Behavioral Interventions May Reduce Seizures in Focal Epilepsy

Deborah Brauser

February 15, 2018

Two stress-reducing behavioral interventions may be effective in reducing seizures in adult patients with medication-resistant focal epilepsy, new research suggests.

In a randomized trial of 64 patients, those who underwent progressive muscle relaxation (PMR) with relaxed breathing and those who underwent focused attention "with extremity movements" (the control group) had significant reductions in seizures from baseline.

However, there were no significant differences between the two therapy groups, with 29% and 25% seizure improvement, respectively (the primary outcome).

On the secondary outcome of self-reported stress, though, reductions were significantly greater in the PMR than in  the focused-attention groups.

The primary outcome finding "did surprise us, but we heard from the patients that just doing a regular behavioral intervention seemed to be helping them," lead author, Sheryl R. Haut, MD, Montefiore-Einstein Epilepsy Center and Department of Neurology at Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York, told Medscape Medical News.

Dr Sheryl R. Haut

"We did think it was interesting that stress levels only went down significantly in the [PMR] group. Still, a regular check-in with patients about how they're feeling may have led to benefit in both groups," said Haut.

The results were published online February 14 in Neurology.  

New Options Needed

"Despite all the advances we have made with new drugs for epilepsy, at least one-third of people continue to have seizures, so new options are greatly needed," said Haut in a press release.

"Since stress is the most common seizure trigger reported by patients, research into reducing stress could be valuable," she added.

The investigators enrolled adult patients at three epilepsy centers in the United States: the Montefiore Health System in Bronx, New York; the University of Cincinnati, Ohio; and the University of California San Francisco.. The study was originally powered for 45 participants in each treatment group, but lack of funding halted enrollment before that number was reached.

Instead, 64 participants (62.5% women; mean age, 37.2 years; mean duration of epilepsy, 26 years) were randomly assigned to twice-daily PMR and diaphragmatic breathing (n = 32) or a focused-attention activity (n = 32) for 12 weeks.

The PMR intervention concentrated on a 16-muscle group "in which each muscle set was tensed vigorously without straining for 5 to 10 seconds, then relaxed," report the investigators.

The control group "practiced a series of movements…plus other attentional tasks such as writing down the activities of the previous day."

Each study participant received a smartphone with a daily electronic diary app. There they recorded self-reported mood, stress ratings, and seizure frequency and filled out questionnaires. The interventions were also administered as audio recordings on the smartphone after an initial meeting with a psychologist for individualized training.

Significant Seizure Reductions

Seizure frequency per 28 days was reduced from baseline by a significant 29% in the PMR group (P < .05) and by a significant 25% in the focused-attention group (P < .05). But, as mentioned earlier, these reductions were not significantly different between the two groups (P = .38).

"During the early days of the treatment phase, the PMR group had faster decreases in stress, i.e., more negative instantaneous rates of change (p < .05 for first 40 days of treatment phase)," the researchers report.

However, there was no significant association between stress and seizure prediction.

In further analyses, 46% of the participants had at least one psychiatric diagnosis, as measured on the Mini-International Neuropsychiatric Interview, with past depressive disorder (21%) and generalized anxiety disorder (8%) being the most frequent.

Baseline or changes from baseline in anxiety or depression symptoms were not significantly linked with any seizure outcome.

Finally, nearly 85% of the participants had diary completion rates over 5 months.

"Feasible, Efficacious, and Accepted"

"This study confirms that a stress-reduction behavioral intervention in medication-resistant epilepsy is feasible, efficacious, and accepted by patients," write the investigators.

But because the mechanism "remains unknown" for the association between these interventions and reduction in seizures, "larger, individually targeted trials are now needed," they add.

Haut noted that other stress-reducing techniques, especially mindfulness-based cognitive therapy, should also be assessed in this patient population.

"We were excited about the results overall. There were significant reductions similar to what is found in drug trials typically," she said.

"Also, we've heard from patient groups that they need more than just medication. Certainly we don't think this is going to replace medication; but as an adjunctive therapy, we think our study shows that behavioral interventions and various mindfulness stress reduction approaches are extremely important."

The study was funded by grants from the Shor Foundation for Epilepsy Research and from the Epilepsy Foundation. Haut currently serves on the editorial board of Epilepsy and Behavior and has received grant support from the Shor Foundation. She also serves or has served as a consultant for Acorda, SIGA, Eisai, Otsuka, and Engage Pharmaceuticals and has received compensation for expert legal testimony. Disclosures for the other study authors are listed in the original article.

Neurology. Published online February 14, 2018. Abstract

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