physical activity in children/teens with epilepsy compared with that in their siblings without...

Epilepsia, 47(3):631–639, 2006Blackwell Publishing, Inc.C© 2006 International League Against Epilepsy

Physical Activity in Children/Teens with Epilepsy Compared withThat in Their Siblings without Epilepsy

∗Judy Wong and †Elaine Wirrell

∗University of Alberta, Edmonton; and †Department of Pediatrics and Neurosciences, Universityof Calgary, Calgary, Alberta, Canada

Summary: Purpose: To determine (a) whether children andteens with epilepsy participate in less physical activity and havehigher body mass index (BMI) percentiles for age than do theirsiblings without epilepsy; and (b) what epilepsy-specific factorslimit their participation.

Methods: Patients 5–17 years, with a ≥3 month history ofepilepsy, a development quotient ≥80, no major motor or sensoryimpairments, and at least one sibling without epilepsy in a similarage range, were identified from the Neurology Clinic databaseor at the time of clinic visit. Parents completed a questionnaireregarding sedentary activities and group, individual, and totalsports activities. Children aged 11–15 years also completed thephysical activity portion of the Health Behavior in School AgedChildren questionnaire. Clinic charts were reviewed for seizure

type, etiology, frequency, duration of epilepsy, and number ofantiepileptic drugs (AEDs) ever taken.

Results: Teens with epilepsy participated in fewer group andtotal sports activities than did controls and were more likely to bepotentially overweight or overweight. Receiving three or moreAEDs in the past showed a significant negative correlation withsports participation. Although a trend was noted for those withhigher seizure frequency to be less active, no other epilepsy-specific factors or prior seizures or seizure-related injury duringa sports event correlated with participation in physical activity.

Conclusions: Programs that promote exercise in adolescentswith epilepsy should be encouraged to improve their physical,psychological, and social well-being. Key Words: Physicalactivity—Sports—Overweight.

Poor physical fitness and obesity place children at riskfor heart disease, stroke, arthritis, and diabetes. Those chil-dren engaged in sedentary activities such as playing videogames for extended periods have greater increases in bodyweight (1–3). In adults, regular participation in physicalactivity is known to make an important contribution toimproving both physical and psychological quality of life(4).

Studies of children with chronic disease have suggestedthat this population is more likely to be physically unfitthan are children without chronic illness (5–7). However,many of these children have illnesses such as arthritis orrespiratory disease, which physically limit how much ex-ercise they can perform.

Epilepsy is one of the most common neurologic disor-ders of childhood, affecting ≤1% of the pediatric popula-tion. Physical activity in persons with epilepsy has beenproven to provide both physiological and psychologicalbenefits (8–10). However, despite the positive effects of

Accepted November 6, 2005.Address correspondence and reprint requests to Dr. E. Wirrell at

Alberta Children’s Hospital, 1820 Richmond Rd. SW, Calgary, AB,Canada T2T 5C7. E-mail: [email protected]

physical activity, health professionals often caution per-sons with epilepsy against certain types of physical exer-cise because of potential concerns about seizure induction(8–11) or injury (11).

Most studies have suggested that adults with epilepsyhave lower rates of physical fitness and elevated body massindices (BMIs) (11–13). Conversely, in a Norwegian studyof 204 adult outpatients with epilepsy, patients were moreactive than expected, with their exercise pattern closelyresembling that of the average Norwegian (10). However,even this study showed that the portion never exercisingwas higher in the epilepsy group. No study has focused ex-clusively on the physical fitness of children with epilepsycompared with controls without epilepsy.

Children and teens with epilepsy are at risk of social iso-lation (14). Participation in physical activity may improveself-esteem and social integration, leading to improvedquality of life (14).

We compared reported levels of physical activity andBMIs in children with epilepsy with those of their siblingswithout epilepsy to determine whether those with epilepsywere less physically fit. We hoped to identify which fac-tors limit participation in physical activity in children withepilepsy and to determine how clinicians might more ef-fectively encourage safe participation in exercise.

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632 J. WONG AND E. WIRRELL

METHODS

This study involved a cross-sectional, cohort survey ofchildren with epilepsy and their siblings without epilepsy.

Identification of cases and controlsCases were identified in two ways: (a) through the Neu-

rology Clinic Database of cases seen at the Alberta Chil-dren’s Hospital between July 1, 2002, and May 1, 2005;and (b) children meeting entry criteria who were seen inNeurology Clinic between June 1 and August 1, 2005.Cases must have met all of the following criteria to beeligible for study:

• Age 5–17 years• Duration of epilepsy, ≥3 months• Estimated developmental quotient of ≥80• No major motor or visual handicap that would limit

participation in physical activity• At least one sibling between 5 and 17 years who could

act as a control

Controls were full or half siblings of cases, aged 5–17years, without a history of seizures or any motor, visual,or cognitive handicap that would limit their participationin physical activity.

