Behavioral Interventions as an Adjunctive Treatment for Canine Epilepsy: A Missing Part of the Epilepsy Management Toolkit?

Epilepsy is more than a simple seizure disorder: Parallels between human and canine cognitive and behavioural comorbidities

Psychiatric and cognitive comorbidities have been known to play a major role in human epilepsy for a long time. People with epilepsy (PWE) frequently express signs of varying psychiatric and cognitive disorders affecting their quality and quantity of life (QoL/QaoL). Over the last few years, research on behavioural comorbidities and their effect on the underlying disease have been performed in canine epilepsy. The following article reviews manifestations of comorbidities in canine epilepsy with an emphasis on patterns of clinical signs and their effects on QoL and QaoL. Cognitive and behavioural alterations in epileptic dogs are mainly represented by fear-/anxiety related behaviour and cognitive impairment (CI). Reduced trainability and altered reactions to daily situations are common results of comorbid changes posing obstacles in everyday life of owners and their dog. In addition, clinical signs similar to attention deficit hyperactivity disorder (ADHD) in humans have been reported. Canine attention-deficit-hyperactivity-disorder-like (c-ADHD-like) behaviour should, however, be evaluated critically, as there are no official criteria for diagnosis of ADHD or ADHD-like behaviour in dogs, and some of the reported signs of c-ADHD-like behaviour could be confused with anxiety-associated behaviour. Many intrinsic and extrinsic factors could potentially influence the development of behavioural and cognitive comorbidities in canine epilepsy. In particular, seizure frequency/severity, signalment and factors concerning disease management, such as pharmacotherapy and nutrition, are closely linked with the presence of the aforementioned comorbid disorders. Further studies of behavioural alterations in epileptic dogs are needed to comprehend the complexity of clinical signs and their multifactorial origin.

Translational veterinary epilepsy: A win-win situation for human and veterinary neurology

Epilepsy is a challenging multifactorial disorder with a complex genetic background. Our current understanding of the pathophysiology and treatment of epilepsy has substantially increased due to animal model studies, including canine studies, but additional basic and clinical research is required. Drug-resistant epilepsy is an important problem in both dogs and humans, since seizure freedom is not achieved with the available antiseizure medications. The evaluation and exploration of pharmacological and particularly non-pharmacological therapeutic options need to remain a priority in epilepsy research. Combined efforts and sharing knowledge and expertise between human medical and veterinary neurologists are important for improving the treatment outcomes or even curing epilepsy in dogs. Such interactions could offer an exciting approach to translate the knowledge gained from people and rodents to dogs and vice versa. In this article, a panel of experts discusses the similarities and knowledge gaps in human and animal epileptology, with the aim of establishing a common framework and the basis for future translational epilepsy research.

Effects of progressive muscle relaxation exercises on patients with epilepsy on level of depression, quality of sleep, and quality of life: A randomized controlled trial

OBJECTIVE

This study aims to evaluate the effects of progressive relaxation exercises applied to patients with epilepsy on patients' depressive symptom severity, quality of sleep, and quality of life.

METHODS

The study was designed as a randomized controlled interventional study with a control group and pre-and post-test intervention. It was conducted with 70 patients with epilepsy, 35 in the intervention group and 35 in the control group, between November 1, 2021, and April 15, 2022. The patients in the intervention group were required to perform 12 progressive muscle relaxation exercise sessions 3 days a week for a total of 4 weeks. No interventions were made in the control group during the study. The data were collected with a "Personal Information Form," "Pittsburgh Sleep Quality Index (PSQI)," "Beck Depression Inventory (BDI)," and "Quality of Life in Epilepsy Inventory (QUOLIE -31)."

RESULTS

The mean PSQI total score, subscale scores, and mean BDI total scores of the patients in the intervention group decreased significantly compared to those in the control group after the intervention (p<0.05). Additionally, a significant difference was found between the mean QUOLIE-31 total scores and subscale scores of the patients in the intervention and control group after the intervention (p<0.05), the mean scores of the intervention group were significantly higher than those of the control group (p<0.05).

