneficial effects in reducing seizures, as supported by a randomized controlled trial [21].
Effect on psychiatric epilepsy comorbidities
Epilepsy often presents in conjunction with psychiatric disorders, including depression, anxiety, insomnia, and “PNES”. PNES stands for Psychogenic Non-Epileptic Seizures. The episodes of PNES bear a resemblance to epileptic seizures but originate from psychological or emotional factors rather than neurological ones, leading to their classification as a dissociative disorder in psychiatric terms [22]. There is substantial evidence to suggest that exercise can yield positive outcomes for these psychiatric comorbidities. Among these, depression and anxiety are the most common [14]. The lifetime prevalence of depression in epilepsy can be as high as 55% [23], while up to 23.6% of individuals with epilepsy experience concurrent anxiety symptoms [24]. Like as the people without epilepsy, exercise may have beneficial effects on depression and anxiety in PWEs. A high-frequency exercise cohort among PWEs has demonstrated reduced levels of depression and anxiety [25, 26]. Insomnia, a prevalent comorbidity in PWEs, presents in a significant percentage of cases, ranging from 36% to 74% [24]. Exercise has the potential to be beneficial in addressing insomnia. In a small cohort of children with epilepsy, those who were physically active displayed objectively improved sleep duration and efficiency [27]. Research on the impact of exercise on PNES and dissociative disorders in both the epilepsy and psychiatric contexts is limited. Direct studies exploring the effect of exercise on PNES are scarce. However, it is plausible that exercise can have a beneficial effect on PNES, primarily due to its mood-stabilizing properties. Since dissociative disorders are often influenced by mood changes and anxiety, exercise may help alleviate the symptoms associated with PNES.
Effect on physical epilepsy comorbidities
Obesity is a common side effect stemming from the usage of valproic acid, a frequently prescribed antiepileptic medication [28]. Additionally, untreated PWEs often present with a tendency towards obesity [11, 12], and exercise is therefore considered pivotal in combating this condition. Furthermore, certain antiepileptic drugs, including carbamazepine have potential side effects such as osteoporosis [29]. Exercise has emerged as a critical preventive measure for osteoporosis because the mechanical stimulation of bones during physical activity stimulates bone formation. Outdoor exercise stimulates vitamin D production through exposure to sunlight. Depression, anxiety, obesity, and osteoporosis can impede individuals from engaging in physical activity, potentially culminating in a detrimental cycle in which reduced exercise exacerbates comorbidities. Consequently, active encouragement of exercise is of paramount importance.
Induction of epileptic seizures and sports
Direct seizure induction by sports
While there is a theoretical possibility that specific forms of exercise can induce seizures in certain types of epilepsy, prevailing evidence suggests that exercise generally exerts a seizure-suppressing effect. Few studies have reported exercise-induced seizures. For instance, Nakken et al. conducted a study involving 204 PWEs, with 10% reporting frequent exercise-related seizures. However, only 2% experienced purely exercise-induced seizures, while 36% indicated that exercise had a seizure-suppressing effect [9, 30]. Comparable investigations have yielded similar findings, indicating that exercise is unlikely to directly induce seizures. Furthermore, epileptic seizures tend to manifest in a state of cognitive haziness, making them less likely to occur during focused sports activities.
Indirect induction by sports
Several factors associated with participating in sports are considered potential triggers of epileptic seizures. These include hyperpnea, fatigue, physical stress, alterations in antiepileptic drug metabolism, electrolyte imbalance, and head impact. For instance, in the absence of epilepsy, seizures can be provoked by hyperventilation, a phenomenon attributed to alkalosis resulting from excessive carbon dioxide loss during hyperventilation. However, exercise-induced hyperventilation is typically regarded as a physiological response that compensates for carbon dioxide retention and acidosis rather than a seizure trigger.
However, the relationship between postexercise fatigue and seizure frequency remains unclear. Certain hormones released in response to physical stress may promote seizures, whereas others may exhibit inhibitory effects. However, the collective effect of these hormonal fluctuations on the occurrence of seizures remains unclear. Exercise is believed to enhance liver metabolism and potentially affects the metabolism of antiepileptic drugs in the liver. Nevertheless, previous studies have failed to establish significant changes in the blood levels of antiepileptic drugs before and after exercise.
Dehydration, hyperthermia, electrolyte imbalances (particularly hyponatremia), and hypoglycemia resulting from excessive exercise are potential factors that could induce seizures. It is crucial to maintain proper fluid and electrolyte balance during physical activity. Notably, severe hypoglycemia has been reported as a potential trigger for seizures [31]. It is also important to note that, in general, repeated minor head impacts are not typically associated with the development of epileptic seizures.
