Epilepsy Therapy Project Accelerating New Therapies for People with Epilepsy and Seizures
1
Hallway Conversations – Exercise and Epilepsy
In this episode of Epilepsy.com’s Hallway Conversations,
Dr. Joseph Sirven, Professor of Neurology at Mayo Clinic Arizona and Editor-in-Chief of Epilepsy.com/Professionals, interviews Dr. Elinor Ben-Menachem from Göteborg University about Exercise and Epilepsy.
Date: Wednesday, January 9, 2013
Dr. Joseph Sirven Dr. Elinor Ben-Menachem
Dr. Joseph Sirven
: Hello to everyone out there and welcome to Hallway Conversations. Today is January 9, 2013. I’m excited because this is the first Hallway Conversations for epilepsy.com that we have set up for the year 2013. And I think that as we get in looking forward to the new year, we’ll be very excited to see the various topics we’re going to cover.
Today, I think we are especially thrilled. We have a dear friend who’s been on these podcasts before who’s joining us. And we’re going to be dealing with a topic that we don’t often talk about. In fact, we’ve never dealt with this topic on Hallway Conversations and that has to do with exercise. How does exercise, epilepsy and some of the other issues related to this interconnect or how do they affect one another? It’s a perfect topic for a January podcast.
To join me is an expert in both medications and epilepsy. A friend and colleague, Dr. Elinor Ben-Menachem. She is professor of neurology from the Institute of Clinical Neuroscience and Physiology from the Sahlgrenska Academy at the University of Göteborg in Sweden. So I am delighted to be speaking to Dr. Ben-Menachem or Elinor from Sweden this morning. And Elinor, Happy New Year and welcome to Hallway Conversations.
Dr. Elinor Ben-Menachem:
Well, Happy New Year to you and thank you, I’m very honored that you invited me. You forgot to say I am an American. Exercise and Epilepsy
Epilepsy Therapy Project Accelerating New Therapies for People with Epilepsy and Seizures
2
Dr. Joseph Sirven
: I now stand corrected.
Dr. Elinor Ben-Menachem:
From Los Angeles.
Dr. Joseph Sirven
: We’ll give our international kudos for your kindness in joining us for your location.
Dr. Elinor Ben-Menachem:
Anyway, the time distance is very great. I think we are nine hours apart, you and me.
Dr. Joseph Sirven
: So it works out very well, your evening, my morning, and I’m just happy to have you here. Elinor, for those who may not know you, can you describe your current role and work in epilepsy so they kind of know your place in the field of epilepsy.
Dr. Elinor Ben-Menachem:
Well, if I talk about what I do at my hospital, besides doing a lot of clinical research, my patient care involves working with refractory epilepsy patients, especially those where epilepsy surgery has not been an option or they have failed surgery. And I’ve also started working a lot with new onset patients, because I think that it’s very important to try to make these people seizure free as soon as possible, and to prevent them from developing refractory epilepsy. I honestly believe that it is possible to do that, and I have been turning my activities more to that area.
Then, I am involved in the American Epilepsy Society and I’m the chairman of the annual meeting for another year. So we’ll see how the American Epilepsy Society next meeting will go. It will be my responsibility.
Dr. Joseph Sirven
: Something tells me it’ll be a huge success.
Dr. Elinor Ben-Menachem:
Well, we’re starting to work on it and so are you. And we’re looking forward to providing education for physicians and nurses and psychologists and other health care professionals in this field of epilepsy, which is so important.
Dr. Joseph Sirven
: Well, that’s very helpful and I think it kind of jumps us to this next point, which is we are talking today about exercise. First of all, before we kind of get into that, tell me your interests in the area of exercise and what has lead you to look, at least, this particular question.
Dr. Elinor Ben-Menachem:
Well, it’s very interesting when we look at – I’ve been doing clinical trials with drugs and neurostimulators, neuromodulations and diets, but nobody is talking about exercise. And if you go into a fields of cognition, dementia, Parkinson, depression, then physicians are talking a lot about how important it is for people to exercise, to have a good cardiovascular function. To be out there among people because it raises their quality of Exercise and Epilepsy
Epilepsy Therapy Project Accelerating New Therapies for People with Epilepsy and Seizures
3
life, and maybe can even improve their condition.