CONCLUSION

Progressive muscle relaxation exercises decreased depressive symptoms severity and improved sleep and life quality in patients with epilepsy. Progressive relaxation exercises may be recommended as a complementary nursing intervention in treating epilepsy.

Emotional Arousal Impacts Physical Health in Dogs: A Review of Factors Influencing Arousal, with Exemplary Case and Framework

Excessive emotional arousal has been shown to impact physiological health in both veterinary species and human animals. The focus of work in many models of veterinary behavioural medicine has predominantly been associated with reducing activation of the protective emotional systems; in particular, fear-anxiety. The management of the engaging emotional systems of desire-seeking, social play, care and lust has not traditionally been considered in the treatment of physiological health of veterinary species. This article reviews the literature in both veterinary and human fields on the relationship between emotional arousal of both protective and engaging emotional systems and physical health conditions. The current literature describing the regulatory control of sleep on emotional arousal is also discussed. An exemplary case report of a seven month old male entire Cocker Spaniel showing fly-snapping behaviour which had been non-responsive to leviteracetam (Keppra) is presented. The emotional health assessment and treatment of this case is described along with the short and long term (fourteen month follow up) outcomes to demonstrate that some patients presenting in this way can be effectively managed with an appropriate behavioural medicine treatment plan. The authors put forward the argument that an emotional health assessment should be considered an essential component of the work up of all such cases.

Optimization of a locomotion-based zebrafish seizure model

BACKGROUND

Locomotor assays in zebrafish have emerged as a screening test in early drug discovery for antiseizure compounds. However, parameters differ considerably between published studies, which may explain some discrepant results with (candidate) antiseizure medications.

NEW METHOD

We optimized a locomotor-based seizure assay in zebrafish with pentylenetetrazol (PTZ) as the pharmacological proconvulsant to generate a therapeutic window in which proconvulsant-treated zebrafish larvae could be discriminated from a non-treated control. To generate a reliable control, exposure time and concentration of valproate (VPA, anticonvulsant) was optimized.

RESULTS

Wells with one or three larvae show a similar PTZ dose-dependent increase in locomotion with less variability in motility for the latter. Zebrafish immersed in 10 mM PTZ showed a significant increase in movement with a sustained effect, without any indication of toxicity. Animals treated with 3 mM VPA showed the strongest reduction of PTZ-induced movement without toxicity. The decrease in PTZ-induced locomotion was greater after 18 h versus 2 h.

COMPARISON WITH EXISTING METHOD(S)

For the larval zebrafish PTZ-induced seizure model, varying experimental parameters have been reported in literature. Our results show that PTZ is often used at toxic concentrations, and we provide instead reliable conditions to quantify convulsant behaviour using an infrared-beam motility assay.

CONCLUSIONS

We recommend using three zebrafish larvae per well to quantify locomotion in 96-multiwell plates. Larvae should preferably be exposed to 10 mM PTZ for 1 h, consisting of 30 min acclimation and 30 min subsequent recording. As positive control for anticonvulsant activity, we recommend exposure to 3 mM VPA for 18 h before administration of PTZ.

Owner reported management of interictal anxiety behaviours in canine epilepsy

BACKGROUND

Idiopathic epilepsy (IE) is the most common chronic neurological condition in dogs, and can be associated with interictal (between seizure) anxiety (IIA). It is unclear how owners manage their pet's IIA, including how much veterinary support they receive for it.

METHODS

An international online questionnaire collected data on IIA prevalence, management of IIA and perceived levels of veterinary support for IIA from owners of dogs diagnosed with IE.

RESULTS

Valid responses were available from n = 220 owners. IIA was reported by 83.6% of owners. Common management strategies were behavioural or training techniques, reported by 90.4% of owners, whilst 34.4% reported use of behavioural products. Only 28.5% of owners felt fully supported by their vet in managing IIA. Owners who felt unsupported were less likely to have received advice on behavioural management or training from their vet (p = 0.003).

