Dr. Shamanthakamani NarendranM.D. (Pead), Ph.D. (Yoga Science)

• Epilepsy (sometimes referred to as a seizure disorder) is a common chronic neurological condition that is characterized by recurrent unprovoked epileptic seizures.

• It affects approximately 50 million people worldwide.

• It is usually controlled, but not cured.

DEFINITION

• A chronic disorder characterized by paroxysmal brain dysfunction due to excessive neuronal discharge, and usually associated with some alteration of consciousness.

• The clinical manifestations of the attack may vary from complex abnormalities of behavior including generalized or focal convulsions to momentary spells of impaired consciousness.

• These clinical states have been subjected to a variety of classifications, none universally accepted to date and, accordingly, the terminologies used to describe the different types of attacks remain purely descriptive and nonstandardized.

They are variously based on1. The clinical manifestations of the seizure

(motor, sensory, reflex or psychic)

2. The pathological substrate (hereditary, inflammatory, degenerative, neoplastic or traumatic)

3. The location of the epileptogenic lesion (rolandic, temporal, diencephalic regions),

4. The time of life at which the attacks occur (nocturnal, diurnal, menstrual, etc.).

Syn: convulsive state, epilepsia, falling sickness, fits, status convulsivus.

CLASSIFICATION

Epilepsies are classified five ways:

• By their first cause (or etiology).

• By the observable manifestations of the seizures, known as "semiology."

• By the location in the brain where the seizures originate.

• As a part of discrete, identifiable medical syndromes.

• By the event that triggers the seizures, as in primary reading epilepsy.

• The diagnosis of epilepsy requires the presence of recurrent, unprovoked seizures.

• It is usually made based on the medical history.

• EEG, brain MRI, SPECT, PET, and magnetoencephalography may be useful to discover an etiology for the epilepsy.

• Discover the affected brain region, or classify the epileptic syndrome, but these studies are not useful in making the initial diagnosis.

• Convulsive or other seizure-like activity, non-epileptic in origin, can be observed in many other medical conditions.

DIAGNOSIS

• The cause of an individual's epilepsy can be divided into two categories: symptomatic and idiopathic.

• Symptomatic epilepsies originate due to some structural or metabolic abnormality in the brain.

• This may be the result of:

CAUSES

1. Genetic conditions such as tuberous sclerosis

2. Complications during pregnancy or birth

3. Stroke

4. Head injury

5. Neurosurgical op

6. Bacterial or viral encephalitis

7. Parasitical infection

• The term idiopathic means "a disorder unto itself", and not "cause unknown".

• No other condition has been implicated as the cause of the epilepsy.

• Idiopathic epilepsies are often but not exclusively genetic and generalized - for example Juvenile Absence Epilepsy.

• Many definitions of epilepsy require that the seizures be "unprovoked", with the implication that the provocant is assumed to be something obviously harmful.

• Some epilepsy syndromes the provocant can reasonably be considered to be part of normal daily life.

• Examples of these normal provocants include reading, hot water on the head, hyperventilation and flashing or flickering lights.

• This last provocant is a special type of reflex epilepsy called photosensitive epilepsy.

TRIGGERS

Certain circumstances can lead to an increased likelihood of seizures in someone with epilepsy or in certain syndromes. For example:

• During sleep

• The transition between sleep and awake

• Tireness

• Illness

• Constipation

• Menstruation

• Stress

• The most common ages of incidence are under the age of 18 and over the age of 65.

• It has been estimated that about 1% of the population meets the diagnostic criteria for epilepsy at any given time, but some theorize that the prevalence may be much higher in fact.

EPIDEMIOLOGY

• Seizure types are organised firstly according to whether the source of the seizure within the brain is localised (partial or focal onset seizures) or distributed (generalised seizures).

• Partial seizures are further divided on the extent to which consciousness is affected.

• If it is unaffected, then it is a simple partial seizure; otherwise it is a complex partial seizure.

SEIZURE TYPES

• A partial seizure may spread within the brain - a process known as secondary generalisation.

• Generalised seizures are divided according to the effect on the body but all involve loss of consciousness.

• These include absence (peitit mal), myoclonic, clonic, tonic, tonic-clonic (grand mal) and atonic seizures.

TONIC-CLONIC SEIZURES

ABSENCE SEIZURES

ATONIC SEIZURE

MYCLONIC SEIZURES

SIMPLE PARTIAL SEIZURES

COMPLEX PARTIAL SEIZURES

• There are many different epilepsy syndromes, each presenting with its own unique combination of seizure type, typical age of onset, EEG findings, treatment, and prognosis.

• Infantile spasms (West syndrome) is associated with brain development abnormalities, tuberous sclerosis, and perinatal insults to the brain. It affects infants, which by definition is between 30 days to 1 year of life.

