CoVID-19 vs. epilepsy: It is time to move, act, and encourage physical exercise

Abstract

Epilepsy is a common disease, found in 2% of the population, that affects people of all ages, geographic localizations, and socioeconomic levels. It is characterized by the occurrence of at least two unprovoked (or reflex) seizures occurring >24 h apart, one unprovoked (or reflex) seizure, and a probability of further seizures similar to the general recurrence risk after two unprovoked seizures, occurring over the next 10 years [[1]Fisher R.S. Acevedo C. Arzimanoglou A. Bogacz A. Cross J.H. Elger C.E. et al.ILAE official report: a practical clinical definition of epilepsy.Epilepsia. 2014; 55: 475-482Crossref PubMed Scopus (2739) Google Scholar]. The prevalence of epilepsy is 6.4 cases/1000 individuals and is higher in low-income countries [[2]Nature Reviews Disease Primers Epilepsy.Nat Rev Dis Primers. 2018; 4: 18025Crossref PubMed Scopus (2) Google Scholar]. Currently, there is a lot of uncertainty and questions regarding epilepsy vs. coronavirus disease 2019 (CoVID-19). Scientific authorities have proposed that the risk of acquiring CoVID-19 infection by people with epilepsy is the same as that of the general population [[3]Epilepsy Society Epilepsy and the coronavirus (COVID-19) FAQs.https://www.epilepsysociety.org.uk/epilepsy-and-coronavirus-covid-19-faqs#.XouB1YhKhPZDate: 2020Date accessed: April 6, 2020Google Scholar]. However, there are some factors (for example, related to lifestyle and side effects of antiepileptic drugs) that could negatively impact the health status of people with epilepsy. Health authorities point out that “those whose seizures are well controlled may not be at any greater risk than the general population, but those with uncontrolled seizures, and particularly seizures triggered by infection, may be more vulnerable” to CoVID-19 infection [[3]Epilepsy Society Epilepsy and the coronavirus (COVID-19) FAQs.https://www.epilepsysociety.org.uk/epilepsy-and-coronavirus-covid-19-faqs#.XouB1YhKhPZDate: 2020Date accessed: April 6, 2020Google Scholar]. However, there are other factors that can put people with epilepsy at higher risk compared with healthy people (even if seizures are controlled), such as the lack/impairment of medical assistance in the course of the pandemic, the presence of comorbidities [[4]Keezer M.R. Sisodiya S.M. Sander J.W. Comorbidities of epilepsy: current concepts and future perspectives.Lancet Neurol. 2016; 15: 106-115Abstract Full Text Full Text PDF PubMed Scopus (335) Google Scholar,[5]Hamed S.A. Atherosclerosis in epilepsy: its causes and implications.Epilepsy Behav. 2014; 41: 290-296Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar], and possible weakening of the respiratory and cardiovascular systems in the course of the disease [[3]Epilepsy Society Epilepsy and the coronavirus (COVID-19) FAQs.https://www.epilepsysociety.org.uk/epilepsy-and-coronavirus-covid-19-faqs#.XouB1YhKhPZDate: 2020Date accessed: April 6, 2020Google Scholar,6World Health Organization (WHO) Coronavirus disease (COVID-2019) situation reports.https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reportsDate: 2020Date accessed: March 17, 2020Google Scholar, 7World Health Organization (WHO) Mental health and psychosocial considerations during the COVID-19 outbreak.https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdfDate: 2020Date accessed: April 8, 2020Google Scholar, 8Godhwani N. Bahna S.L. Antiepilepsy drugs and the immune system.Ann Allergy Asthma Immunol. 2016; 117: 634-640Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 9Beghi E. Shorvon S. Antiepileptic drugs and the immune system.Epilepsia. 2011; 3: 40-44Crossref Scopus (75) Google Scholar, 10Duncan J.S. Sander J.W. Sisodiya S.M. Walker M.C. Adult epilepsy.Lancet. 2006; 367: 1087-1100Abstract Full Text Full Text PDF PubMed Scopus (616) Google Scholar]. In relation to medical assistance, the health systems are currently focused on combating the CoVID-19 pandemic, and routine medical consultations for patients with other chronic diseases, in general, have been postponed. This could increase the level of emotional stress and uncertainty, as people with epilepsy use multiple controlled medications that require the presentation of medical prescription and authorization [[3]Epilepsy Society Epilepsy and the coronavirus (COVID-19) FAQs.https://www.epilepsysociety.org.uk/epilepsy-and-coronavirus-covid-19-faqs#.XouB1YhKhPZDate: 2020Date accessed: April 6, 2020Google Scholar,[6]World Health Organization (WHO) Coronavirus disease (COVID-2019) situation reports.https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reportsDate: 2020Date accessed: March 17, 2020Google Scholar,[7]World Health Organization (WHO) Mental health and psychosocial considerations during the COVID-19 outbreak.https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdfDate: 2020Date accessed: April 8, 2020Google Scholar]. It is important to point out that sudden unexpected death in epilepsy (SUDEP) represents the most common epilepsy-related cause of death of people with epilepsy (1 to 2 per 1000 patient-years) and some associated factors are the presence of respiratory and cardiac complications due to seizures [[11]Maguire M.J. Jackson C.F. Marson A.G. Nevitt S.J. Treatments for the prevention of sudden unexpected death in epilepsy (SUDEP).Cochrane Database Syst Rev. 2020; 4CD011792PubMed Google Scholar]. In this context, it is possible to hypothesize that this would already be a factor in “turning on the warning signal” in relation to these patients. Another risk factor is that people with epilepsy are more sedentary and have worse levels of physical fitness [10Duncan J.S. Sander J.W. Sisodiya S.M. Walker M.C. Adult epilepsy.Lancet. 2006; 367: 1087-1100Abstract Full Text Full Text PDF PubMed Scopus (616) Google Scholar, 11Maguire M.J. Jackson C.F. Marson A.G. Nevitt S.J. Treatments for the prevention of sudden unexpected death in epilepsy (SUDEP).Cochrane Database Syst Rev. 2020; 4CD011792PubMed Google Scholar, 12Eriksen H.R. Bjørn E. Grønningsaeter H. Nakken K.O. Løyning Y. Ursin H. Physical exercise in women with intractable epilepsy.Epilepsia. 1994; 35: 1256-1264Crossref PubMed Scopus (132) Google Scholar, 13McAuley J.W. Long L. Heise J. Kirby T. Buckworth J. Pitt C. et al.A prospective evaluation of the effects of a 12-week outpatient exercise program on clinical and behavioral outcomes in patients with epilepsy.Epilepsy Behav. 2001; 2: 592-600Abstract Full Text PDF PubMed Scopus (118) Google Scholar, 14Nakken K.O. Bjørholt P.G. Johannesen S.L. Loyning T. Lind E. Effect of physical training on aerobic capacity, seizure occurrence, and serum level of antiepileptic drugs in adults with epilepsy.Epilepsia. 1990; 31: 88-94Crossref PubMed Scopus (145) Google Scholar, 15Heise J. Buckworth J. McAuley J.W. Long L. Kirby T.E. Exercise training results in positive outcomes in persons with epilepsy.Clin Exerc Physiol. 2002; 4: 79-84Google Scholar], which could be worse in this scenario. Considering the current perspective and the recommendation from local and global health authorities for social isolation and quarantine, the aim of this article is to present the practice of physical activity as an alternative strategy with which to cope with the pandemic of CoVID-19 for people with epilepsy and the health professionals who take care of them. The pandemic of CoVID-19 is frightening the world because of its potential for transmission-dissemination-hospitalization-lethality among more vulnerable populations, such as elderly people [[6]World Health Organization (WHO) Coronavirus disease (COVID-2019) situation reports.https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reportsDate: 2020Date accessed: March 17, 2020Google Scholar,16Center for Disease Control and Prevention (CDC) How to protect yourself.https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.htmlDate: 2020Date accessed: March 18, 2020Google Scholar, 17Center for Disease Control and Prevention (CDC) Stress and coping.https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.htmlDate: 2020Date accessed: April 9, 2020Google Scholar, 18Cascella M. Rajnik M. Cuomo A. Dulebohn S.C. Di Napoli R. Features, evaluation and treatment coronavirus (COVID-19). Book chapter.https://www.ncbi.nlm.nih.gov/books/NBK554776/Date accessed: March 17, 2020Google Scholar, 19Phua J. Weng L. Ling L. Egi M. Lim C.M. Divatia J.V. Asian Critical Care Clinical Trials Group et al.Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.Lancet Respir Med. 2020; S2213-2600: 30161-30162Google Scholar]. This could include people with epilepsy because the prevalence of epilepsy is higher in elderly people. Furthermore, many people with epilepsy have other comorbidities (depression, anxiety, hypertension, and obesity) and risk factors (low levels of physical activity) associated or not with the side effects of antiepileptic drugs [[20]Zaccara G. Neurological comorbidity and epilepsy: implications for treatment.Acta Neurol Scand. 