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Arida RM, Teixeira-Machado L. Physical exercise for children and adolescents with epilepsy: What have we learned? Seizure 2023; 111:1-8. [PMID: 37480838 DOI: 10.1016/j.seizure.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/05/2023] [Accepted: 07/08/2023] [Indexed: 07/24/2023] Open
Abstract
PURPOSE Although clinical and experimental studies have extensively evidenced the positive effect of physical exercise on epilepsy, these benefits in children and adolescents with epilepsy have been less investigated. We explored the published literature evaluating the impact of long-term exercise programmes on seizure frequency and quality of life in children/adolescents with epilepsy. METHODS A scoping review of the literature was performed in accordance with PRISMA guidance with suitable search terms. A comprehensive search of PubMed, PEDro, Web of Science, Scopus, Google Scholar and SPORTDiscus with Full Text (EBSCO) was performed from March to April 2023. A methodological quality assessment was completed for the included studies. The included studies were analysed qualitatively to identify key themes and provide a narrative description of the evidence by two reviewers. RESULTS Of 1,316 papers screened, 13 studies were selected for full reading. Only six studies evaluated the seizure frequency and quality of life in children and adolescents with epilepsy after a long-term exercise programme. Two studies observed positive findings in seizure frequency and three in quality of life. No study was classified with strong methodological quality. Three studies presented good quality 78-61%, one study presented adequate quality 57%, and two studies presented poor methodological quality (39% and 43%). CONCLUSIONS Our review highlights a limited number of investigations evaluating the long-term effect of exercise in children and adolescents with epilepsy. Longitudinal investigations with good methodological quality may be performed to examine the effectiveness of exercise in this population.
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Affiliation(s)
- Ricardo Mario Arida
- Department of Physiology, Federal University of São Paulo, São Paulo, Brazil.
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Associations between 24-hour movement guideline adherence and mental health disorders among young people with active and inactive epilepsy. Epilepsy Behav 2021; 125:108386. [PMID: 34781060 DOI: 10.1016/j.yebeh.2021.108386] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/20/2021] [Accepted: 10/16/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE (1) Examine 24-hour movement guideline adherence among young people with active and inactive epilepsy compared to population norms. (2) Investigate associations between 24-hour movement guideline adherence and mental health disorders among these subpopulations. METHODS Cross-sectional data from the 2016 to 2019 cycles of the National Survey of Children's Health were used. Parental/caregiver reports of movement behaviors (physical activity, screen time, sleep, and sport participation) were used to determine adherence to the 24-hour movement guidelines and associations with mental health disorders for young people with active (n = 663) and inactive epilepsy (n = 526) as well as population norms (n = 49,067) between 6 and 17 years old. Multivariate logistic regression analyses were conducted. RESULTS Young people with active epilepsy were less likely to meet the 24-hour movement guidelines than population norms, largely driven by below average levels of physical activity guideline adherence. Sport participation was lower among both young people with active and inactive epilepsy; seizure severity and health-related limitations played an influential role. Beneficial associations were generally observed between 24-hour movement guideline adherence and mental health disorders, although for young people with active and inactive epilepsy, there was considerable variability among these relationships. CONCLUSIONS Further dissemination of the International League Against Epilepsy's Task Force on Sports and Epilepsy report can help improve promotion of physical activity and sport participation among young people with active and inactive epilepsy. The relationship between 24-hour movement guideline adherence and mental health disorders is complex among young people with epilepsy and longitudinal research is needed to determine causal links.
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Comparison of physical fitness, activity, and quality of life of the children with epilepsy and their healthy peers. Epilepsy Res 2021; 178:106795. [PMID: 34741994 DOI: 10.1016/j.eplepsyres.2021.106795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/03/2021] [Accepted: 10/15/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify physical fitness and activity levels, and health-related quality of life of children with epilepsy in Turkey and compare the results with their healthy peers. METHODS The study included 21 children with epilepsy (with no seizures and not taking anti-epileptic drugs for at least a year) and 20 healthy peers. The FitnessGram Physical Fitness Test Battery was used to assess physical fitness, the 6-Minute Walk Test to assess physical performance, the Pediatric Quality of Life Inventory 4.0 (PedsQL) to assess the quality of life, and a pedometer was used to assess the physical activity of the children. RESULTS The physical fitness assessments including the trunk-lift test and flamingo balance test results were significantly lower in the children with epilepsy (p < 0.05). There was no significant difference between the groups in terms of BMI, the cadence-based curl-up test, the push-up test and the back saver sit/reach test (p > 0.05). Physical activity, physical performance, and quality of life results were significantly lower in children with epilepsy (p < 0.05). CONCLUSION The presence of epilepsy may negatively affect many aspects of physical fitness, physical activity, and quality of life in childhood. The children with epilepsy adopted a more sedentary lifestyle than their healthy peers. Quality of life outcomes reveal that epilepsy has negative physical and psychosocial effects on children. These results support the necessity of raising awareness in both health professionals and families to encourage their children to be more active.