For cases identified through the Database, invitationletters were mailed to the mother or primary caregiver,and phone contact was made within 2 weeks of mailingthe letter to request participation. After obtaining parentalconsent and determining the number of eligible controlsiblings, we mailed a package to the family that con-tained a set of parent-completed questionnaires on physi-cal activity both for the child with epilepsy and for his orher nonepileptic sibling(s) as well as child/teen-completedquestionnaires on physical activity for cases and controlsaged 11 to 15 years.

For cases identified at the time of their Neurology Clinicvisit, the research assistant met with families to explain thestudy, obtain informed consent, and determine the numberof eligible control siblings. The parent or caregiver thenreceived a set of questionnaires that they were asked tocomplete at home and return by mail.

The number of nonconsenting families was docu-mented, but no further information was obtained fromthem.

This study received ethical support from the Universityof Calgary Conjoint Ethics Committee.

Instruments used

Parent reportWe reviewed the literature to search for a validated

parent-completed scale to measure physical activity overthe range of ages that we wished to study and that couldbe administered over summer vacation when this studywas being conducted. However, such a scale could notbe found on literature review. We designed a parent re-

Table 1. Parental questionnaire details

port to determine time spent at sedentary activities, ingroup sports activities, and in individual sports activities(Table 1).

Our parent report is a modified version of the SchoolsPhysical Activity and Nutrition Surveys (SPANS), whichis a self-report instrument for school-aged children devel-oped by Booth et al. (15).

Physical activity portion of the HBSCCases and controls aged 11–15 years were asked to

complete the Physical Activity portion of the Health Be-havior in School-Aged Children (HBSC), which is a toolused by the World Health Organization in 36 countriesand regions to measure health and well-being of youngpeople. The activity portion of the questionnaire has beenshown to be reliable and valid in an Australian study ofhealthy schoolchildren age 11–15 years (16).

BMIParents were asked to report the current weight and

height of cases and controls in pounds or kilograms andinches or centimeters, respectively. The BMI was deter-mined by dividing the weight in kilograms by the square ofthe height in meters, and the BMI percentile for age wasdetermined by using Centers for Disease Control charts(17).

Review of Neurology Clinic chartsNeurology Clinic charts of cases were reviewed for

the following information: age at seizure onset; seizuretype; syndrome (if identified); seizure etiology (idio-pathic, cryptogenic, symptomatic); frequency over the

Epilepsia, Vol. 47, No. 3, 2006

PHYSICAL ACTIVITY IN CHILDREN WITH EPILEPSY 633

past year; predominant seizure timing (nocturnal, diur-nal, mixed); duration of epilepsy; number and type ofantiepileptic drugs (AEDs) used at present and in the past;prior or present use of the ketogenic diet; prior seizuresurgery; cognitive status (normal, learning disorder); andfamily history of seizures in first-degree relatives (present,absent).

Seizure etiology was defined as idiopathic if the childfit into one of the accepted benign idiopathic epilepsysyndromes, such as the idiopathic generalized epilepsies(18–21) or benign focal epilepsies of childhood (22,23);as remote symptomatic if a known brain insult or lesionaccounted for the seizures; and as cryptogenic if the childwas cognitively normal and had no underlying lesion orinsult but did not meet criteria for one of the known idio-pathic epilepsy syndromes.

Statistical analysisData processing and analysis were done with SPSS Ver-

sion 13.0.

Primary analyses1. Comparison of physical-activity levels between

cohorts. Data from the parent-completed questionnaireswere used to compare physical-activity levels between co-horts. The mean number of hours of sedentary activitiesper day (TV, computer/video games, reading, art, music)and the mean number of hours per year in team sports,individual sports, and total sports participation were com-pared between children/teens with epilepsy and their nor-mal siblings by using the Mann–Whitney test to determinewhether those with epilepsy spend more time in sedentaryactivities and less time in sports participation. As age mayaffect the degree of physical activity, cases and controlswere stratified into two age groups (5–12 years and 13–17 years), and an analysis was performed similar to thatdescribed earlier for each age group. As other chronic dis-ease may limit sports participation, a further analysis wasdone after excluding subjects with chronic disease otherthan epilepsy or attention-deficit disorder alone.