And I’m thinking well exercise doesn’t cost that much money. It’s not a drug. It’s not anything anybody is selling. And therefore, unfortunately, it may be less of interest to look at the importance of epilepsy care and exercise. And all of our patients are people with epilepsy. And so these people have just as many problems with overeating, sitting and not moving enough. And they have problems with their heart and diabetes and overweight. And so therefore we have to look at how can we fit in exercise as a treatment for epilepsy, or even just to make the person feel better and have less comorbidities.
So that’s why I became interested in it. And I have some colleagues, Marie O’Barry and Yenne Newberry and Yior Kun who have access to an amazing database of people, men, all men, who at the age of 18, had to go into the military. They were recruits in Sweden. It was obligatory to – there was a draft – forever in 1987 when the draft stopped. So we have a register of everybody who was enlisted from 1959 to 1987.
And because Sweden has been a very homogeneous population, and a small population, we have been able, through registries, to follow these patients, looking at different diseases. And we’ve looked at depression, dementia and we’ve looked at epilepsy in 1,170,000 people. And when these people enter the military, they have to make an IQ test, and they do ergonomic tests with a bicycle. And they also have a strength test. And these tests have basically been unchanged from 1959 to 1987.
So we have an extremely homogeneous group and the methodology of looking, at least at baseline how they were at the age of 18 is the same through all these years. And some of these patients we have been able to follow up to 40 years. So this is a unique population and we can get a better understanding anyway about the effect of having a high cardiovascular function at the age of 18, and what happens later on in life.
And there will be many publications about many types of diseases, because this is a huge and unique and homogeneous population. So that’s why I became interested in all of this.
Dr. Joseph Sirven
: Which is fascinating and given that they’ll be a lot of material that I imagine, as you said, will come out of this. Before we get into some of the nuances and more specifics of the studies, I know many of our listeners, and for that matter, those are both patients, caregivers and professionals, will be asking the most obvious question, which is is there a best exercise? Or are there exercises that are absolutely a no-no for individuals with epilepsy? I think those are often the first two questions and we’ll go from there. Exercise and Epilepsy
Epilepsy Therapy Project Accelerating New Therapies for People with Epilepsy and Seizures
4
Dr. Elinor Ben-Menachem:
Well, to answer that question, which I can’t do unequivocally, animal research of epilepsy and exercise has mainly been based on running. You know, they put them in those little treadmills. And these are all cardiovascular type of exercises, not lifting weights. And we really have very little information about people who lift weights, but don’t have high cardiovascular function, except for our recruit study.
Now studies in people have been based also on cardiovascular conditions and improving that. And so the sport that is easiest studied, and they have the largest groups involved in this would be cardiovascular. And this is running. So running is what we have the most knowledge on.
However, if you just extrapolate, I think any sport that builds up cardiovascular fitness is okay, like tennis and aerobics, bicycling, running on a soccer field. Even swimming with supervision would equally raise cardiovascular fitness.
Now sports are good for everyone and they increase wellbeing, they lower stress levels. And which is a dangerous sport needs to be decided on by the patient and the people in his surroundings, thinking about how often a person has seizures. And maybe they haven’t had seizures for years, well they can do almost everything.
If you think about what type of exercises you shouldn’t do, well you can tell a person to just go and sit on the sofa. And then they’re safest, maybe, except that they’ll die, probably, of a heart attack because they have such bad condition. But there’s certain exercises like diving or skiing alone up on a mountain, climbing mountains, these are all dangerous sports, especially for people with active epilepsy. So common sense is really important, I think.
Dr. Joseph Sirven
: So in many ways, there really isn’t an absolute answer to this.
Dr. Elinor Ben-Menachem:
There is not an absolute answer. For example, if you think of Marion Cliquet who won a silver medal in the Olympics in bicycling. In America, she was an American, but had a French passport as well. And they would not let her join the Olympic team in America because she had epilepsy. So she went over to France and she joined their Olympic team and won a silver medal.
So there are people who do amazing things. And they succeed beyond expectations and the wildest imaginations. But if you talk about a group, then you can do a lot of sports, as long as it’s under supervision. In fact we have patients who have a lot of comorbidities and have some other physical handicaps and bad epilepsy who are out there riding horses as well. So it depends on the circumstance and who’s with you,
Exercise and Epilepsy
Epilepsy Therapy Project Accelerating New Therapies for People with Epilepsy and Seizures
5
probably doing sports like that alone is really crazy. But with other people and everyone knows about it, it would certainly work out.
