Epilepsy Case Study: A Queen's University Neuromotor Function Project

Key words:

Epilepsy,

Authors:

Nate Saddy MScPT (c), Aamir Aboosally MScPT (c), Jordan Aslanidis MScPT (c), & Anthony Beilin MScPT (c)

Abstract:

see video about epilepsy

Case Presentation:

A 61 year old South Asian male came into clinic with balance and coordination complaints stemming from a switch in his epilepsy medication. The patient was diagnosed with epilepsy at age 16 after having multiple seizures without a cause. He has been on medications since this diagnosis for the past 45 years and has not had any major issues with seizures since. However, he reports suffering from an acute exacerbation of the seizures approximately 11 months ago, experiencing 4 of them in the span of a few months at this time. This coincided with a period of increased stress in his life, due to challenges at work and in his personal life. As a result of this spike in seizures, he ended up switching medications from the valproic acid he had been taking for decades to a newer drug, lacosamide, in order to try and restabilize his condition. He reports that the seizures have now been nullified, but his balance and coordination have subsequently worsened in response.  

He now states that his ability to walk, get around the city, and function effectively at work, have all been impaired since switching to the new medication. He does not want to change medications again, given that the seizures have been eliminated, but he does hope to improve the aforementioned impairments and get back to participating in his regular daily activities.

Subjective:

History of Presenting Illness:

He was diagnosed at the age of 16 years after having many seizures from unknown causes. His epilepsy is pharmacologically managed, however Abu is fearful of movement and exertion.

Past Medical History:

His epilepsy has been managed primarily through medications for the last 45 years and was fairly stable. However, he suffered a spike in seizure frequency approximately 11 months ago that coincided with a period of immense stress in his life. He experienced 4 seizures within a period of months at this time, leading him to change his anti-seizure medications

Current Interventions:

Currently, medication is the main intervention to manage his epilepsy. Abu is not currently exercising but wants to get involved as he understands this can have a very beneficial effect on his overall health, including his management of epilepsy, mental health, and balance/coordination.

Medications:

Lacosamide Vimpat 200 mg/day - an Anti Epileptic Drug (AED) used in patients with generalized seizures as a mono-therapy (Hoy SM).

Health Habits:

Patient does not smoke and reports drinking alcohol on occasion, approximately 3-4 drinks a week. He reports that his drinking is very tied to his mood, stating that he will drink a lot more whenever his depressive symptoms worsen. He reports not participating in any sports or routine physical activity since switching to the new medication due to the aforementioned issues with his balance that come as a side effect of these drugs. (Overview of Drugs Used For Epilepsy and Seizures - PMC). He was an avid bowler before switching to the new medication and would like to get some confidence back so that he can resume this activity with his friends.

Social History:

He works in human resources at a local manufacturing company 5 days per week. He has a wife and 2 middle aged children who live minutes away from him. He has some friends but typically avoids going out to play sports with them as he is fearful that he may fall and embarrassed of his poor coordination.

Prior Functional History:

Patient was very active in his youth, prior to his epilepsy diagnosis. He played competitive soccer from the age 11-16 and would train his body extensively during this time. Additionally, he had a very high activity tolerance and was able to perform all BADLs and IADLs with ease. However, after being diagnosed with epilepsy and prescribed AEDs, he reports feeling clumsy and imbalanced. These lead to decreased confidence with activities like driving long distances, climbing stairs, grocery shopping, and bowling which he tends to refrain from in order to avoid embarrassment or hurting himself.

Current Functional History:

He remains fearful of movement primarily due to the balance and coordination deficits that come as side-effects with all of his medications. As a result, his activity tolerance has decreased substantially due to his overall deconditioning. He lives independently but remains partially restricted in IADLs.

Family History:

Mr. Ghe does not have a family history of epilepsy, however there have been clinical diagnoses of depression on Mr. Gee’s paternal side, including his father, grandfather and uncle.

Co-morbidities:

Depression is a common comorbidity in epilepsy patients. Due to the information gathered in the subjective history that lined up with several yellow flags, we ended up administering the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). He scored 16/24 which is considered positive for depression. Although we may suspect that Mr. Gee may have depression, he has not been formally diagnosed and this is not within the scope of physiotherapy. Therefore we may want to refer him to a specialist to gain a more accurate clinical picture (as mentioned in the discussion).

Objective:

Problem List:

Body structure & function: Patient reports having balance impairments and clumsiness as a result of his switching to his new AED.

Activity Problem: Patient struggles with his ability to walk when he is navigating various environments.

Participation Problem: Patient has a fear of movement due to his coordination issues that is impairing his ability in participating in social activities like his workplace bowling league

Discussion:

Three health care professionals that Mr. Gee could be referred to are an Occupational Therapist, a Social worker, and a Psychiatrist.

An Occupational Therapist (OT) would be able to help Abu in his care by collaborating to come up with cognitive and organizational tools that can help him return to his functional ADL’s. An OT would be able to support Mr. Gee by gaining a thorough understanding of what is meaningful to him, and ways to gain back confidence in completing tasks outside of his comfort zone (in a safe way). This would help to complement our PT intervention and provide prognostic support.

A Social Worker would help Abu in his care by helping to address some of the major stressors in his life. This includes his financial troubles and retirement plan. This would help Mr. Gee’s mental health by giving him a better idea of ways to navigate this next stage of his life, managing this extra stress by giving him ways to work through these issues. It would help give Abu better peace of mind and confidence that he can support his family.

The Psychiatrist would help play a role in better understanding his depressive symptoms and help form a potential diagnosis in regards to this. They would also be able to provide further benefit in finding a well suited treatment to help with Abu’s mental health status. See below for a sample referral to a Psychiatrist for Abu.

Sample referral to a Psychiatrist:

Mr. Abu Gee is a 61 year old man came into my clinic with balance and coordination complaints stemming from a switch in his epilepsy medication. The patient was diagnosed with epilepsy at age 16 after having multiple seizures without a cause. 11 months ago, he experienced an acute exacerbation of seizures that coincided with a period of increased stress in his life, due to challenges at work and in his personal life. As a result of this spike in seizures, he ended up switching medications from the valproic acid he had been taking for decades to a newer drug, lacosamide, in order to try and restabilize his condition.

Upon further assessment, Mr. Gee reported that he periodically has depressive symptoms that lead to decreased motivation to complete ADL’s and socialize. Along with this, he stated that he has a family history of depression (including his father, grandfather, and uncle). Due to the information gathered in the subjective history that lined up with several yellow flags, we ended up administering the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). He scored 16/24 which can be interpreted as positive for depression.

I think that it is important you are aware of this information and I believe that Mr. Abu Gee would benefit from your expertise. Feel free to contact me if you would like to chat or need any additional information.