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

Original Editor - Nate Saddy, Aamir Aboosally, Jordan Aslanidis and Anthony Beilin as part of the Queen's University Neuromotor Function Project
Top Contributors - Anthony Beilin, Aamir Aboosally, Nate Saddy, Jordan Aslanidis and Carina Therese Magtibay

Authors:

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

Abstract:

This case is about a 61 year old man by the name of Abu Gee presenting with epilepsy. He was initially diagnosed with epilepsy at the age of 16 and since then, he has been on antiepileptic drugs (AEDs) that have largely stopped his seizures, except for an exacerbation of symptoms 11 months ago that led him to switch medications. Since then, his seizures have been controlled, but he reports issues with balance as well as ambulation in more complex environments. This contributes to an inability to participate in meaningful social activities. Physiotherapy interventions were focused on improving static balance, dynamic balance, as well as education on appropriate gait aids and on the importance of exercise. Mr. Gee will also be referred to other healthcare professionals surrounding aspects of his care that fall outside the physiotherapy scope of practice.

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:

Mr. Gee was diagnosed with epilepsy at the age of 16 after having multiple seizures from unknown causes. He was successfully able to medically manage his seizures for the past 45 years but recently suffered a spike in the frequency of them approximately 11 months ago.  He experienced 4 seizures within a period of months at this time, leading him to change his anti-seizure medication from valproic acid to lacosamide, a newer drug. This switch was successful at eliminating the seizures, but seemed to trigger a vast array of balance and coordination impairments that have left Mr. Gee quite fearful and apprehensive of movement. He decided to come into our clinic for guidance surrounding these balance issues in particular.

Past Medical History:

Patient’s epilepsy had been managed primarily through valproic acid AEDs for the last 45 years and was fairly stable. He reported having only a handful of seizures during that time span that were all quite minor. A key point of note is the fact that he mentioned most of the seizures arose during or following periods of stressful events in his life.

Current Interventions:

Medically manages his epilepsy with Lacosamide based treatment

Not currently exercising as he is worried about reaggravating his seizures and worried about losing balance/potentially falling

Medications:

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

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 . 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:

Mr. Gee works in human resources at a local manufacturing company 5 days per week. His responsibilities were changed 11 months ago to more tedious, repetitive assignments that often have very short-term and strict deadlines. He was expecting a promotion this fiscal year but was just informed that it is not coming due to company-wide restructuring. He has a wife and 2 middle aged children who live minutes away from him. He has a few friends but hasn’t been socializing with them much recently 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. He was also quite active over the past 45 years while medically managing his epilepsy with valproic acid. He had a high activity tolerance and was able to perform all basic activities of daily living (BADLs) and instrumental activities of daily living (IADLs) with ease. He participated in a weekly bowling league with his workplace colleagues over the past 20 years and ended up winning the championship 5 times.

Current Functional History:

After switching medications, Mr. Gee reports feeling very clumsy and imbalanced. This led 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. As a result, his activity tolerance has decreased substantially due to his overall deconditioning. He is still quite independent but remains partially restricted in IADLs.

Family History:

Mr. Gee 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:

Based off of the information that was gathered from the subjective history, a number of yellow flags were noted. These findings combined with the fact that depression is a common comorbidity in epilepsy patients, led us to administer the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) . The NDDI-E is a questionnaire containing 6-items that is validated for screening epilepsy patients for depression . 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 it is not within the scope of physiotherapy to diagnose him. Therefore we may want to refer him to a specialist to gain a more accurate clinical picture (as later discussed in the discussion).

Objective:

Observation: patient displays no visible deformities or abnormalities while in static position. Was able to walk into the clinic independently, although at a slightly slowed and controlled cadence combined with an apprehensiveness to movement across uneven surfaces and tight corners. 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 (Based on the ICF Model):

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 "complex" 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 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 . 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 .

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. this has been utilized 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 step length, foot clearance, step length, step symmetry, step continuity, and others. In the instance of Mr. Gee, however, there aren’t as many activity limitations with specific aspects of gait, but instead a general apprehensiveness of movement which is especially pronounced 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. Gee’s activity limitations, thus making it more difficult to create goals and meaningful interventions.

The patient completed ABC scale produced a final 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 .

