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 willingness to participate in social activities like his workplace bowling league

Outcome Measures:

Activities-Specific Balance Confidence (ABC) Scale

Based on the problem list, Mr. Gee’s main activity based issue is related to his ability to ambulate in various environments, including walking around his house, parking lots, shopping malls and uneven surfaces. To assess this, the ABC Scale will be used, which is a patient reported outcome measure assessing a patient’s confidence in various walking and non-walking based activities and can also serve as a predictor of falls. As highlighted by Camara-Lemarroy et al., (2016), this has been validated for elderly patients as well as those with epilepsy.

The ABC scale was chosen over other validated measures, such as the Tinetti Balance and Gait assessment. The rationale here was that the “gait assessment” subscale of the Tinetti (which would be the relevant subscale for assessing aforementioned activity-based construct) captures very “basic” functions of gait, including components such as step length, foot clearance, step length, step symmetry, step continuity, and others. In the instance of Mr. Ghee, however, there aren’t as many activity limitations with specific aspects of gait, but more so the application of this activity in various more “complex” contexts, including his house, stairs, across a parking lot, and or uneven surfaces. As such, even though the Tinetti is a well validated measure for this population, it would not accurately highlight Mr. Ghee’s activity limitations, thus making it more difficult to create goals and meaningful interventions.

Intervention:

Short-term goal #1: Improve patient’s ability to walk in complex environments, as captured by a score of 58% on the ABC scale in 1 month

To address activity limitations in ambulation in various complex environments, Mr. Gee’s intervention program will be focused on ambulation exercises that are aimed at improving his dynamic balance. This intervention will follow the AllActive Information guide which is based on the American College of Sports Medicine (ACSM) guidelines from 2014. In general, this intervention will require the patient to adhere to the program for 2-3 days per week at an intensity that is highest but does not cause any fall or near-fall states. These exercises will become more difficult as the patient’s base of support (BoS) will be progressively challenged, causing the patient to adjust their positioning such that their centre of gravity (CoG) falls within the BOS, preventing them from falling. This will mimic the type of demands that are placed on Mr. Gee in the activity of walking, specifically within the aforementioned “complex” environments (i.e. walking in a crowded mall, walking on uneven surfaces). Furthermore, this will improve their confidence in these environments, which will be represented by improvements on the ABC scale.

Exercise 1 - Sideways walk

The patient will be instructed to stand in an upright posture while holding onto the back of the chair with one hand. The patient will be asked to side-step to the right, back to the centre and then to the left. The patient will then return to the starting position and repeat this exercise for a total of 2 sets of 10 repetitions or until they feel they are close to falling, in which case they can stop and take a break ahead of time.

Exercise 2 - Backwards walk

With the chair positioned at the patient’s side, Mr. Gee will place one of his hands on it for support. He will then be asked to walk backwards, while adjusting the grip he has on the chair. This will be followed by the patient walking forward back to his original position. This will be repeated for 2 sets of 10 repetitions.

Exercise 3 - Heel-to-toe-walk - forwards

With the chair positioned at the patient’s side, Mr. Gee will place one of his hands on it for support. He will then be asked to place his left foot directly in front of his right foot, in a heel to toe manner. Mr. Gee will continue this toe walk pattern through the length of the chair, while adjusting the grip he has on the chair. This will be followed by the patient turning around and walking back to his starting position in the same heel-to-toe manner. This will be repeated for 2 sets of 10 repetitions.

Exercise 4 - Heel-to-toe-walk - backwards

With the chair positioned at the patient’s side, Mr. Gee will place one of his hands on it for support. He will then be asked to place his left foot directly behind his right foot, in a toe to heel manner. Mr. Gee will continue this toe walk pattern through the length of the chair, while adjusting the grip he has on the chair. This will be followed by the patient turning around and walking back to his starting position in the same toe-to-heel manner. This will be repeated for 2 sets of 10 repetitions.

Exercise 5 - Heel walking

With the chair positioned at the patient’s side, Mr. Gee will place one of his hands on it for support. He will then be asked to raise his toes from the floor such that the heel is the only part of the foot making contact with the ground. He will then be asked to walk forwards, while adjusting the grip he has on the chair. This will be followed by the patient turning around and walking back to his starting position in the heel walking manner. This will be repeated for 2 sets of 10 repetitions.

Long-term goal #1: Improve patient’s ability to walk in complex environments, as captures by a score of 70% on the ABC scale in 3 months

Exercise 1 - Sideways walk progression

The patient will follow the same instructions as previously mentioned, however, a few alterations will be made. The patient will progress this exercise in the following ways: first, there will be a transition to just using the fingertips of one hand, then to no hand support from chair.

Exercise 2 - Backwards walk progression

Mr. Gee will be asked to follow the same instructions mentioned above, however, a few progressions will be added. First, he will be asked to use only his fingertips for support as he walks backwards and forwards (instead of his full hand), followed by no hand support.

Exercise 3 - Heel-to-toe-walk progression

Mr. Gee will be asked to follow the same instructions mentioned above, however, a few progressions will be added. First, he will be asked to use only his fingertips for support as he walks (instead of his full hand), followed by no hand support. After these progressions have been mastered, a line (out of masking tape) can be taped on the floor, along which he will have to carefully walk along in a straight line.

Exercise 4 - Heel-to-toe-walk backwards progression

Mr. Gee will be asked to follow the same instructions mentioned above, however, a few progressions will be added. First, he will be asked to use only his fingertips for support as he walks (instead of his full hand), followed by no hand support. After these progressions have been mastered, a line (out of masking tape) can be taped on the floor, along which he will have to carefully walk along in a straight line.

Exercise 5 - Heel walking progression

Mr. Gee will be asked to follow the same instructions mentioned above, however, a few progressions will be added. First, he will be asked to use only his fingertips for support as he walks (instead of his full hand), followed by no hand support.

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.