Data from the HBSC questionnaires also were used tocompare physical activity levels between cohorts aged 11–15 years. The mean number of hours of sedentary activi-ties per week (watching TV or videos, doing homework,or using a computer) and the mean number of days inwhich subjects reported they were active for a total of≥60 min, both in the last 7 days and in a typical week,were compared between children/teens with epilepsyand their siblings without epilepsy by using the Mann–Whitney test to determine if those with epilepsy spendmore time in sedentary activities and less time in sportsparticipation.

Parent perceptions of adequacy of physical activity lev-els, based on their response (Yes or No) to the question“Over the past year, has your child/teen been as physi-

cally active as you would like them to be?” were com-pared between those with and without epilepsy by usingχ2 analysis.

The number of children with epilepsy who were re-ported to be limited in participation in either group orindividual sports activities was expressed as a percentage,and the reasons for limitation were noted.

2. Comparison of BMI for age between cohorts. Withthe Centers for Disease Control charts (17), BMI per-centiles for age were compared between cohorts with andwithout epilepsy by using the Mann–Whitney test, to de-termine whether those with epilepsy have a higher BMIpercentile for age.

Subjects were further divided into the following cate-gories based on their BMI by using the standardized per-centile curves of BMI for children and adolescents (under-weight, BMI≤5th percentile for age; appropriate, BMI 5thto 85th percentile; potentially overweight, BMI ≥85th to95th percentile; and overweight, BMI ≥95th percentile).The proportion of subjects in each cohort falling into ei-ther the potentially overweight or overweight categoriesversus the underweight or appropriate was compared byusing χ2 analysis.

Secondary analyses1. Comparison of parental questionnaire with the

self-completed HBSC in 11- to 15-year-old subjects. Tocompare parent-reported versus self-reported levels ofphysical activity, the number of hours per year of to-tal sports participation from the parental questionnairewas compared with the first two questions on the self-completed HBSC in 11- to 15-year-old subjects. Thesetwo questions asked the subjects to rate the number ofdays they were active for ≥60 min/day in the last weekand in a typical week. Each of these questions was com-pared with parent report by using the Pearson correlationcoefficient to determine the relation between the parentalreport and HBSC survey.

Similarly, the responses to the next three questionson the physical activity portion of the HBSC, whichasked about time spent on sedentary activities (watchingTV/videos, doing homework, using a computer), both onweekdays and on weekends, were recoded as follows: 0,none at all; 1, about half an hour per day; 2, ∼1 h/day;3, ∼2 h/day; 4, ∼3 h/day; 5, ∼4 h/day; 6, ∼7 h/day; and8, ∼7 or more hours per day. For each question, two re-sponses were given; one for weekdays and a second forweekends. These numbers were added for all three ques-tions and divided by 6, to provide a number ranging from0 to 8, with a higher number representing greater seden-tary activity. This number was compared with the numberof hours per week of sedentary activity from the parentalreport, by using the Pearson correlation coefficient, to de-termine the relation between the parental report and theHBSC survey.



2. What epilepsy-specific factors correlate with reducedlevels of physical activity in children with epilepsy? Theeffect of seizure frequency, seizure type, etiology, epilepsyduration, and number of prior AEDs used on physicalactivity levels and BMI percentiles for age was studied.Children with epilepsy were stratified based on seizurefrequency (every 3 months or more vs. less than every3 months), presence of generalized tonic–clonic seizuresin the previous year (present vs. absent), etiology (idio-pathic vs. cryptogenic/remote symptomatic), duration ofepilepsy (≤24 months vs. >24 months), and total num-ber of AEDs ever used (two or fewer vs. three or more).The mean number of hours spent in sedentary activities perweek; the mean number of hours spent in team, individual,and total sports activities per year; and BMI percentilesfor age were compared for each epilepsy-specific factorbetween groups by using the Mann–Whitney test to deter-mine whether those with higher seizure frequency, gener-alized tonic–clonic seizures in the preceding year, nonid-iopathic etiology, briefer duration of epilepsy, or greaternumber of previously used AEDs had lower physical ac-tivity levels and greater BMI for age. The proportion ofsubjects in each group falling into either the potentiallyoverweight or overweight categories versus the under-weight or appropriate categories also were compared withχ2 analysis.