Abu Gee's Completed ABC Scale

Quality of Life in Epilepsy Inventory

Based on the patient's complaint regarding his participation limitations after switching medications, the Quality of Life in Epilepsy Inventory 89 item version (QOLIE-89) was chosen to be administered. This outcome measure is able to assess seizure related worry, health discouragement, medication effects, and work/driving/social functioning with a high degree of validity in epilepsy patients of varied demographic characteristics . This scale has been validated thoroughly in North American epilepsy patients so it will provide a detailed picture of the specific participation related domains our patient is facing impairments within . The scale is split into 17 subscales that each correspond to unique health concepts. Each of these subscales is scored from 0-100, with higher scores corresponding to better quality of life ratings. An overall score is obtained using a weighted average of the sub-scale scores, and is also in a range between 0-100 with 100 representing a higher quality of life .

Based on the QOLIE-89 scoring system, our patient scored lowest in the domains of emotion related role limitations (0/100), work/driving/social function (22.3/100), social isolation (20/100), and social support (31.3/100). He also mentioned feeling very socially isolated in the subjective interview, noting that he is particularly upset about not being able to participate in his workplace social bowling league since starting his new medication. We will thus try to tailor our interventions to these specific areas in order to help Mr. Gee regain confidence in his ability to participate in more social situations, such as his cherished workplace bowling league.

AbuGeeQOLIE-89

Clinical Impression:

Diagnosis: After assessing Mr. Gee, we have observed that he has impaired balance, fear of movement, and has yellow flags surrounding social interactions. The impaired balance was indicated from the SR as he held the tandem stance for 13 seconds (normative for his age is 29 seconds). The fear and difficulty with movement was indicated by Abu’s score on the ABC scale, achieving a mean score of 54.38% (<67% indicates risk of falls due to confidence with activities). Finally, the yellow flags surrounding social interaction were not only attributed to the subjective interview but also to the results of the QOLIE-89, specifically the domains of emotion related role limitations, work/driving/social function, social isolation, and social support.

Prognosis: In terms of prognosis, many factors go into play in attempts to determine this. Some supporting factors that may shorten the length of Abu’s rehabilitation include his supportive family, the current stability of his seizures, his meaningful goals, and the fact that he came to physiotherapy for help. Some factors that may lengthen the time needed to achieve his goals include the stressors in his life (work/finances), many of the yellow flags (that are not currently being addressed), and his low intrinsic motivation. With this being said, it is hard to determine a specific prognosis as many of these factors can change day by day, however we believe that within 3 months, Abu Gee should be able to return to his participation in bowling.

Intervention:

Balance:

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

Intervention: Following the American College of Sports Medicine (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

Figure 1. Toe Standing Exercise

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 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, practicing these sorts of maneuvers will improve Mr. Gee's confidence in these environments, which will be represented by improvements on the ABC scale.

Figure 2. Sideways Walk Exercise for Dynamic Stability

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. This will be repeated for 2 sets of 10 repetitions.

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. This will be repeated for 2 sets of 10 repetitions.

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. This will be repeated for 2 sets of 10 repetitions.

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. This will be repeated for 2 sets of 10 repetitions.

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. This will be repeated for 2 sets of 10 repetitions.

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 are to be completed. 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 published in 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 and any emerging feelings of instability. If Mr. Gee feels like he is becoming unstable and or likely to fall, 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 preventing complications in his daily life and improving his confidence in ambulating in “complex” environments.

Social Engagement:

Short Term Goal: improve 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 improve his scores on the above sub-scales within 1.5 months as he develops 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 improvement. 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 use the gait aid to reduce his balance related worries in order to make him feel more confident about ambulating in a variety of different social situations, thus reducing his fear of movement while also improving his functional mobility.