Concussion-induced convulsions
Following a severe head impact that leads to concussion, individuals may experience convulsions resembling epileptic seizures. These events are attributed to brainstem dysfunction rather than to true epileptic seizures. While concussions typically result in loss of consciousness, video analyses have documented cases involving tonic limb movements and subsequent convulsions after a concussion, mimicking the symptoms of an epileptic seizure [32].
Participation of PWEs in sports
General considerations
There is a potential risk of incidental seizures occurring during sporting activities, necessitating certain restrictions. It is crucial to recognize the heterogeneity of epilepsy and apply restrictions that are proportional to the assessed degree of risk and nature of activity. Therefore, uniform restrictions should be avoided. Analogous to evaluating eligibility for a driver’s license, factors such as the likelihood of seizure occurrence, seizure type, and other relevant factors should be weighed against the specific sport and its environmental context for each individual with epilepsy. Seizures leading to loss of consciousness, weakness, and falls are naturally considered a higher risk, whereas those accompanied by auras, manageable pre-seizure states, or seizures restricted to specific body regions are typically lower risk. Some forms of epilepsy only manifest nocturnally and risk assessments should be tailored accordingly.
The ILAE task force has issued preliminary guidelines on sports participation, which can provide valuable guidance [6]. It categorizes sports into three groups. Group 1: no significant additional risk, Group 2: moderate risk for PWEs but not for bystanders, and Group 3: high risk for PWEs, and, in some sports, also for bystanders. Group 1 comprises judo, wrestling, baseball, basketball, golf, and tennis. Group 2 includes alpine skiing, archery, boxing, karate, cycling, gymnastics, fencing, skateboarding, and swimming. Group 3 contains climbing, horse racing, scuba diving, ski jumping, and surfing. For each group, the guidelines offer directives based on seizure profiles and frequencies. The directives extend from “permitted” to “generally barred’ with many exceptions. However, the assertion that all sports are permissible after 12 months of seizure freedom, as stated in this trial proposal, has faced scrutiny. Certain draft guidelines suggest that activities such as boxing and surfing should in principle be “prohibited” [33].
Water-based sports
Special attention must be paid to water-based sports given the risk of drowning associated with a single seizure, which can lead to grave outcomes, including fatality. For aquatic activities, aside from considering seizure type and frequency as per the aforementioned recommendations, it is advisable to opt for swimming in controlled environments such as swimming pools rather than in open waters such as seas or rivers. Continuous supervision with multiple monitors, shallow and clear water usage, avoidance of diving or submersion, and the use of distinctively marked attire or equipment to distinguish individuals with epilepsy, are also recommended. Scuba diving, due to the profound risk associated with deep diving and potential interactions between nitrogen poisoning and antiepileptic drugs, generally requires at least five years of seizure freedom without antiepileptic medications, as advised by the UK Sport Diving Medical Committee. Some advocate a four-year seizure-free period, even with the use of antiepileptic drugs. However, participation in scuba diving is often contingent on obtaining a “C-card,” a technical certification issued by diving instruction organizations. In practice, epilepsy often disqualifies individuals from obtaining this certificate, effectively limiting their participation.
Contact sports
Contact sports entail the possibility of untimely seizures occurring just before physical contact. Extra precautions are necessary for striking martial arts, such as boxing and karate, which pose a substantial risk of head impact in individuals without seizure protection. Sports, such as rugby, American football, and wrestling, frequently involve tackling and falling, which may result in severe injuries if seizures occur without protection. Vigilance should also be exercised in sports in which falls from heights or unstable apparatuses may occur, such as gymnastics, pole vaulting, and mountaineering.
Participation of children with epilepsy in school activities
Integration of children with epilepsy into school life
Inclusive school environments aim to treat children with epilepsy on par with their peers without the condition, foster socialization, and prevent feelings of alienation that may hinder their physical and mental development. Overprotective parents and lack of epilepsy knowledge often lead to restrictions, particularly in cases of severe epilepsy and comorbidities. While most specialists in epilepsy endorse the participation of children with epilepsy in activities such as group swimming, long-distance running, and skiing along with their peers, general practitioners and educators are less likely to do so. Therefore, it is crucial to disseminate accurate information, including risk assessments, and respond thoughtfully to school inquiries regarding participation and medical documentation.