3. Do children with a seizure during a sports event, orthose who had a seizure-related injury during a sportsevent have reduced levels of physical activity comparedwith those with epilepsy without these factors? Childrenwith epilepsy were stratified into two groups, based onwhether they ever had a seizure during a sports event,and also based on whether they had a seizure-related in-jury during a sports event. The mean number of hoursspent in sedentary activities per week; the mean numberof hours spent in team, individual, and total sports activi-ties per year; and BMI percentiles for age were comparedbetween these two groups by using the Mann–Whitneytest, to determine whether those with prior seizures insports activities or those with prior seizure-related injuriesin sports activities have lower physical-activity levels andgreater BMI for age. The number of subjects in the po-tentially overweight or overweight categories versus theunderweight or appropriate categories also were comparedwith χ2 analysis.

RESULTS

Demographic dataThe 130 subjects who met inclusion criteria for this

study (117 identified through the Neurology ClinicDatabase and 12 identified through Neurology Clinic attime of their appointment with a neurologist) and 99 fam-ilies agreed to participate. Of these, 75 (76%) returnedcompleted questionnaires. Twenty-seven parents declinedparticipation because of lack of time, and four families

gave initial consent but later declined because of parent orchild medical emergencies.

Seventy-nine children with epilepsy and 99 sibling con-trols (number of sibling controls per case, 25,75 percentile:1, 1; range, 1–3) were included in this study. The meanage for the children with epilepsy was 11.2 (SD, 3.3 years;range, 5–17 years) and for their siblings was 11.0 (SD, 3.4;range, 5–17) (p = NS). Gender ratio was 43 M/36 F forchildren with epilepsy and 48 M/51 F for sibling controls(p = NS). Twelve (15%) children with epilepsy had otherchronic medical conditions compared with 21 (21%) sib-ling controls (p = 0.34). Other chronic health conditionsin those with epilepsy included attention-deficit disorder(n = 3), allergies (n = 2), asthma (n = 3), diabetes (n = 1),hypothyroidism (n = 2), and scoliosis (n = 1); and in sib-ling controls, attention-deficit disorder (n = 2), allergies(n = 1), asthma (n = 10), diabetes (n = 1), high-functioning autism (n = 1), Gaucher disease with no neu-rologic manifestations (n = 1), migraine (n = 2), eczema(n = 1), and kidney disease (n = 2).

Epilepsy characteristicsOf the 23 (29%) with primary generalized epilepsy, 17

had been diagnosed with one of the idiopathic general-ized epilepsy syndromes (10 childhood absence epilepsy,one juvenile absence epilepsy, and six juvenile myoclonicepilepsy), and six had generalized tonic–clonic seizuresalone with generalized spike–wave on EEG. Of the 56with partial-onset seizures, 16 were diagnosed with oneof the idiopathic partial epilepsies (15 benign rolandicepilepsy and one early-onset benign occipital epilepsy),six were remote symptomatic, and 34 were cryptogenic.Of those with partial-onset seizures, 37 had secondarilygeneralized events with or without partial seizures, 13 hadonly complex partial seizures with or without simple par-tial seizures, and six had simple partial seizures alone.

The mean duration of epilepsy was 46 months (SD, 35;range, 3–203). Over the past year, 41 (52%) children hadbeen seizure free; 17 (22%) had seizures less than every 6months; seven (9%), less than every 3 months but at leastevery 6 months; three (4%), less than every month but atleast every 3 months; eight (10%), less than every week butat least every month; and three (4%) had seizures at leastweekly. Fifty-one (65%) cases had predominantly diur-nal seizures, 13 (16%) were predominantly nocturnal, and15 (19%) had seizures without clear diurnal or nocturnalpredominance.

The median number of AEDs used at present was one(25, 75 percentile 1, 1; range, 0–3) and in the past was one(25, 75 percentile 0.1; range, 0–8). Only one (1%) hadbeen on a ketogenic diet, and four (5%) had prior epilepsysurgery. Seven (9%) children with epilepsy had a mildlearning disorder but still met the developmental quotientof ≥80. Ten (13%) children with epilepsy had a familyhistory of seizures in first-degree relatives.



TABLE 2. Comparison of sedentary, group sports, individual sports, and total sportsactivities between children with epilepsy and their siblings without seizures

Epilepsy Sibling controlsActivity type [Mean (SD)] [Mean (SD)] p Value

SedentaryAll 3.7 (1.6) n = 79 3.8 (1.7) n = 99 0.72 (0.96)Ages 5–12 yr 3.6 (1.5) n = 51 3.8 (1.5) n = 63 0.33 (0.38)Ages 13–17 yr 4.0 (1.8) n = 28 3.8 (2.0) n = 36 0.44 (0.27)

Group sportsAll 38.1 (61.2) 73.4 (130.1) 0.19 (0.26)Ages 5–12 yr 41.9 (63.8) 40.1 (72.5) 0.83 (0.99)Ages 13–17 yr 31.3 (56.5) 131.7 (180.5) <0.03 (0.08)