Dr. Joseph Sirven
: That’s actually fascinating and that’s the story of the cycles. I did not know that. That’s a great one. Let me ask you this –
Dr. Elinor Ben-Menachem:
Actually you can go onto her website and you can read all of this. It’s just really amazing. The last name is spelled C-L-I-Q-U-E-T. So go onto the website everybody and look at this amazing person.
Dr. Joseph Sirven
: No, we will because that is one that people should definitely know about. Elinor, I know it’s early in terms of – especially some of the data that you’re hoping to mine from the work that you’re doing, but at this moment, can you tell us, can exercise help control or even prevent epilepsy?
Dr. Elinor Ben-Menachem:
Yes, well this is what our study really alludes to, and even animal studies allude to it. There is a research Arida, A-R-I-D-A in São Paulo, in Brazil who has done a lot of animal studies. And he likes to theorize on how important it is for people with epilepsy as well. But he has some kindling models and some pilocarpine models seen in animal studies. That if the animal is well trained before being kindled, or getting pilocarpine to induce status epilepticus, then the seizure frequency is much less and it’s harder to initiate seizures in these animals. In other words, we’re raising the seizure threshold.
And I think that’s how we need to think about exercise is that it probably doesn’t prevent epilepsy, but it probably raises the seizure threshold and makes it harder to elicit a seizure. But in our study we found that the – and we controlled for the different recruiting centers, for the parents, educational level. And for heredity and a lot of other factors we controlled for. We found that there was a 79% increase in epilepsy after the age of 18 in people who had low cardiovascular fitness.
In other words, these people were all fit. They were all allowed to be in the military, so they weren’t so bad to begin with. They weren’t the rejects. But the ones that had the low cardiovascular fitness had 79% higher risk of developing epilepsy. And, if there was a brother with epilepsy, then the one with the high cardiovascular fitness, still had about a 50% less chance to develop epilepsy than if someone had a low cardiovascular fitness and he had a brother with epilepsy.
Dr. Joseph Sirven
: Wow, that is fascinating.
Dr. Elinor Ben-Menachem:
So that’s fascinating. That, I think is important. Exercise and Epilepsy
Epilepsy Therapy Project Accelerating New Therapies for People with Epilepsy and Seizures
6
Dr. Joseph Sirven
: Elinor, does anything else exist that shows similar things like that, other studies like that?
Dr. Elinor Ben-Menachem:
This is the only study in the world so far. So I can’t tell you anything else. But I can tell you what we also looked at was we looked at head trauma. And after the age of 18. So the guys went into the military when they started they didn’t have any head trauma. We factored that out, those patients, those people. And then if they developed head trauma after the age of 18, then the ones with the low cardiovascular fitness given similar traumas had an 80% higher risk of developing epilepsy.
So exercise before the age of 18, that’s one thing we can say, is very important to help protect against developing many disorders because we found that depression, although not bipolar but depression, the risk of developing depression, major depression, is much lower if you have exercised and have good cardiovascular fitness when you’re 18. The same we’re finding with dementia. So this is a fascinating area. And as young people are doing less and less exercise and sitting more and more in front of the computer, we realize how dangerous this practice really is for their future health.
Dr. Joseph Sirven
: Absolutely. Elinor, one of the big things that pops up, and you just mentioned this, is a lot of the comorbid conditions associated with epilepsy are things like depression, are things like memory problems. You’ve mentioned dementia, you’ve mentioned depression, where does exercise fit in helping those aspects of the epilepsy spectrum of conditions?
Dr. Elinor Ben-Menachem:
Yes, there have been a few studies, really double blind studies. And one of them, which was rather interesting was a trial published in 2011 by Trivedi, T-R-I-V-E-D-I. And this was a randomized study looking at exercise and a dose of exercise for depression. In other words a higher dose, more exercise, actually affected the amount of depression that – the entered people who had major depression. And the people who – how many were there? There were 80 men and women who had depression. They were randomized to five different doses of exercise. And the higher remission rates were significant in the high dose group. So that was the first study really that’s a randomized study. Which gives support to the fact that exercise can be important in people who have depression.