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Bermejo-Cantarero A, Álvarez-Bueno C, Martínez-Vizcaino V, Redondo-Tébar A, Pozuelo-Carrascosa DP, Sánchez-López M. Relationship between both cardiorespiratory and muscular fitness and health-related quality of life in children and adolescents: a systematic review and meta-analysis of observational studies. Health Qual Life Outcomes 2021; 19:127. [PMID: 33882937 PMCID: PMC8059195 DOI: 10.1186/s12955-021-01766-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/07/2021] [Indexed: 01/01/2023] Open
Abstract
Background No review to date has evaluated the association between physical fitness and health-related quality of life (HRQoL) in healthy children and adolescents. The aims of this systematic review and meta-analysis were to examine the relationship between both cardiorespiratory fitness (CRF) and muscular fitness (MF) and HRQoL in healthy subjects under 18 years of age and to describe the dimensions of HRQoL in which these relationships are more robust. Methods The Medline, Embase, Cochrane Library, SCIELO, SPORTDiscus and PEDro databases were systematically searched to collect observational studies that examined the relationship between CRF and HRQoL and between MF and HRQoL in participants under 18 years of age without any diagnosed medical condition. Pooled effect sizes (ES) were estimated for the associations between both CRF and MF and the various HRQoL dimensions. Results The pooled ES (95% CI) estimates for the relationship between CRF and HRQoL were as follows: 0.19 (0.10 to 0.27) for physical well-being, 0.19 (0.07 to 0.32) for psychological well-being, 0.20 (− 0.14 to 0.55) for perceived health status, 0.10 (0.00 to 0.20) for self-perception/self-esteem, 0.07 (− 0.05 to 0.19) for quality of family relationship, 0.14 (0.04 to 0.25) for quality of peer relationship, 0.17 (0.04 to 0.29) for everyday functioning at school and 0.20 (0.12 to 0.28) for total HRQoL score. The pooled ES (95% CI) estimates for the relationship between MF and HRQoL were: 0.25 (0.12 to 0.37) for physical well-being, 0.11 (0.04 to 0.17) for psychological well-being, 0.08 (0.01 to 0.15) for quality of family relationship, 0.14 (0.03 to 0.25) for quality of peer relationship, and 0.09 (0.03 to 0.14) for total HRQoL score. Conclusions Our data suggest that both CRF and MF are positively associated with HRQoL, mainly in physical, psychological and peer relationships. Moreover, CRF is positively associated with school dimensions and MF is positively associated with family relationships. Trail registration Protocol PROSPERO registration number: CRD42015025823. Supplementary Information The online version contains supplementary material available at 10.1186/s12955-021-01766-0.
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Affiliation(s)
- Alberto Bermejo-Cantarero
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Castilla-La Mancha, Spain
| | - Celia Álvarez-Bueno
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Castilla-La Mancha, Spain. .,Universidad Politécnica y Artística del Paraguay, Asunción, Paraguay.
