Epilepsy

DEFINATION:
Epilepsy is a condition in which a person has recurrent seizures.
A seizure is defined as an abnormal, disorderly discharging of the brain’s nerve cells, resulting in a temporary disturbance of motor, sensory, or mental function.

EXPLANATION:
Epilepsy is a brain disorder, When someone has epilepsy, clusters of nerve cells called neurons in his or her brain sometimes starts firing in an abnormal way. Which results in
involuntary, motor, sensory or automatic disturbances with or without alteration of sensorium?
The age and neuro-developmental maturity status is important in determining clinical manifestations and type of seizures.
Children develop seizures due to non neurological insults [provoked seizures] more frequently than adults. Age is very important in determining the sequelae post ictus.
In neonates, seizure tends to be atypical, bizarre, fragmentary and often subtle. They show subtle episodes of grimacing blinking, frothing or apnoeic spells all of which may be missed if clinician is not alert.
Almost all structural malformations, gray or white matter diseases, neuro-metabolic disorder and some diseases produce epileptic fits.
Prevalence of epilepsy is 4-8%
For a person with epilepsy, the normal pattern of activity changes. This can cause the person to have strange sensations, emotions, and behavior, or sometimes convulsions or seizures, muscle spasms, and loss of consciousness.
During a seizure, these neurons may fire as many as 500 times a second, much faster than normal. In some people this happens only once in a while; for others, it may happen up to hundreds of times a day.
Generalized seizures are produced by electrical impulses from throughout the entire brain, whereas partial seizures are produced (at least initially) by electrical impulses in a relatively small part of the brain. The part of the brain generating the seizures is sometimes called the focus.
Seizures can occur at any age, in infancy, childhood, adulthood. Proneness to seizure varies in individuals as people vary with respect to seizure threshold. Many electrical changes takes place during and after ictus. Neuro transmitter imbalance occurs at synaptic level.

ETIOLOGY:
Neonates: HIE (Hypoxic ischemic encephalopathy), intra cranial
haemorrhage, intrauterine infection, septicaemia, genetic
Childhood:- birth trauma, infection, toxins [heavy metals like lead, carbon monoxide poisoning], congenital abnormality.
Adolescence [10-20yrs]:- idiopathic, infection, head injury, toxic, degenerative.
Young adult [25-30yrs]:- head injury, neoplasm, infection, idiopathic.
Older adult [36-65yrs]:-head injury, neoplasm, Cerebro-vascular accident,
Degenerative [Alzheimer”s]

CLASSIFICATION: Based on behaviour and brain activity, seizures are divided into two broad categories:
Generalized Seizures
1. Generalized Tonic-Clonic
2. Absence seizures
3. Myoclonic
4. Clonic
5. Tonic
6. Atonic
Partial (also called local or focal).
1. Simple (awareness is retained) partial seizures
a. Simple motor
b. Simple sensory
c. Simple psychological
2. Complex partial seizures
3. Partial seizure with secondary generalization
The most common types of seizures are listed in signs and symptoms

SIGNS AND SYMPTOMS:
Generalized Seizures: six types of generalised seizures are known:
1.”Grand Mal” or Generalized tonic-clonic: the patient loses consciousness and usually collapses. The loss of consciousness is followed by generalized body stiffening (called the “tonic” phase of the seizure) for 30 to 60 seconds, then by violent jerking (the “clonic” phase) for 30 to 60 seconds, after which the patient goes into a deep sleep (the “postictal” or after-seizure phase). During grand-mal seizures, injuries and accidents may occur, such as tongue biting and urinary incontinence.
2.Absence: cause a short loss of consciousness for just a few seconds with few or no symptoms. The patient, most often a child, typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are usually not aware that they are having a seizure, except that they may be aware of losing time
3. Myoclonic: sporadic jerks, usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent, these seizures may result in dropping or involuntarily throwing objects.
4. Clonic: repetitive, rhythmic jerks that involve both sides of the body at the same time.
5. Tonic: Muscle stiffness, rigidity
6. Atonic: consist of a sudden and general loss of muscle tone, particularly in the arms and legs, which often results in a fall.

Partial Seizures (Produced by a small area of the brain)
Simple (awareness is retained) a. Simple Motor:Jerking, muscle rigidity, spasms, head-turning
b. Simple Sensory: Unusual sensations affecting either the vision, hearing, smell taste, or touch
c. Simple Psychological: Memory or emotional disturbances
1. Complex : Automatisms such as lip smacking, chewing, fidgeting, walking and other repetitive, involuntary but coordinated movements
(Impairment of awareness) 2. Partial seizure with secondary generalization: Symptoms that are initially associated with a preservation of consciousness that then evolves into a loss of consciousness and convulsions.

ASSOCIATED PROBLEMS:
Seizure disorder with cerebral palsy
Seizure disorder with head injury
Seizure disorder with mental retardation
Seizure disorder with hemiplegia
Seizure disorder with developmental delay
Seizure disorder with global developmental delay
Seizure disorder with autism

MYTHS/QUERIES:
1. Seizure disorder cannot be cured.
DR SUMIT(OCCUPATIONAL THERAPIST): Seizures cannot be cured, but they need to be controlled. First line of management is drug therapy, even surgery is recommended for certain epilepsy. Every convulsion brings with it some harm to brain which compromises brains potential. Therefore for such children to maintain and improve their capacity they need to undergo a specialised rehabilitation programme. This programme enables child to cope and match to his surrounding and tackle challenges effectively.
2. Seizure disorder child inherits same to next generation
DR SUMIT(OCCUPATIONAL THERAPIST): No! Not always. Rarely for some types has this been observed.
3. Seizure disorder children always present with mental retardation
DR SUMIT(OCCUPATIONAL THERAPIST): Prevalence of mental retardation with seizures is documented in literature, but they both are different disorders. Uncontrolled seizures lead to damage to brain. For a brain which is developing this can compromise its capacity to a variable extent from very subtle changes to major extent. Early intervention programme can help these children to great extent.
4. For Seizure disorder children to go to school or other outings is never safe
DR SUMIT(OCCUPATIONAL THERAPIST): Barring few risk taking extreme conditions like heights, deep water, etc person with seizures can lead a normal life. Care needs to be taken that if a precipitating factor is known, like sudden exposure to light, sound then avoid those. Safety is must , but still person”s ability to participate in social situations like schools, gatherings etc should not be underestimated.

EARLY DETECTION, A STEP TOWARDS BETTER CURE:
Every convulsion causes some brain damage. So there is always some adaptive capacity of brain is getting affected. When seen that child with seizures is lagging behind his developmental milestone, he or she should be immediately taken to an Occupational Therapist for early remediation. Earlier the intervention more will be retention of brain learning capacity. For child presenting with IQ deficits more intensive learning program is needed to match his age appropriate abilities. Early intervention will not only remediate for loss of brain ability, it will also guide parents for type of seizure, precautions and how to take child forward for maximum abilities.

PARENTS APPROACH TO DISORDER:
Though epilepsy is said to be incurable but damage caused by epilepsy can be managed. After any epileptic attack a parent should always consult a Neurologist as early as possible. Get the diagnosis confirmed, and know about associated disorder if any, and mark any developmental delay which should be brought into notice of the neurologist who should in turn bring it to the notice of the rehabilitation team who will take care of his normal physical- mental development.
Parents should identify the risk factors and safety measures for their child and also train the child to take care of himself. Any learning problems associated with epilepsy should be dealt with affection.
A parent should never experiment with medication schedule, and never skip any dose.