2009; 120: 1-15Crossref PubMed Scopus (30) Google Scholar]. In addition, quarantine and social isolation, associated with the CoVID-19 pandemic, could impact negatively on the lifestyles (physical activity and diet) and health status (mental health) of health people and those with chronic diseases/morbidities [[21]Hall G. Laddu D.R. Phillips S.A. Lavie C.J. Arena R. A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.Prog Cardiovasc Dis. 2020; (S0033–0620. 3): 30077Google Scholar]. Li et al. [[22]Li S. Wang Y. Xue J. Zhao N. Zhu T. The impact of COVID-19 epidemic declaration on psychological consequences: a study on active Weibo users.Int J Environ Res Public Health. 2020; 17E2032Crossref PubMed Scopus (917) Google Scholar] conducted a study with the aim of exploring the impact of CoVID-19 on people's mental health. To this end, the posts of 17,865 active Weibo users were analyzed using the approach of Online Ecological Recognition based on machine-learning models. The authors observed many negative psychological, emotional, and mood states during the quarantine period associated with the CoVID-19 pandemic, such as anxiety, depression, indignation, increased sensitivity to social risks, unhappiness, and life dissatisfaction. Therefore, it is reasonable to assume that the CoVID-19 pandemic is a bad scenario for people with epilepsy, since psychological and emotional stress is a known factor that induces seizures and depression among them. Additionally, epilepsy-related stress − the burden of epilepsy − explains depression in many people with epilepsy [[23]Elger C.E. Johnston S.A. Hoppe C. Diagnosing and treating depression in epilepsy.Seizure. 2017; 44: 184-193Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar]. Although there are still no longitudinal studies in this area, it is possible to suppose that the period of social isolation and quarantine, indicated by the global and local health authorities, would negatively impact mental health and the levels of physical activity, and increase sedentary behavior, such as watching TV, sitting, staying on cell phones and social networks, and spending longer time on the computer, both in the general population and in people with epilepsy. Recently, an interesting article was published on this topic entitled “A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?” In this article, Hall et al. [[21]Hall G. Laddu D.R. Phillips S.A. Lavie C.J. Arena R. A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.Prog Cardiovasc Dis. 2020; (S0033–0620. 3): 30077Google Scholar] highlight that the drastic change in people's daily lives (due to the recommendation for social isolation and quarantine) around the world, associated with the pandemic caused by CoVID-19, could negatively impact physical activity habits and emphasize sedentary behaviors. It is clear that there is a need for a change in the way that health systems are conducted and in strategies for health/education promotion that include changes in lifestyle (encourage the practice of physical exercise) around the world in order to face and cope better with scenarios of this type. In this regard, a physical inactivity pandemic is a real fact, and the practice of physical activity by people with epilepsy could improve their physical and mental health [24Althoff T. Sosič R. Hicks J.L. King A.C. Delp S.L. Leskovec J. Large-scale physical activity data reveal worldwide activity inequality.Nature. 2017; 547: 336-339Crossref PubMed Scopus (502) Google Scholar, 25Arida R.M. Cavalheiro E.A. Scorza F.A. From depressive symptoms to depression in people with epilepsy: contribution of physical exercise to improve this picture.Epilepsy Res. 2012; 99: 1-13Crossref PubMed Scopus (24) Google Scholar, 26Arida R.M. Cavalheiro E.A. da Silva A.C. Scorza F.A. Physical activity and epilepsy: proven and predicted benefits.Sports Med. 2008; 38: 607-615Crossref PubMed Scopus (89) Google Scholar, 27Pedersen B.K. Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases.Scand J Med Sci Sports. 2015; 3: 1-72Crossref Scopus (1514) Google Scholar, 28Vancini R.L. Andrade M.S. de Lira C.A. Exercise as medicine for people with epilepsy.Scand J Med Sci Sports. 2016; 26: 856-857Crossref PubMed Scopus (2) Google Scholar]. Coping with the CoVID-19 pandemic and the great emotional stress would make society (individually and collectively) stronger. Coping is described as behavioral efforts (positive and/or negative) to deal with situations of harm and problem-solving techniques that are utilized to reduce psychological and emotional burden. Strategies of coping may include emotional support, meditative techniques, and religiosity/spirituality and physical exercise practice [29Vancini R.L. de Lira C.A. Arida R.M. Alternative medicine as a coping strategy for people with epilepsy: can exercise of religion and spirituality be part of this context?.Epilepsy Behav. 