| | - Vicente Martínez-Vizcaino
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Castilla-La Mancha, Spain.,Universidad Autónoma de Chile, Facultad de Ciencias de la Salud, Talca, Chile
| | - Andrés Redondo-Tébar
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Castilla-La Mancha, Spain
| | | | - Mairena Sánchez-López
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Castilla-La Mancha, Spain.,Universidad de Castilla-La Mancha, School of Education, Ciudad Real, Castilla-La Mancha, Spain
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Dimitri P, Joshi K, Jones N. Moving more: physical activity and its positive effects on long term conditions in children and young people. Arch Dis Child 2020; 105:1035-1040. [PMID: 32198161 DOI: 10.1136/archdischild-2019-318017] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 11/04/2022]
Abstract
While the benefits of regular participation in physical activity in children and young people are clear, misconceptions have developed about the possible negative effects and potential complications of exercise on long-term conditions such as epilepsy, asthma and diabetes. Over the last decade evidence has emerged supporting the positive impact that physical activity has on long-term conditions. Previous concerns were raised about the risks of hypoglycaemia in children with type 1 diabetes mellitus (T1DM) thus limiting participation in sports. Importantly, physical activity improves the metabolic profile, bone mineral density, cardiorespiratory fitness and insulin sensitivity while lowering mortality risk in children with T1DM. Children with asthma were prevented from doing exercise due to concerns about precipitating an acute asthmatic episode. To the contrary, physical activity interventions have consistently shown an increase in cardiovascular fitness, physical capacity, asthma-free days and quality of life in childhood asthmatics. Children with epilepsy are often excluded from sports due to concerns relating to increased seizure frequency, yet evidence suggests that this is not the case. The evidence supporting physical activity in childhood survivors of cancer is growing but still primarily confined to patients with acute lymphoblastic leukaemia. Participation in sports and physical activity also reduces mental health problems developing in adolescence. While further research is required to investigate benefits of physical activity on specific aspects of long-term conditions in children, in general this group should be advised to increase participation in sports and exercise as a means of improving long-term physical and mental health.
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Affiliation(s)
- Paul Dimitri
- Paediatric Endocrinology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Kush Joshi
- Faculty of Sports and Exercise Medicine, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK
| | - Natasha Jones
- Faculty of Sports and Exercise Medicine, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK
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Johnson EC, Helen Cross J, Reilly C. Physical activity in people with epilepsy: A systematic review. Epilepsia 2020; 61:1062-1081. [DOI: 10.1111/epi.16517] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Emma C. Johnson
- Research Department Young Epilepsy Surrey UK
- Great Ormond Street Hospital for Children National Health Service Trust London UK
| | - J. Helen Cross
- Research Department Young Epilepsy Surrey UK
- Great Ormond Street Hospital for Children National Health Service Trust London UK
- University College London Great Ormond Street Institute of Child Health London UK
| | - Colin Reilly
- Research Department Young Epilepsy Surrey UK
- University College London Great Ormond Street Institute of Child Health London UK
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van den Bogard F, Hamer HM, Sassen R, Reinsberger C. Sport and Physical Activity in Epilepsy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:1-6. [PMID: 32008605 DOI: 10.3238/arztebl.2020.0001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 05/04/2019] [Accepted: 10/28/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND For many years, people with epilepsy were advised not to engage in sports. In this systematic review, we investigated whether persons with epilepsy exercise less than the general population, and what effect physical activity has on epilepsy. METHODS A literature search was carried out in PubMed and the Web of Science, and 14 269 studies were entered into the selection process. The selected studies were assessed for their methodological quality and accordingly assigned an evidence level. RESULTS 42 studies were included in the review; 10 were classified as evidence level 3, 27 as evidence level 2-, 2 as evidence level 2+, and 3 as evidence level 1-. Persons with epilepsy are less physically active and less physically fit than the general population. Reduced physical activity is associ- ated with a higher frequency of comorbidities and lower quality of life. Physical interventions can improve quality of life. In most cases, physical exercise did not increase seizure frequency. CONCLUSION There is no reason to forbid persons with epilepsy to participate in sports; they should, rather, be encour- a particular type of sport should, however, be taken individually in each case.