Long Term Goal: patient will be able to bowl a full game within his workplace bowling league every week without having any balance concerns by the end of 3 months of treatment

Intervention: We plan on educating Mr. Gee on the value of exercise for improving the balance and coordination related side effects linked to his new AEDs. We will use empirical research evidence to first remove any fears Mr. Gee has in regards to exercise and his ability to perform it due to his current condition. Will also use empirical evidence to illustrate the beneficial effects exercise can have on depression related symptoms in order to try and combat some of his displayed yellow flags . 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

One possible adverse effect concerning all of the education provided to Mr. Gee involves the chance that he gets overwhelmed and even more reluctant to participate in the balance oriented treatment interventions we have proposed for him. As someone who has been fearful of movement for almost a year now, it might be tough for him to hear us lecture him on the value of activities he is just too fearful to perform currently. If this is the case, we would likely aim to step back and simplify all the information we provided into smaller, more easily digestible chunks provided over the course of multiple treatment sessions as opposed to all at once. We could start by fitting him and educating him for the walking poles at the first or second session, before then trying to illustrate to him that movement is safe and very valuable for his balance impairments at subsequent sessions.

Another possible adverse effect that could occur with Mr. Gee is the occurrence of another seizure. If this were to happen, we would change the theme of our education to focus more on the general triggers of seizures and how interventions such as better quality of sleep more exercise, and stress coping mechanisms can help combat them These strategies would thus function as non-pharmacological treatment techniques for Mr. Gee’s epilepsy and would hopefully help even further reduce his frequency of seizures going forward

Technology-Based Intervention:

One innovative technology-mediated tool that may be used to help reduce Abu’s anxiety and fear of movement would be virtual reality (VR). A scoping review, observing the use of VR to treat anxiety disorders, found that it can be a valuable tool for simulating environments that clients with anxiety disorders have difficulty being in . This may provide benefits in terms of enhancing patient outcomes. This suggests that introducing Abu into stressful situations (such as participating in social situations with colleagues or being in a busy mall) could expose him to this environment in a controlled way. This exposure (when graded properly) may provide benefit to Abu when dealing with this in real life.

Although this area of research can be quite promising, there are some challenges when trying to implement it. The first challenge is whether or not there is a risk in using immersive VR for someone with epilepsy. This is a difficult question to ask due to the variability in patient triggers and individual tolerances. Even for populations without epilepsy, some may become nauseous when using the head mounted device for a prolonged period of time and some may have no issues at all. A clinical trial protocol out of York University in Ontario aims to answer this question, however unfortunately no results have yet been published . A way to mitigate this issue would be to gain an understanding if they have used VR before and how the experience was, or simply start with a very short duration using the technology to minimize potential risks. It is vital that physiotherapists understand the risks and benefits of using VR as an intervention for this patient population and stick to the most evidence-based treatment in order to maximize patient outcomes in a safe way. More research is needed to create clinical guidelines that allow health care professionals to safely integrate VR therapy for patient populations with epilepsy.

Figure 3. Technology mediated intervention - VR

Another challenge with implementing this technology is having virtual interactive experiences that blend well to the real world. A systematic review observing the use of VR for anxiety-related disorders discusses that this technology has positive findings surrounding its use for exposure therapy, however it needs to improve its ability to have immersive simulations that blur lines between the virtual and real world . Although it can provide patients with multisensory situations that relate to real life experiences, there are still factors that come into play during a real life experience that can not be replicated through VR. This limitation can be mitigated by finding a well developed simulation that is on the higher end of the scale for how realistic these simulations can currently get. Further, it may be important to emphasize with patients that these simulations are not all inclusive in truly replicating a real life experience, however attempt to create a related experience that allow clients to practice strategies when a real life situation may come along. Creating patient buy-in through education that furthers their understanding could allow this technology to be more useful, regardless of how realistic the simulations may actually be.

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.

Self Study Questions:

1.What is a common comorbidity seen in patients with epilepsy?

a) Parkinson’s Disease

b)Eating Disorders

c) Depression

d)Multiple Sclerosis

2. In the case that your patient experiences an adverse event such as a fall or near fall while performing prescribed exercises. What change(s) to your treatment plan could you implement as the therapist?

a)Simplify the exercise

b)Provide more/sturdier supports for the patient to use as balance aids during their exercises

c)Educate friends/family on proper guarding techniques and encourage that they help your patient while they perform their home exercise program

d)All of the above

3. What is a common side effect of Anti Epileptic Drugs mentioned in this case study?

a)Impaired balance

b)Acne

c)Heart palpitations

d)Trouble swallowing

Correct answers:

1. c)
2. d)
3. a)