2014; 31: 194-195Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 30Cairney J. Kwan M. Veldhuizen S. Faulkner G.E.J. Who uses exercise as a coping strategy for stress? Results from a national survey of Canadians.J Phys Act Health. 2014; 11: 908-916Crossref PubMed Scopus (50) Google Scholar, 31Livneh H. Wilson L.M. Duchesneau A. Antonak R.F. Psychosocial adaptation to epilepsy: the role of coping strategies.Epilepsy Behav. 2001; 2: 533-544Abstract Full Text PDF PubMed Scopus (50) Google Scholar]. Emotional and psychological stress before, during, and after the CoVID-19 pandemic could include fear, change in sleep patterns, eating, physical inactivity, difficulty in concentration, worsening of chronic health problems and mental health conditions, and increased use of alcohol, tobacco, or other illicit drugs [[16]Center for Disease Control and Prevention (CDC) How to protect yourself.https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.htmlDate: 2020Date accessed: March 18, 2020Google Scholar,[17]Center for Disease Control and Prevention (CDC) Stress and coping.https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.htmlDate: 2020Date accessed: April 9, 2020Google Scholar]. In such a situation, people with epilepsy are going through two extremely important and impactful situations (CoVID-19 vs. epilepsy) at the same time. Following the same line of reasoning as Hall et al. [[21]Hall G. Laddu D.R. Phillips S.A. Lavie C.J. Arena R. A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.Prog Cardiovasc Dis. 2020; (S0033–0620. 3): 30077Google Scholar], people with epilepsy may be facing three risk factors at the same time: CoVID-19 vs. epilepsy vs. physical inactivity. This scenario in the short, medium, and long terms could produce even more negative effects on the physical, mental, and general health of people with epilepsy. Thus, it is necessary to draw up plans for minimizing scenarios like this. “Physical exercise is medicine” for many diseases [25Arida R.M. Cavalheiro E.A. Scorza F.A. From depressive symptoms to depression in people with epilepsy: contribution of physical exercise to improve this picture.Epilepsy Res. 2012; 99: 1-13Crossref PubMed Scopus (24) Google Scholar, 26Arida R.M. Cavalheiro E.A. da Silva A.C. Scorza F.A. Physical activity and epilepsy: proven and predicted benefits.Sports Med. 2008; 38: 607-615Crossref PubMed Scopus (89) Google Scholar, 27Pedersen B.K. Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases.Scand J Med Sci Sports. 2015; 3: 1-72Crossref Scopus (1514) Google Scholar], such as neurological (dementia), metabolic (obesity), cardiovascular (hypertension), pulmonary (asthma), and musculoskeletal disorders (osteoporosis) and psychiatric (depression) conditions, and also for epilepsy [25Arida R.M. Cavalheiro E.A. Scorza F.A. From depressive symptoms to depression in people with epilepsy: contribution of physical exercise to improve this picture.Epilepsy Res. 2012; 99: 1-13Crossref PubMed Scopus (24) Google Scholar, 26Arida R.M. Cavalheiro E.A. da Silva A.C. Scorza F.A. Physical activity and epilepsy: proven and predicted benefits.Sports Med. 2008; 38: 607-615Crossref PubMed Scopus (89) Google Scholar, 27Pedersen B.K. Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases.Scand J Med Sci Sports. 2015; 3: 1-72Crossref Scopus (1514) Google Scholar, 28Vancini R.L. Andrade M.S. de Lira C.A. Exercise as medicine for people with epilepsy.Scand J Med Sci Sports. 2016; 26: 856-857Crossref PubMed Scopus (2) Google Scholar]. However, people with epilepsy are known to have low levels of physical activity [[32]Arida R.M. Scorza F.A. de Albuquerque M. Cysneiros R.M. de Oliveira R.J. Cavalheiro E.A. Evaluation of physical exercise habits in Brazilian patients with epilepsy.Epilepsy Behav. 2003; 4: 507-510Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar], which can negatively impact their overall health status, physical fitness, and mental health [32Arida R.M. Scorza F.A. de Albuquerque M. Cysneiros R.M. de Oliveira R.J. Cavalheiro E.A. Evaluation of physical exercise habits in Brazilian patients with epilepsy.Epilepsy Behav. 2003; 4: 507-510Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 33Vancini R.L. Andrade M.S. Lira C.A.B. Could physical activity practice minimize the economic burden of epilepsy?.Arq Neuropsiquiatr. 