Individual sportsAll 95.0 (127.2) 102.4 (159.0) 0.89 (0.75)Ages 5–12 yr 97.2 (119.2) 82.3 (84.4) 0.75 (0.61)Ages 13–17 yr 91.0 (142.8) 137.5 (237.0) 0.90 (0.91)

Total sportsAll 133.1 (139.6) 175.8 (200.6) 0.18 (0.26)Ages 5–12 yr 139.1 (132.7) 122.4 (106.9) 0.72 (0.80)Ages 13–17 yr 122.3 (153.3) 269.3 (279.9) <0.02 (<0.03)

The p value in parentheses indicates the p value after exclusion of subjects with other chronicdiseases excepting epilepsy or attention-deficit disorder alone or both.

Comparison of physical activity levelsbetween cohorts

Parental report

No significant differences in the number of hours ofsedentary activities per week, and the mean number ofhours per year in team, individual, and total sports partic-ipation were seen between the cohorts with and withoutepilepsy when all ages were analyzed together and in the5- to 12-year-old category (Table 2). Within the 13- to17-year age group, however, a significant difference wasfound in the number of hours per year spent in group(p < 0.03) and total sports activities (p < 0.02) betweencases and controls, although no significant difference ap-peared in the time spent on sedentary activities and indi-vidual sports. After excluding subjects with chronic dis-eases other than epilepsy or attention-deficit disorder, thedifference in total sports participation remained signifi-cant (p < 0.03).

More parents of teens aged 13–17 years with epilepsyreported them to be less physically active than they wouldlike (18 of 28, 64%) compared with siblings withoutepilepsy in the same age group (13 of 36, 36%) (p < 0.03).Reasons given by parents were “laziness or lack of interestin exercise” in 11 (61%) of 18 teens with epilepsy versusonly four (31%) of 13 sibling controls. Other reasons in-cluded “limits self due to medical condition in two subjectsin each group,” and “inability to get to games/practices,”“too busy with other activities,” or “costs too much” in theremainder. However, no significant difference was notedin the 5- to 12-year-olds (p = 0.26) between children withepilepsy (47%) and controls (37%).

Ten (13%) children with epilepsy were reported by theirparent/caregiver to be limited in participation in sportsactivities compared with only four (4%) controls (p <

0.05). Of those with epilepsy who were reported to belimited, six of 10 gave reasons that we thought did notwarrant limitation: four parents stated that their childrenwere limited simply because they had epilepsy, and twostated they could not “get hit in the head,” as this mightworsen their seizures.

Self-report: physical activities section of the HBSCSelf-Report in 11- to 15-year-olds

No significant differences were seen between theamount of self-reported physical activity in the past week(those with epilepsy: mean, 4.2; SD, 2.3; sibling controls:mean, 4.5; SD, 2.2; p = 0.58), physical activity in an aver-age week (those with epilepsy: mean, 4.2; SD, 2.1; siblingcontrols: mean, 4.4; SD, 2.1; p = 0.59) or sedentary ac-tivities (those with epilepsy: mean, 2.4; SD, 1.0; siblingcontrols: mean, 2.3; SD, 0.9; p = 0.99) between cases andcontrols.

Comparison of BMI for age between cohortsOverall, the cases with epilepsy had a significantly

higher BMI percentile for age than did their siblings with-out seizures (p < 0.05) (Table 3). However, this differencewas notable only for the younger age group, aged 5–12years (p = 0.05) and was no longer significant after ex-clusion of subjects with other chronic disease. When BMIwas stratified into potentially overweight or overweightcategories versus underweight or appropriate categories,no significant difference was found between children withand without epilepsy (p = 0.45). However, more teens withepilepsy were in the potentially overweight or overweightcategories than were nonepileptic controls in the same agegroup (p < 0.05), and this difference became even moremarked after exclusion of subjects with other chronic ill-nesses (p < 0.02).



TABLE 3. BMI percentiles and BMI categories in 5- to 12- and 13- to 17-year-old children withand without epilepsy

Epilepsy Sibling controlsAge [Mean (SD)] [Mean (SD)] p Value

All 59.3 (28.5) n = 79 49.9 (31.5) n = 99 0.05No. (%) potentially overweight 18/79 (23) 17/99 (17) 0.45 (0.22)

or overweight5–12 yr 59.1 (29.0) n = 51 46.1 (33.7) n = 63 0.05 (0.18)No. (%) potentially overweight 9/51 (18) 13/63 (21) 0.81 (0.62)

or overweight13–17 yr 59.5 (28.1) n = 28 56.5 (26.4) n = 36 0.56 (0.22)No. (%) potentially overweight 9/28 (32) 4/36 (11) <0.05 (<0.02)

or overweight

The p-value number in parentheses indicates the p value after exclusion of subjects with other chronic diseasesexcepting epilepsy or attention deficit disorder alone or both.