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Affiliation(s)
- Fanziska van den Bogard
- Institute of Sports Medicine, Paderborn University; Epilepsy Centre at the Department of Neurology, Universitätsklinikum Erlangen; Department of Epileptology, University Hospital Bonn
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Abstract
Common genetic generalised epilepsy syndromes encountered by clinicians include childhood and juvenile absence epilepsies, juvenile myoclonic epilepsy and generalised tonic-clonic seizures on awakening. Treatment of these syndromes involves largely the use of broad-spectrum antiseizure drugs. Those effective for the generalised epilepsies include sodium valproate, phenobarbital, ethosuximide, clobazam, clonazepam, lamotrigine, levetiracetam, topiramate, zonisamide and, more recently, perampanel and brivaracetam. Results from the few rigorous studies comparing outcomes with drugs for genetic generalised epilepsies show valproate to be the most effective. The majority of patients with genetic generalised epilepsy syndromes will become seizure free on antiseizure monotherapy; those for whom control proves elusive may benefit from combination regimens. Early counselling regarding management may assist the patient to come to terms with their diagnosis and improve long-term outcomes. Treatment can be lifelong in some individuals, although others may remain seizure free without medication. Choice of antiseizure medication depends on the efficacy for specific seizure types, as well as tolerability. For patients prescribed comedication, drug interactions should be considered. In particular, for young women taking oral hormonal contraceptives, ≥ 200 mg/day of topiramate can decrease the circulating concentration of ethinylestradiol and ≥ 12 mg/day of perampanel can induce levonorgestrel metabolism. The use of valproate in women of childbearing potential is limited by associated teratogenic and neurodevelopmental effects in offspring. Given that valproate is often the antiseizure drug of choice for genetic generalised epilepsies, this creates a dilemma for patients and clinicians. Decision making can be aided by comprehensive assessment and discussion of treatment options. Psychiatric comorbidities are common in adolescents and adults with genetic generalised epilepsies. These worsen the prognosis, both in terms of seizure control and quality of life. Attendant lifestyle issues can impact significantly on the individual and society. Frontal lobe dysfunction, which can present in patients with juvenile myoclonic epilepsy, can adversely affect the long-term outlook, regardless of the nature of seizure control. Ongoing management requires consideration of psychosocial and behavioural factors that can complicate diagnosis and treatment. An assured supportive attitude by the neurologist can be an important contributor to a positive outcome. The mechanisms underlying genetic generalised epilepsies, including genetic abnormalities, are unclear at present. As the pathophysiology is unravelled, this may lead to the development of novel therapies and improved outcomes for patients with these syndromes.
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Affiliation(s)
- Linda J Stephen
- West Glasgow Ambulatory Care Hospital, Dalnair St, Glasgow, G3 8SJ, UK.
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Ronen GM, Janssen I. Patterns of daily activity among young people with epilepsy. Dev Med Child Neurol 2019; 61:1386-1391. [PMID: 30927258 DOI: 10.1111/dmcn.14223] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2019] [Indexed: 11/30/2022]
Abstract
AIM To: (1) explore how young people with epilepsy spend time on physical activity, screen-time, and sleep in a 24-hour period; (2) compare these findings to young people without epilepsy; and (3) evaluate the findings relative to the Canadian 24-hour movement guidelines for children and youth. METHOD The study is based on Canadian data from the 2013 to 2014 'Health Behaviour in School-aged Children study' (HBSC), a cross-sectional sample of young people aged 10 to 17 years. Three groups participated: 163 young people with epilepsy, 3613 young people with non-neurological conditions, and 18 339 population norms. Self-reported activity data were compared across groups. RESULTS Demographics were similar across groups. Young people with epilepsy spent 5.8 hours per week on moderate-to-vigorous physical activity versus 5.6 hours per week in population norms; 32% met the recommended 1 hour or more per day. Screen-time was 8.7 hours per day versus 7.4 hours per day in population norms; only 5.4% met the 2 hours or less per day recommendation. Sleep duration was 10.2 hours per day versus 9.8 hours per day in population norms, and 50.7% met the recommendation. Overall, 25.7% of young people with epilepsy did not meet any of the guidelines, 60.5% met one, 13.5% met two, and 0.3% met all three recommendations; whereas 2.8% of population norms and 2% of young people with non-neurological conditions met all three recommendations. INTERPRETATION These data could inform future interventions and alert policy-makers, health care professionals, parents, educators, and advocacy-groups to the low adherence of young people with epilepsy with Canadian guidelines and their risk for poor health. WHAT THIS PAPER ADDS Young people with epilepsy adhere poorly to Canadian guidelines for daily sleep duration, physical activity, and sedentary screen time. Young people with epilepsy accumulate more screen-time than those with non-neurological conditions or population norms.