Utilizing guidelines
Guidelines have been developed to aid children with epilepsy in participating in school events, including sports. In Japan, the Ministry of Health, Labour and Welfare’s “Research on the Total Care of Chronic Childhood Disorders” offers two guidelines: Guideline A, designed for regular classes, and Guideline B, intended for special schools and institutions for disabled children. These guidelines provide recommendations based on seizure frequency and intensity, daily life, and event involvement. It is important to note that the term “strict attention” does not signify prohibition, but indicates that participation should occur under close supervision, with the fundamental rule being participation in events whenever possible.
Famous athletes openly disclosing their epilepsy diagnosis
Public acknowledgment of epilepsy by athletes remains relatively scarce, a trend that stands in stark contrast to the prevalence of epilepsy in the general population. Prejudice and societal stigma are believed to play significant roles in limiting such disclosures. Consequently, athletes may choose not to disclose their epilepsy diagnoses. However, among those who chose transparency, many have emerged as passionate advocates for epilepsy awareness. Several noteworthy examples include the following.
Alan Faneca
Alan Faneca, a former professional American football player renowned for his career in the NFL, was diagnosed with epilepsy in 2003. However, he continued to excel as an offensive lineman for the Pittsburgh Steelers, New York Jets, and Arizona Cardinals. Faneca established the “AFC Fitness” program, short for “Athletes for a Cure,” with the goal of fundraising for epilepsy research and promoting awareness through fitness-related activities and events.
Marion Clignet
Marion Clignet, a retired French professional cyclist with four Olympic silver medals and numerous world championships, was diagnosed with epilepsy at a young age. Born as a French-American, she changed her nationality from American to French, a decision influenced by the US Cycling Federation’s reluctance to include individuals with epilepsy on their team. Despite her poor condition, Clignet enjoyed a highly successful cycling career. She became a passionate advocate for epilepsy awareness, actively working to raise awareness and support those affected by the disease.
Dai Greene
Dai Greene, a British track and field athlete specializing in the 400 m hurdles and a World and European champion in this event, openly discussed his epilepsy diagnosis and the challenges of managing the condition while pursuing a professional athletic career. Greene serves as an ambassador for “Young Epilepsy,” a prominent UK-based charitable organization dedicated to improving the lives of children and young individuals with epilepsy.
Makoto Tosa
Makoto Tosa, a Japanese professional rugby player primarily occupies the “No 8” position, known for its aggressive nature in rugby. He has experienced seizures during actual game matches. Remarkably, Tosa continued his rugby career in Japan’s top division, the “Top League,” following successful epilepsy surgery.
The openness of these athletes regarding their epilepsy diagnoses not only sheds light on their condition, but also contributes to epilepsy awareness and support initiatives.
Epilepsy and athletic identity
Epilepsy, characterized by unpredictable and unprovoked seizures, can disrupt both positive and negative psychological factors due to its often uncontrollable nature. This disruption extends to Athletic Identity (AI), which pertains to an individual’s self-concept and their perception of themselves as athletes [34]. AI tends to strengthen with greater involvement in sports and is closely linked to higher athletic achievements, increased motivation, and heightened competitiveness [34]. The development of a healthy AI relies on factors such as confidence, a competitive spirit, and an internal locus of control, all of which can be disrupted by epilepsy’s apparent lack of control. The internal locus of control represents the belief that individuals have influence over their own actions and outcomes, a crucial factor in developing AI [35]. Epilepsy’s unpredictable and unprovoked seizures appear contradictory to the concept of an internal locus of control [36]. Consequently, PWEs may encounter challenges in maintaining their internal locus of control, which can impede the development of a strong AI. Moreover, epilepsy often triggers anxiety, which can further disrupt confidence and an athlete’s competitive mindset.
Conclusion
Physical activity not only promotes physical and mental well-being, but also fosters self-fulfillment. This is especially pertinent for PWEs who often face unwarranted stigma and prejudice. However, encouraging physical activity among those who lack an inherent interest can be challenging. When prescribing exercises for individuals with epilepsy, it is crucial to tailor the recommendations based on the individual’s specific condition and preferences. For instance, even when suggesting something as simple as walking, one can enhance the experience by proposing exploratory walks to nearby historical sites or by engaging in competitive sports that involve scoring or timekeeping. By implementing such strategies, we aim to kindle interest in physical activity and sports, thereby increasing the overall engagement and adherence rates.
We thank the Ministry of Health, Labor, and Welfare Grants-in-Aid for Scientific Research (Research Project Number: 22JA1006) and JSPS KAKENHI (Grant Number 23K14794) for the support.
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