And so for our patients with epilepsy, exercise is important, not only for epilepsy, raising the seizure threshold, but also to help against depression. And also, there has been a study showing that it can improve neurocognitive performance.
There was recently a meta-analysis in 2010 by Smith. And this study was a meta-
Exercise and Epilepsy
Epilepsy Therapy Project Accelerating New Therapies for People with Epilepsy and Seizures
7
analysis of 29 studies. And I went through all of the studies, and there were about 2,000 participants in all of these studies. And they found that aerobic exercise training is associated with modest improvements in attention, processing speed, executive function and memory. But working memory, it was less consistent, the results on working memory. But on more long-term memory than it was very helpful.
So there is evidence out there. But in epilepsy, we really need to get started with doing some prospective studies in patients with epilepsy and looking at seizure frequency and seeing, and their depression scales, and memory and neurocognitive testing. And see if we can, by simple means, improve their way of life.
Dr. Joseph Sirven
: Which makes perfect sense. And Elinor, we’re in our last minute and a half or so of this podcast. This has been absolutely fascinating, and as I listen and as I suspect most of our listeners will be agreeing with me, this is fairly powerful material you are mentioning here. What points, what take home points do you want to leave with our audience now? Because we have to have you back when you have some of these things published to talk about.
Dr. Elinor Ben-Menachem:
Yes. Well, if I could just mention, which I didn’t mention is that we have basic neuroscience evidence that exercise improves neuroplasticity and the development of new neurons, especially in the hippocampus. And that there’s some new studies coming out showing that there’s dendritic sprouting and reorganization during exercise, which is – I could talk another half an hour on that one because it’s fascinating.
But what I would like to say is it is important to encourage our patients to exercise, however they may do it. If they’re not very mobile, then a treadmill or sitting on a bicycle. Or even those little feet bicycles that they could move their legs around and around. Anything is important and it’s better than just sitting or sitting in a wheelchair, whatever. People need to move to feel better.
And this applies even to ourselves and to our families and to our kids. It’s not just concerning epilepsy. It’s for all of us. We should get out there and move. And since I started doing this, I go on my treadmill every day.
Dr. Joseph Sirven
: I love it. You lead by example.
Dr. Elinor Ben-Menachem:
Oh yes, I wouldn’t miss it now after I’ve done the study.
Dr. Joseph Sirven
: Elinor, let me thank you for a terrific podcast interview here. You have given us a lot to think about. It’s also timely given that at the beginning of the year is when everyone Exercise and Epilepsy
Epilepsy Therapy Project Accelerating New Therapies for People with Epilepsy and Seizures
8
thinks about weight loss, exercise regime. And your message hits right on the bull’s eye when it comes to this.
Dr. Elinor Ben-Menachem:
Yes, exercise is good for the brain. Just as for the heart and everything else. The brain needs it.
Dr. Joseph Sirven
: Huge message. And for that, I want to think Dr. Elinor Ben-Menachem. She is professional of neurology from the Institute of Clinical Neuroscience and Physiology, the Sahlgrenska Academy at the University of Göteborg in Sweden. An American from Los Angeles, as she pointed out, and a very well-known epileptologist. Elinor, we will hope that you will join us as your work unfolds from this database and we learn a lot more about how exercise impacts epilepsy.
Dr. Elinor Ben-Menachem:
Thank you very much.
Dr. Joseph Sirven
: Oh it’s a pleasure. To everyone out there, today has been a great conversation with Dr. Elinor Ben-Menachem. We’ve been talking about exercise and epilepsy. This is the first of our Hallway Conversations for epilepsy.com. Just as a side note, I’m excited to be reporting, this is our first Hallway Conversations in which epilepsy.com is part of the Epilepsy Foundation. And we expect a lot of wonderful new things that we hope to provide our listeners, viewers and readers as we join forces.
Today’s a wonderful example and we’re just so delighted to have had Dr. Ben-Menachem with us. I hope that everyone out there enjoys their day or their evening, depending on where in the world you are listening to this. And lastly, please join us again for upcoming Hallway Conversations on epilepsy.com. My name is Dr. Joseph Sirven, Editor-in-Chief of epilepsy.com. I hope that you have a great day. Thanks again.