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Affiliation(s)
- Gabriel M Ronen
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Ian Janssen
- School of Kinesiology and Health Studies, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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Vancampfort D, Ward PB, Stubbs B. Physical activity and sedentary levels among people living with epilepsy: A systematic review and meta-analysis. Epilepsy Behav 2019; 99:106390. [PMID: 31466870 DOI: 10.1016/j.yebeh.2019.05.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
How physically active and sedentary people with epilepsy are is unclear. We conducted a meta-analysis to investigate physical activity and sedentary behavior levels compared with the general population in people with epilepsy across the lifespan. Embase, PubMed, PsycARTICLES, and CINAHL Plus were searched from inception until 1/3/2019. A random effects meta-analysis was conducted. Adults with epilepsy (mean age range = 30-47 years) were significantly less likely to comply with physical activity recommendations [odds ratio (OR) = 0.68; 95% confidence interval (CI) = 0.53-0.87; P < 0.001; N analyses = 10; n epilepsy = 1599; n controls = 137,800] and more likely to be inactive (as defined by individual study criteria) (OR = 1.57; 95% CI = 1.34-1.84; P < 0.001; N analyses = 6; n epilepsy = 6032; n controls = 928,184). Data in children (mean age range = 10-12 years) were limited (N = 4; n = 170) and inconsistent while there were no data available for middle-aged and old age (>65 years) people with epilepsy. Our data demonstrate that adults with epilepsy are less physically active than the general population. Public health campaigns specifically targeting the prevention of physical inactivity in adults with epilepsy are warranted. More research on physical activity and sedentary levels in children, adolescents, middle-aged, and old age but also adult people with epilepsy is needed before specific recommendations can be formulated.
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Affiliation(s)
- Davy Vancampfort
- KU Leuven - University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium; KU Leuven - University of Leuven, University Psychiatric Center KU Leuven, Kortenberg, Belgium.
| | - Philip B Ward
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.; Schizophrenia Research Unit, Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Brendon Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, UK
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Pohl D, Alpous A, Hamer S, Longmuir PE. Higher screen time, lower muscular endurance, and decreased agility limit the physical literacy of children with epilepsy. Epilepsy Behav 2019; 90:260-265. [PMID: 30342878 DOI: 10.1016/j.yebeh.2018.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 05/06/2018] [Accepted: 05/06/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this study was to determine the physical literacy (the motivation, confidence, physical competence, and knowledge contributing to the capacity for physical activity) of children with epilepsy, as compared with that of their healthy peers. METHODS Patients age 8-12 years with epilepsy, without any disabilities interfering with their ability to answer questionnaires and perform vigorous physical activity, were recruited from the Neurology Clinic at the time of visits. They completed the Canadian Assessment of Physical Literacy (CAPL), a comprehensive battery of tests reflecting the primary domains of physical literacy (motivation/confidence, physical competence, knowledge/understanding, and daily behavior). Daily behavior was assessed by pedometer step counts, as well as self-reported moderate-to-vigorous physical activity and screen time. Physical competence included agility and movement skill measures as well as physical fitness. Children with epilepsy were matched with healthy peers from a large research database of over 6000 Canadian children. RESULTS We tested 35 children with epilepsy, divided into those with presumed self-limiting forms of epilepsy (49%) and those with chronic disease (51%). Only a small proportion of participants (23%) were taking more than one antiepileptic medication, and only one patient was taking three anticonvulsants. Children with epilepsy including those with self-limiting forms had significantly lower total physical literacy scores, lower agility and movement skills, and lower muscular endurance, and reported more screen time than their healthy peers. Only 11% of the children with epilepsy achieved the recommended level of physical literacy. However, the children with epilepsy were knowledgeable about and highly motivated to participate in a physically active lifestyle. CONCLUSIONS Children with epilepsy demonstrate poor physical literacy levels, with potential immediate and long-lasting negative impacts on general health and psychosocial well-being. Programs promoting physical literacy in children with epilepsy should be encouraged, specifically interventions decreasing screen time and enhancing muscular endurance and motor skills, thereby facilitating healthier lifestyles.
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Affiliation(s)
- Daniela Pohl
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada; University of Ottawa, Faculty of Medicine, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada; Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada.
| | - Anastasia Alpous
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
| | - Sabrina Hamer
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
| | - Patricia E Longmuir
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada; University of Ottawa, Faculty of Medicine, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
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