Secondary analyses

Comparison of parental questionnaire with theSelf-Completed HBSC in 11- to 15-year-old subjects

The amount of sedentary activities reported on theHBSC questionnaire correlated well with the total amountof sedentary activities per day on the parental report (p <

0.007). However, neither the number of days of physi-cal activity in the previous 7 days nor a typical week onthe HBSC form correlated with the total amount of sportsparticipation per year on the parental report (p = 0.51 andp = 0.70, respectively).

TABLE 4. Correlation of seizure frequency, seizure type, and total AEDs ever used with reported physical activity, BMI percentilesfor age, and BMI category in children with epilepsy

Group Individual Total BMISedentary sports sports sports percentile

activity activity activity activity for age[Mean (SD)] [Mean (SD)] [Mean (SD)] [Mean (SD)] [Mean (SD)]

Seizure frequency≥q3 mo (n = 15) 3.7 (1.6) 18.7 (34.5) 74.5 (114.2) 93.1 (125.2) 72.5 (24.9)<q3mo (n = 64) 3.7 (1.6) 42.7 (65.3) 99.8 (130.4) 142.5 (142.1) 56.2 (28.6)p Value 0.58 0.16 0.18 0.09 <0.03

Seizure typeGTCS in the previous year 3.8 (1.7) 21.4 (38.0) 73.8 (94.9) 95.2 (105.8) 62.9 (26.8)(n = 22)No GTCS in the previous year 3.6 (1.5) 44.4 (68.1) 102.0 (137.8) 146.4 (149.5) 57.5 (29.5)(n = 57)p Value 0.94 0.18 0.59 0.21 0.64

Seizure etiologyIdiopathic (n = 33) 3.7 (1.6) 43.5 (71.5) 121.7 (169.6) 165.2 (170.7) 59.8 (29.2)Cryptogenic or remote 3.7 (1.6) 34.3 (53.1) 75.9 (81.9) 110.2 (108.6) 58.9 (28.3)symptomatic (n = 46)p Value 0.80 0.87 0.52 0.22 0.95

Duration≤24 mo (n = 22) 3.5 (1.6) 31.7 (44.7) 90.0 (114.4) 121.6 (122.3) 66.4 (24.4)>24 mo (n = 57) 3.8 (1.6) 40.6 (66.7) 97.0 (132.7) 137.6 (146.5) 56.9 (29.6)p Value 0.39 0.87 0.91 0.84 0.17

Total no. of AEDs≥3 (n = 19) 4.0 (1.4) 21.1 (46.7) 44.6 (52.0) 65.7 (82.7) 64.2 (30.6)≤2 (n = 60) 3.6 (1.7) 43.5 (64.5) 111.0 (139.6) 154.5 (147.5) 57.7 (27.9)p Value 0.27 0.06 <0.03 <0.004 0.34

AED, antiepileptic drug; BMI, body mass index; GTC, generalized tonic–clonic seizure.

What epilepsy-specific factors correlate with reducedlevels of physical activity in children with epilepsy?

No significant differences were found in the physicalactivity levels, BMI percentiles for age, and BMI cate-gories between children with epilepsy based on presenceof generalized tonic–clonic seizures in the preceding year,etiology, or duration of epilepsy (Table 4). Children with ahigher seizure frequency had a significantly greater BMIpercentile for age and had a nonsignificant trend to par-ticipate in less total sports activity (p = 0.09). Thosewith seizures at least every 3 months also were signifi-cantly more likely to fall into the overweight or potentially



overweight categories than were those with less-frequentseizures (seven of 15 vs. 11 of 64; p < 0.04). Cases thathad been treated with three or more AEDs reported sig-nificantly lower levels of both individual (p < 0.03) andtotal sports activities (p < 0.004) than did those receivingtwo or fewer AEDs but were not significantly more likelyto have a BMI in the overweight or potentially overweightcategory.

Do children who had a seizure during a sports event, orthose who had a seizure-related injury during a sportsevent have reduced levels of physical activity comparedwith those with epilepsy without these factors?