SEIZURE SYNDROMES

• Generalized 3 Hz spike and wave discharges in EEG Childhood absence epilepsy affects children between the ages of 4 and 12 years of age. These patients have recurrent absence seizures that can occur hundreds of times a day.

• Benign focal epilepsy of childhood (Benign Rolandic epilepsy) begins in children between the ages of 4 and 13 years.

• Juvenile myoclonic epilepsy (JME) begins in patients aged 8 to 20 years.

• Temporal lobe epilepsy is the most common epilepsy of adults. In most cases, the epileptogenic region is found in the mesial temporal structures (e.g., the hippocampus, amygdala, and parahippocampal gyrus). Seizures begin in late childhood and adolescence.

• Frontal lobe epilepsy

• Lennox-Gastaut syndrome

• Epilepsy is usually treated with medication prescribed by a physician; primary caregivers, neurologists, and neurosurgeons all frequently care for people with epilepsy.

• In some cases the implantation of a stimulator of the vagus nerve, or a special diet can be helpful.

• Neurosurgical operations for epilepsy can be palliative, reducing the frequency or severity of seizures; or, in some patients, an operation can be curative.

TREATMENT

• The proper emergency response to a generalized tonic-clonic epileptic seizure is simply to prevent the patient from self-injury by moving him or her away from sharp edges, placing something soft beneath the head, and carefully rolling the person onto his or her side to avoid asphyxiation.

• Should the person regurgitate, the material should be allowed to drip out the side of the patient's mouth by itself.

RESPONDING TO A SEIZURE

• If the seizure lasts longer than 5 minutes, Emergency Medical Services should be contacted.

• Prolonged seizures may develop into status epilepticus, a dangerous condition requiring hospitalization and emergency treatment.

• Objects should never be placed in a person's mouth during a seizure as this could result in injury to the person's mouth or obstruction of the airway.

• Despite common folklore, it is not possible for a person to swallow their own tongue during a seizure.

• Some medications can be taken daily in order to prevent seizures or reduce the frequency of their occurrence.

• These are termed "anticonvulsant" or "antiepileptic" drugs (sometimes AEDs).

• All such drugs have side effects which are idiosyncratic and others which are dose-dependent; it is not possible to predict who will suffer from side effects or at what dose the side effects will appear.

PHARMACOLOGIC TREATMENT

• Some people with epilepsy will experience a complete remission when treated with an anticonvulsant medication.

• If this does not occur, the dose of medication may be increased, or another medication may be added to the first.

• The general strategy is to increase the medication dose until either the seizures are controlled, or until dose-limiting side effects appear.

• Serum levels of AEDs can be checked to determine medication compliance and to assess the effects of drug-drug interactions; serum levels are generally not useful to predict anticonvulsant efficacy in an individual patient, though in some cases (such as a seizure flurry) it can be useful to know if the level is very high or very low.

• If a person's epilepsy cannot be brought under control after adequate trials of two different drugs, that person's epilepsy is generally said to be 'medically refractory.'

• Various drugs may prevent seizures or reduce seizure frequency: these include carbamazepine, clobazam, clonazepam, valproic acid, and vigabatrin, etc.

• Other drugs are commonly used to abort an active seizure or interrupt a seizure flurry; these include diazepam and lorazepam.

• Drugs used only in the treatment of refractory status epilepticus include paraldehyde and pentobarbital.

• Surgical treatment can be an option for epilepsy when an underlying brain abnormality, such as a benign tumor or an area of scar tissue (e.g. hippocampal sclerosis) can be identified.

• The abnormality must be removable by a neurosurgeon.

• Surgery is usually only offered to patients when their epilepsy has not been controlled by adequate attempts with multiple medications.

SURGICAL TREATMENT

• Before surgery is offered, the medical team conducts many tests to assess whether removal of brain tissue will result in unacceptable problems with memory, vision, language or movement, which are controlled by different parts of the brain.

• These tests usually include a neuropsychological evaluation, which sometimes includes an intracarotid sodium amobarbital test (Wada test).

• Many patients decide not to undergo surgery owing to fear or the uncertainty of having a brain operation.

• The most common form of resective surgical treatment for epilepsy is to remove the front part of either the right or left temporal lobe.

• Palliative surgery for epilepsy is intended to reduce the frequency or severity of seizures.

• Hemispherectomy is a drastic operation in which most or all of one half of the cerebral cortex is removed.

• It is reserved for people suffering from the most catastrophic epilepsies, such as those due to Rasmussen syndrome.

• Ketogenic diets may occasionally be effective in controlling some types of epilepsy.

• The mechanism behind the effect is not fully understood, shifting of pH towards a metabolic acidosis and alteration of brain metabolism may be involved.

• Ketogenic diets are high in fat and extremely low in carbohydrates, with intake of fluids often limited.

• Ketogenic diets are sometimes prescribed in severe cases where drugs have proven ineffective.

DIET & OTHER TREATMENT

• Ketogenic diet is not good for the heart or kidneys and medical problems resulting from the diet have been reported.