2018; 76: 209Crossref PubMed Scopus (1) Google Scholar, 34Vancini R.L. Lira C.A. Andrade Mdos S. Cd Lima Arida R.M. Low levels of maximal aerobic power impair the profile of mood state in individuals with temporal lobe epilepsy.Arq Neuropsiquiatr. 2015; 73: 7-11Crossref PubMed Scopus (10) Google Scholar, 35Vancini R.L. de Lira C.A. Arida R.M. Physical exercise as a coping strategy for people with epilepsy and depression.Epilepsy Behav. 2013; 29: 431Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 36Vancini R.L. de Lira C.A. Arida R.M. Physical exercise: potential candidate as coping strategy for people with epilepsy.Epilepsy Behav. 2013; 28: 133Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar]. In this period of necessary social isolation and quarantine, it is likely that the already low level of physical activity in people with epilepsy will further deteriorate, and sedentary behaviors will increase. Therefore, strategies are needed to at least maintain mental health and physical fitness in a safe way, such as practicing light and home-based physical exercises. This practice needs to be adapted to the home environment and directed by skilled health professionals; people with epilepsy should be guided/advised in practicing home-based exercise, which should include aerobic exercises, muscle strength exercises, and flexibility exercises [[21]Hall G. Laddu D.R. Phillips S.A. Lavie C.J. Arena R. A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.Prog Cardiovasc Dis. 2020; (S0033–0620. 3): 30077Google Scholar,[37]Jiménez-Pavón D. Carbonell-Baeza A. Lavie C.J. Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: special focus in older people.Prog Cardiovasc Dis. 2020; (S0033–0620): 30063Google Scholar]. Indeed, physical exercise in times of the CoVID-19 pandemic has gained great relevance. For instance, the article by Jiménez-Pavón et al. [[37]Jiménez-Pavón D. Carbonell-Baeza A. Lavie C.J. Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: special focus in older people.Prog Cardiovasc Dis. 2020; (S0033–0620): 30063Google Scholar] entitled “Physical exercise as therapy to fight against the mental and physical consequences of CoVID-19 quarantine: Special focus on older people” proposed some home-based physical exercise strategies to face the pandemic of CoVID-19 and to maintain and eventually improve health-related physical fitness components in older people, which could be used safely by other populations in this period of uncertainty. Thus, it is necessary to outline effective education and health strategies [[37]Jiménez-Pavón D. Carbonell-Baeza A. Lavie C.J. Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: special focus in older people.Prog Cardiovasc Dis. 2020; (S0033–0620): 30063Google Scholar,[38]Oni T. Unwin N. Why the communicable/non-communicable disease dichotomy is problematic for public health control strategies: implications of multimorbidity for health systems in an era of health transition.Int Health. 2015; 7: 390-399PubMed Google Scholar] in the short, medium, and long terms in order to minimize the negative impact of social isolation and quarantine caused by CoVID-19 for the general population and people with epilepsy. “Physical exercise is medicine and recommended for people with epilepsy” [[27]Pedersen B.K. Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases.Scand J Med Sci Sports. 2015; 3: 1-72Crossref Scopus (1514) Google Scholar,[28]Vancini R.L. Andrade M.S. de Lira C.A. Exercise as medicine for people with epilepsy.Scand J Med Sci Sports. 2016; 26: 856-857Crossref PubMed Scopus (2) Google Scholar] and the general population. There are sufficient evidences that physical exercise produces positive effects on physical fitness, mental health, and lifestyle. The advice of the Epilepsy Society [2020] is to “Try to keep healthy by following a nutritious diet and taking light exercise” during the CoVID-19 pandemic. The most prudent thing to do is to respect social isolation and quarantine and seek alternative strategies, such as home-based physical exercise, which may include popular social networks (Instagram) and video and information search sites (YouTube) for health promotion among the general population and people with epilepsy. Authors have no competing interests to declare. To all health professionals and scientists who donate their knowledge and experience to save lives. To all people, victims, patients, families, parents, and friends who have lost loved ones. RLV receives a productivity fellowship at the Fundação de Amparo à Pesquisa e Inovação do Espírito Santo (FAPES) agency (Edital No. 18/2018-Bolsa Pesquisador Capixaba).