Among children with epilepsy, those who had a previ-ous seizure during a sports event (n = 15) reported sig-nificantly less sedentary activity (p < 0.03) than did thosewho had not had a seizure during a sports event (n =64). However, no significant differences were noted in theamounts of group (p = 0.12), individual (p = 0.28), or to-tal sports participation (p = 0.13), BMI percentiles for age(p = 0.82), or BMI category (p = 0.50). Of the 15 who hada previous seizure during a sports event, only five led toinjury. No significant differences were found in total phys-ical activity (p = 0.11) or BMI percentile (p = 0.54) inchildren with epilepsy who had sustained a prior injury ina sports event compared with those that have not. Three ofthese five cases had their injury while playing ice hockey,and cases who had a seizure-related injury tended to playmore ice hockey than did those without injury (mean, 45.0h/year vs. 8.4 h/year; p = 0.05).

DISCUSSION

We found that teens with epilepsy are less physicallyactive than their sibling controls in the amount of bothtotal sports and group sports activities. Although the dif-ference in individual sports activities between teens withand without epilepsy was not statistically significant, thosewith epilepsy participated in only about two thirds as muchindividual sports activities compared with their siblings,a result that may be clinically significant. Interestingly,significant differences between amounts of sports partici-pation were not found in younger, preadolescent children.Reported sedentary activities in both age groups did notdiffer between cases and controls.

The lower amounts of participation in physical activityin adolescents with epilepsy do not appear to be due toexcessive parental restrictions. Rather, parents were morelikely to report that their teens with epilepsy were not asactive as they would like them to be. The most commonreasons reported by parents for this inactivity were eithera lack of interest or being too lazy to be involved in anytype of sports activity. Compared with younger children,teenagers have more independence in their choice of ac-tivity, and parents exert less control on physical activity

levels. The lack of participation in group sports activi-ties may also reflect a broader social isolation, which iscommon in teens with epilepsy (14). In addition, teensmay avoid physical activity for fear it might exacerbatea seizure, or because of concern that adverse effects oftheir AEDs may affect their performance and make themappear less physically adept to their peers.

Despite differences seen on parental report, we foundno significant difference between cases and controls inthe HBSC self-report of levels of physical and sedentaryactivities. However, this instrument includes both pread-olescent and adolescent age groups, and inclusion of theyounger children may have obscured any differences seenin the adolescents.

We found that although the correlation between parent-and child-reported sedentary activities was high, this wasnot the case for sports activities. Possible explanationsfor this finding are several. First, children might be par-ticipating in more physical activity than the parents areaware. Conversely, children may exaggerate their hoursof physical activity either to appear more active and “so-cially appropriate” than they really are, or to tell us whatthey think we “want to hear.”

No significant differences were seen in parent-reportedphysical activity limitations between children withepilepsy and their siblings without epilepsy. Only a mi-nority of children with epilepsy were restricted for rea-sons that we thought were “unreasonable,” such as “worryabout being hit in the head.” Only a single report has beenmade of seizures provoked by blows to the head (24).

The physical and psychological benefits of exerciseare beneficial to patients who have chronic diseases andshould not be a deterrent to sports participation. Althoughthe majority of sports are safe for persons with epilepsy,some activities may require direct supervision, such aswater sports and swimming, gymnastics, harnessed rockclimbing, and horseback riding. Higher-risk sports such ashang-gliding, scuba diving, or free climbing are still notrecommended (11).

BMI percentiles for age between cohortsAlthough children with epilepsy had greater BMI per-

centiles than their siblings without epilepsy, they still weremostly within the appropriate BMI range. However, in the13- to 17-year-old group, more potentially overweight oroverweight cases were found in those with epilepsy thanin controls (p < 0.05), consistent with the parental reportsof decreased physical activity.

In adults, Steinhoff (12) reported a significantly ele-vated BMI in persons with epilepsy compared with con-trols. However, no similar study can be found in childrenwith epilepsy. One of the more common side effects ofVPA is excessive weight gain; however, in our 13- to 17-year-old age group, the higher BMI percentiles could notbe accounted for by the use of this medication.



Which epilepsy-related factors correlate to the levelof physical activity?

Surprisingly, children who have had a prior seizure dur-ing a sports event had significantly fewer sedentary activ-ities than did those who had never had a seizure duringphysical activity. These individuals could have been moreactive to begin with, resulting in a greater chance of havinga seizure during a sports event; however, it is reassuringthat this occurrence did not appear to lead to excessive re-strictions and decreased participation. Although our num-bers were small, we did not find that children who hada prior seizure-related injury during a sports event par-ticipated in fewer physical activities or had higher BMIscompared with other children with epilepsy. Although per-sons with epilepsy may have a slightly higher rate of injurythan their peers (25), most injuries are minor (26), and thepotential for this occurrence should not lead to restrictionsfor most types of physical activity. The possible increasedrisk of injury in ice hockey warrants further evaluation.