CONCLUSION

Access to veterinary support for the management of IIA is needed for owners of dogs with IE.

Research priorities for idiopathic epilepsy in dogs: Viewpoints of owners, general practice veterinarians, and neurology specialists

BACKGROUND

Epilepsy is the most common chronic neurological disease in dogs that adversely affects the quality of life (QoL) of affected dogs and their owners. Research on epilepsy in dogs is expanding internationally, but where best to focus limited research time, funds, and expertise to achieve better outcomes for affected dogs and their owners has not been studied.

OBJECTIVE

To explore idiopathic epilepsy (IE) research priorities of owners of dogs with IE, general practice veterinarians, and veterinary neurologists.

METHODS

An international online survey was conducted in 2016 and repeated in 2020. Participants rated the absolute importance and relative rank of 18 areas of IE research, which were compared between groups and time points.

RESULTS

Valid responses were received from 414 respondents in 2016 and 414 respondents in 2020. The development of new anti-seizure drugs (ASD) and improving the existing ASD management were considered the most important research priorities. Areas of research with increasing priority between 2016 and 2020 included non-ASD management, with the greatest potential seen in behavioral and dietary-based interventions. Disagreements in priorities were identified between groups; owners prioritized issues that impacted their and their dog's QoL, for example, adverse effects and comorbidities, whereas general practitioner vets and neurologists prioritized clinical issues and longer-term strategies to manage or prevent IE, respectively.

CONCLUSIONS AND CLINICAL IMPORTANCE

Ensuring that voices of owners are heard in the planning of future research should be a broader goal of veterinary medicine, to target research efforts toward areas most likely to improve the QoL of the dog-owner dyad.

A Review of Medical Conditions and Behavioral Problems in Dogs and Cats

Not all animals behave identically when faced with the same situation. These individual differences in the expression of their behavior could be due to many factors, including medical conditions. These medical problems can change behavior directly or indirectly. The aims of this review are to describe the state of the art of the relationship among some medical and behavioral problems, and to propose new lines of investigation. The revision is focused on the relation between behavioral problems and pain, endocrine diseases, neurological problems, vomeronasal organ alterations, and cardiac disorders. These problems represent a diagnostic challenge from a practical point of view. The most common sign of pain in animals is a change in behavior. Although the relation of pain to behavioral problems has been widely studied, it is not absolutely clear. As an example, the relation between sleep disorders and pain is poorly known in veterinary medicine. New studies in humans and laboratory animals show that a reciprocal relationship does, in fact, exist. More specifically, the literature suggests that the temporal effect of sleep deprivation on pain may be stronger than that of pain on sleep. Some behavioral problems could modify the sleep-awake cycle (e.g., cognitive dysfunction). The impact of these behavioral problems on pain perception is completely unknown in dogs and cats. Thyroid hormones play an important role, regarding behavioral control. Both hypothyroidism and hyperthyroidism have been related to behavioral changes. Concerning hypothyroidism, this relationship remains controversial. Nonetheless, new neuro-imaging studies provide objective evidence that brain structure and function are altered in hypothyroid patients, both in laboratory animals and in humans. There are many neurological problems that could potentially change behavior. This paper reviews those neurological problems that could lead to behavioral changes without modifying neurological examination. The most common problems are tumors that affect central nervous system silent zones, mild traumatic brain injury, ischemic attacks, and epilepsy. Most of these diseases and their relationship to behavior are poorly studied in dogs and cats. To better understand the pathophysiology of all of these problems, and their relation to behavioral problems, may change the diagnostic protocol of behavioral problems.

A double-blinded randomised dietary supplement crossover trial design to investigate the short-term influence of medium chain fatty acid (MCT) supplement on canine idiopathic epilepsy: study protocol

Background

Epilepsy is the most common brain disease in dogs. Recently, diets have been reported to have a positive impact on seizure activity and behaviour in various species including dogs with idiopathic epilepsy (IE). Historically, classic high fat ketogenic diets (KD) and medium chain triglycerides (MCT) KD have been successfully used to manage drug-resistant epilepsy. Similarly, an MCT enriched diet has been shown to improve seizure control and behavioural comorbidities in some dogs with IE. However, it is unknown whether an MCT dietary supplement (DS) may provide similar positive effects.

