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) (Friendman et al., 2009).

Objective:

Observation: patient displays no visible deformities or abnormalities while in static position. Was able to walk into the clinic independently, although at a noticeably slowed and controlled cadence. Displayed intact cognition and was able to answer all questions with no issue. Mood was noted to be worth mentioning as the patient seemed quite down and low on energy throughout the assessment.

AROM: U/E and L/E WNL

Manual Muscle Testing: (only lower extremity)

Scores of 4-/5 bilaterally in hip flexors, extensors, abductors, and adductors

Scores of 4/5 bilaterally in knee flexors and extensors

Scores of 4-/5 bilaterally in ankle dorsiflexors and plantar flexors

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's balance impairments are affecting his willingness to participate in social activities like his workplace bowling league

Outcome Measures:

The Sharpened Romberg (SR)

Based on the problem list, Mr. Gee’s most pressing functional issue was his balance. Due to the patient’s age and overall independence, the SR with eyes open will be used to assess static balance as it was used in Fife TD et al. () to assess balance in older adults with epilepsy who take AEDs. The SR has been found to be a valid and reliable tool for assessing balance and can be used to assess functional balance in older adults when performed with eyes open (Gras LZ). The Normative values for healthy older adults are also available for healthy populations of the same age. As per El-Kashlan (), adults between ages 60-69 years could hold the tandem position for an average of 29 seconds with their eyes open. It is important to note that sway should be measured using posturography when assessing balance in younger healthy populations because the SR alone may not be sensitive enough to measure changes in balance (Fife TD et al.).

Initial Findings: Mr. Gee held the Tandem stance for 13 seconds.

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.

The patient scored a mean of 54.38% across the 16-item scale. Compared to normative values for elderly adults, any score of lower than 67% indicates a risk of falls that is based on the patient’s own confidence in their ability to navigate various environments (Lajoie et al., 2004).

Intervention:

Balance:

Short-Term Goal: Increase SR time to 17 seconds by the end of the first month of treatment

Intervention: Following the ACSM (2014) guidelines for balance training in older adults, Mr. Gee will be prescribed static balance exercises that alter his base of support and challenge his balancing abilities without inducing a fall or near fall. As per the AllActive Information Guide () based on the ACSM (2014) guidelines, the following three exercises will be performed 2-3 times a day, 2-3 days a week, for as long as possible (up to 15 seconds). The support of a chair can also be used if needed. These exercises include: feet apart standing, semi tandem standing, and tandem standing.

Long-Term Goal: Increase SR time to 25 seconds by the end of 3 month of treatment

Intervention: In the case that Mr. Gee has met his short term goal, he should be more than ready to progress his exercises. The next exercises will start to minimize the size of the patient’s base of support by decreasing the amount of contact that his feet have with the ground. These exercises will follow the same parameters as the previous intervention as per AllActive Information Guide () and are as follows: single-foot standing, toe standing, heel standing.

In the case of an adverse event such as a fall during any of his exercises, education on the importance of not going to the point of a fall or near fall would be provided and the need for regression of his exercises would be assessed. Next, the patient can start to do his exercises by a more stable surface such as a kitchen counter. Additionally, his kids could be educated on proper guarding during exercise and could come over to Mr. Gee’s house while he exercises to help him in the case that he experiences another fall.

Walking:

Short-term goal : 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 : 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.

Adverse Effects

If Mr. Gee experienced an adverse event, such as a fall, his treatment program would have to be adjusted. Specifically, this can be done by simplifying the given exercises to an earlier progression. Factors that can be modified here include adding additional support through placing both hands on the chair for support, using full contact of the hands with the chair, slowing down of the movement and or reducing the number of repetitions/sets that the patient would be asked to complete. In addition to these practical changes to the treatment program, there is also an important education component. Mr. Gee would have to be reminded of the importance of maintaining a safe intensity to these exercises. Based on the ACSM (2014), the appropriate intensity of exercise is one where there is no fear/likelihood of falling. As such, we would remind Mr. Gee to pay attention to his level of exertion, feelings of stability and his perceived feelings of instability. If Mr. Gee feels like he is becoming unstable and or likely to feel, we would advise him to take a break and resume the exercises/walking after a period of rest. These pointers would also be transferable to his daily life and preventing complications and improving his confidence in ambulating in “complex” environments.

Participation:

Short Term Goal: improve patient’s QOLIE-89 sub-scale scores by 10 points in the domains of social isolation, social support, and work/driving/social function by the end of 1.5 months of treatment

Intervention: Will aim to improve Mr. Gee’s confidence in his ability to participate in social events by educating him about gait aids and then fitting him for walking poles. By explaining the stability benefits associated with these devices, we hope to lessen his fear of movement and thus improve his scores on the above sub-scales within 1.5 months as he develops more and more confidence using them. We specifically picked the aid that is the most mobile and least restrictive in order to provide the most functional mobility and quality of life without any additional undue risks. We will teach him how to ambulate with the walking poles using a 2 point step-through gait pattern, while also teaching him how he can use the poles to assist his sit-to-stand. The overall goal will be to reduce his balance related worries with the prescribed aid in order to make him feel more confident about ambulating in a variety of different social situations, thus improving his functional mobility.

Long Term Goal: patient will be able to complete all 10 frames of bowling within his workplace bowling league without having any balance or coordination concerns by the end of 3 months of treatment

Intervention: Educating the patient on the value of exercise for improving the balance and coordination related side effects linked to the new AEDs taken by Mr. Gee. Will use empirical research evidence to first remove any fears Mr. Gee has in regards to exercise and safety concerns associated with it due to his current condition (Pimentel et al). Will also use empirical evidence to illustrate the beneficial effects exercise can have on mood and depression related symptoms in order to try and combat some of his displayed yellow flags (Kvam et al). The overall goal will be to utilize the educative nature of the physiotherapy profession to provide accurate, detailed information to Mr. Gee that will make it easier for him to buy in and carry out the static and dynamic balance training interventions mentioned above.

Adverse Effects

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.