Although one might anticipate that children with noni-diopathic etiologies or more recent severe seizure typesmight participate less in physical activities, we foundno such correlation. However, a trend was seen betweenhigher seizure frequency and lower total sports participa-tion. This is not a surprising finding, as this group mayhave more restrictions placed on them for fear of injuryor may feel less confident participating in activities be-cause of more frequent seizures. A significant statisticalassociation was also found between the total number ofAEDs ever taken and total sports participation. The moreAEDs that were taken in the case’s history, the less theparticipation in individual and total sports. Although thetrend toward decreased group sports activities was noted,statistical significance was lacking. Medication side ef-fects such as fatigue, drowsiness, dizziness, or gastroin-testinal upset could account for the decrease in total sportsactivity. Another possible explanation is that children whohad taken more AEDs were considered more “vulnerable”and therefore participated less in activities.

What are the implications of decreased physicalactivity?

Lack of physical activity has multiple repercussions.Persons with epilepsy, like those in the general populationwho are not physically active, are at an increased risk forobesity and its associated complications including hyper-tension, diabetes, and heart disease. The psychological andsocial benefits of exercise, such as improved self-esteem,improved mood, and decreased stress and anxiety, are lostas well.

As a group, patients with epilepsy tend to be less phys-ically fit and live more sedentary lives compared with thepopulation without epilepsy. Steinhoff et al. (12) foundthat compared with controls, adults with epilepsy partic-ipated less frequently in regular sports and had poorer

aerobic endurance, muscle-strength endurance, and phys-ical flexibility. Jalava et al. (13) also documented poorerperformance on standardized muscle tests in cases withepilepsy. Another study found that adults with epilepsywere half as physically active as the general population,and their overall physical fitness corresponded to theirsedentary lifestyle (27).

Although numerous adult studies compared physicalactivity in epilepsy patients, our study is unique in that itfocuses exclusively on the physical fitness of children withepilepsy compared with sibling controls. Using siblingcontrols minimizes differences between families, such asattitudes toward physical fitness, household income, andfamily dynamics. This is the first study to look at phys-ical activity in cognitively normal children with epilepsywith no significant motor or visual impairment, whichprovides information on the effect of epilepsy alone andexcludes the effect of cognitive and motor comorbidities.A 3-month diagnosis of epilepsy ensures that sufficienttime has elapsed for any lifestyle adjustments that mayhave occurred shortly after the diagnosis of epilepsy.

Several limitations to our study exist. First, given thenumber of statistical comparisons performed, results ofour secondary analyses are tentative, including the effectsof several epilepsy-specific factors and having a seizure orseizure-related injury on physical activity levels. Second,we made assumptions of the physical fitness of cases andcontrols based on parental reports of their physical andsedentary activities. Future work should include physio-logic measures of physical fitness to confirm these sus-picions. The weights and heights of cases and controlswere based on parental report rather than on measure-ments at our clinic, rendering greater potential error in thecalculated BMIs. However, we found good correlation incases between BMIs based on our measured weight andheight from their most recent clinic visit and those calcu-lated based on parental reported values (Pearson correla-tion coefficient, 0.991; p < 0.01), indicating that parentalreport was probably accurate. Third, the parent question-naire we developed to measure physical and sedentary ac-tivities was not standardized; however, it was similar to theSchools Physical Activity and Nutrition Survey (SPANS2004). We were unable to compare this instrument witha similar parentally reported independent measure to de-termine its reliability and validity. Finally, recall bias mayhave been encountered in both the parental and HBSC re-ports. However, this did not likely alter the study resultsto any significant degree, as both cases and controls wereretrospective.

Overall, we have shown that cognitively normal teenswith epilepsy are less physically active than their siblings.Clinicians should encourage participation in recreationaland physical activity programs, particularly those that alsopromote interaction with peers. Such activity will reduceepilepsy-related comorbidities and improve well-being:



physically, by preventing the development of diabetes,hypertension, and heart disease; socially, by improvingself-esteem and social integration; and psychologically,by lessening anxiety and depression.

Acknowledgment: We thank Drs. L. Hamiwka, J. Mah,K. Barlow, H. Sarnat, and R. Haslam for the opportunity to studytheir patients. This study was funded by the Alberta HeritageFoundation for Medical Research.

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