Methods

A 6-month prospective, randomised, double-blinded, placebo-controlled, crossover, multicentre dietary trial is designed comparing a 9% metabolic energy based calculated medium-chain triglyceride (MCT) oil supplement to a conventional ‘control’ DS. Only dogs which will have an International Veterinary Epilepsy Task Force Tier II level like diagnosis of IE which satisfied the following inclusion criteria are included: age between 6 months and ≤ 12 years; weighing between 4 and ≤ 65 kg; unremarkable interictal neurological examinations; no clinically significant findings on routine laboratory diagnostics; unremarkable brain MRI scan; have had at least 3 seizures in the previous 3 months prior to enrolment; treated with at least one ASD and being classified as resistant. All dogs are fed initially for 90 ± 2 days with either the control oil or the MCT oil alongside their normal diet, followed by 97 ± 2 days with the other supplement including a 7-day washout period. Overall, the aim is to recruit thirty-six patients at five different centres and to investigate the effect of MCTs as DS on seizure activity, tolerability, behavioural comorbidities and quality of life (QoL).

Discussion

Dietary interventions are rarely studied in a standardised form in veterinary medicine. The background diet, the cohort of animals and ASD received is standardised in this prospective diet trial to ensure representative data about the potential effect of MCT DS. If the study data confirms former findings, this would provide further evidence for the efficacy of MCTs as a management option for canine epilepsy. This publication should offer a repository of trial conditions and variable description with forecasted statistical analysis.

Electronic supplementary material

The online version of this article (10.1186/s12917-019-1915-8) contains supplementary material, which is available to authorized users.

Music-Enhanced Analgesia and Antiseizure Activities in Animal Models of Pain and Epilepsy: Toward Preclinical Studies Supporting Development of Digital Therapeutics and Their Combinations With Pharmaceutical Drugs

Digital therapeutics (software as a medical device) and mobile health (mHealth) technologies offer a means to deliver behavioral, psychosocial, disease self-management and music-based interventions to improve therapy outcomes for chronic diseases, including pain and epilepsy. To explore new translational opportunities in developing digital therapeutics for neurological disorders, and their integration with pharmacotherapies, we examined analgesic and antiseizure effects of specific musical compositions in mouse models of pain and epilepsy. The music playlist was created based on the modular progression of Mozart compositions for which reduction of seizures and epileptiform discharges were previously reported in people with epilepsy. Our results indicated that music-treated mice exhibited significant analgesia and reduction of paw edema in the carrageenan model of inflammatory pain. Among analgesic drugs tested (ibuprofen, cannabidiol (CBD), levetiracetam, and the galanin analog NAX 5055), music intervention significantly decreased paw withdrawal latency difference in ibuprofen-treated mice and reduced paw edema in combination with CBD or NAX 5055. To the best of our knowledge, this is the first animal study on music-enhanced antinociceptive activity of analgesic drugs. In the plantar incision model of surgical pain, music-pretreated mice had significant reduction of mechanical allodynia. In the corneal kindling model of epilepsy, the cumulative seizure burden following kindling acquisition was lower in animals exposed to music. The music-treated group also exhibited significantly improved survival, warranting further research on music interventions for preventing Sudden Unexpected Death in Epilepsy (SUDEP). We propose a working model of how musical elements such as rhythm, sequences, phrases and punctuation found in K.448 and K.545 may exert responses via parasympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis. Based on our findings, we discuss: (1) how enriched environment (EE) can serve as a preclinical surrogate for testing combinations of non-pharmacological modalities and drugs for the treatment of pain and other chronic diseases, and (2) a new paradigm for preclinical and clinical development of therapies leading to drug-device combination products for neurological disorders, depression and cancer. In summary, our present results encourage translational research on integrating non-pharmacological and pharmacological interventions for pain and epilepsy using digital therapeutics.