• The diet is extremely unpalatable and few patients are able to tolerate it for any length of time.

• Since a single potato chip is adequate to break the ketosis, staying on the diet requires either great willpower or perfect control of a person's dietary intake.

• People fed via gastrostomy or young children who receive all their food in the presence of a caregiver are better candidates.

• Vagus nerve stimulation is a recently developed form of seizure control which uses an implanted electrical device, similar in size, shape and implant location to a heart pacemaker, which connects to the vagus nerve in the neck.

• Once in place the device can be set to emit electronic pulses, stimulating the vagus nerve at preset intervals and milliamp levels.

• Magnesium and vitamin B6 exerted a positive non-specific influence on the mental states of patients with epilepsy, depression and anxiety during an experiment.

• A number of systematic reviews by the Cochran Collaboration into treatments for epilepsy looked at acupuncture, psychological interventions, vitamins and yoga and found there is no reliable evidence to support the use of these as treatments for epilepsy.

• Mutations in several genes have been linked to some types of epilepsy.

• Several genes that code for protein subunits of voltage-gated and ligand-gated ion channels have been associated with forms of generalized epilepsy and infantile seizure syndromes.

• Several ligand-gated ion channels have been linked to some types of frontal and generalized epilepsies.

• Epilepsy-related mutations in some non-ion channel genes have also been identified.

PATHOPHYSIOLOGY

• One interesting finding in animals is that repeated low-level electrical stimulation to some brain sites can lead to permanent increases in seizure susceptibility: in other words, a permanent decrease in seizure "threshold."

• This phenomenon, known as kindling (by analogy with the use of burning twigs to start a larger fire) was discovered by Dr. Graham Goddard in 1967.

• Chemical stimulation can also induce seizures; repeated exposures to some pesticides have been shown to induce seizures in both humans and animals.

• One mechanism proposed for this is called excitotoxicity.

• The roles of kindling and excitotoxicity, if any, in human epilepsy are currently hotly debated.

• Diagnosis and classification by EEG.

• Bursts of spike – wave discharges of high voltage.

• Interictal record may be normal even after repetitive photo stimulation or induce hyperventilation.

Suksma Vyama

• Wrist-Manibandha Sakti Vikasaka 11 rounds

• Back of Hand-Karaprasta 11 rounds

• Sakti vikasaka

• Fingers – Anguli Sakti Vikasaka 11 rounds

• Elbows – Kaphoni Sakti Vikasaka 11 rounds

• Neck – Griva Sakti Vikasaka-I 11 rounds

• Neck – Sakti Vikasaka-II 11 rounds

• Back – Kati Sakti Vikasaka-I 11 rounds

INTEGRATED APPROACH OF YOGA THERAPY

Suksma Vyama• Back – Kati Sakti Vikasaka-II 11

rounds• Knees – Janu Sakti Vikasaka 11

rounds• Claves – Pindali Sakti Vikasaka 11

rounds• Eyes – Netra Sakti Vikasaka 11

rounds• Ears – Karna Sakti Vikasaka 11

rounds

Shithilikarana vyayama (Loosening Exercise)• Jogging• Pavanamuktasana Kriya 3 stages each• Quick Relaxation technique

Yogasana• Suryanamaskara 12 counts 3 rounds• Ardhakati Cakrasana 1 min• Ardha Cakrasana 1 min• Padahasatasana 3 min• Bhujangasana 1 min• Salabhasana 1 min• Viparita Karani 3 min• Sarvangasana 3 min• Matsyasana 1 min• Sirsasana or Ardhasirsasana 1-3 min• Sasankasana or Yoga Muda 3 min• Ustrasana 1 min• Savasana (DRT)

Kriya

• Jala Neti

• Trataka (on non-flickering lamp)

Meditation (Dharana, Dhyana)

• Nadanusandhana

• AAA-9, UUU-9, MMM-9

• OM Meditation Twice a day 10 min

• Cyclic Meditation with open eyes 30 min

AVOID FAST BREATHING

• General considerations: People with epilepsy usually need long-term medication to prevent further seizures. Their physical condition and psychological states vary considerably and individual approach is advisable.

• Contraindications: It is safer to avoid long yoga Nidra because of the risk of untimely sleep which may induce a seizure. On the other hand short-term muscle relaxation like Savasana is helpful. Kapalabhati and Bhastrika could induce a seizure and should probably be avoided.

SPECIFIC YOGA PRACTICE

• Recommendations: There is medical data about the usefulness of short muscle relaxation in the prevention of seizures. Yoga tradition recommends many other practices, see VYASA, Yoga publications.

Recommended asanas :

• Suryanamaskaras

• Sarvangasana

• Sirshasana

• Halasana

• Pachhimottanasana

• Matsyasana

• Paryankasana

• Shavasana

• Pranayama

THANK YOU