Pathophysiology
- Mechanism: Abnormal synchronous neuronal electrical discharges create a wave of excitation that overrides normal inhibitory circuits. The location and extent of the discharge determines the seizure type and clinical presentation
- Focal (partial) seizures: Begin in a specific area of one hemisphere. May include automatisms (lip smacking, hand rubbing, clothes picking). Consciousness may be preserved (simple partial) or impaired (complex partial). May secondarily generalize
- Generalized seizures: Involve both hemispheres simultaneously with loss of consciousness from onset
- Absence (petit mal): Brief staring spells lasting seconds; no postictal state; commonly in children
- Tonic-clonic (grand mal): Tonic phase (sustained contraction, falling, cyanosis) followed by clonic phase (rhythmic jerking); postictal exhaustion, confusion, soreness
- Provoked vs. unprovoked: Provoked seizures (febrile, drug withdrawal, metabolic) are distinct from chronic epilepsy and do not require the diagnosis
- Triggers: Brain damage at birth, traumatic brain injury, stroke, tumors, CNS infections, metabolic disturbances, toxins, sleep deprivation, stress, photosensitivity
- Psychogenic non-epileptic seizures (PNES): Seizure-like episodes with no EEG abnormality, related to psychological stressors. Important differential
Signs and Symptoms
- Aura/prodrome: Odd smells, sounds, visual sparks, deja vu, rising epigastric sensation — indicates focal seizure that may secondarily generalize
- Automatisms: Lip smacking, pacing, picking at clothes — complex partial seizure activity
- Postictal state: Exhaustion, muscle soreness, disorientation, headache, sometimes Todd's paralysis (temporary weakness) after tonic-clonic seizures
- Evidence of tongue biting and secondary musculoskeletal injuries from falls during seizures
- Fatigue and dizziness from antiseizure medications (chronic side effects)
Red Flags
- Status epilepticus: Seizure lasting longer than 5 minutes or repeated seizures over 30 minutes without regaining consciousness — life-threatening medical emergency. Call 911 immediately
- "Worst headache ever" or sudden confusion after head injury: Requires immediate referral to rule out intracranial hemorrhage
- New-onset seizures in an adult: May indicate brain tumor, stroke, or CNS infection — requires urgent medical evaluation
- Seizure during treatment: Do not restrain the client. Clear the area of hazards. Protect the head. Time the seizure. Call 911 if it exceeds 5 minutes
Massage Therapy Considerations
- It is strictly inappropriate to massage during a seizure. Discuss a first aid protocol with the client before beginning any session
- Environmental audit: Check the treatment room for seizure triggers — flashing lights, flickering fans, specific scents, and certain music can provoke episodes. Remove or mitigate triggers before treatment
- Medication side effects: Antiseizure medications (carbamazepine, valproate, phenytoin, levetiracetam) cause fatigue, dizziness, and reduced bone density (osteoporosis risk). Allow extra time for position transitions. Use conservative depth over bony prominences. Nutrient depletion note: CYP450 enzyme-inducing anticonvulsants (phenytoin, carbamazepine, phenobarbital) accelerate vitamin D catabolism, depleting vitamin D, calcium, and folate. 10-30% of patients on these drugs show biochemical evidence of vitamin D depletion, leading to osteomalacia and increased fracture risk over time. Clients on long-term anticonvulsants who present with diffuse bone pain or unexplained fractures may have drug-induced bone disease. See pharmacology-for-massage-therapists/drug-nutrient-depletion-reference
- Post-seizure care: Massage helps manage post-seizure muscle soreness, soft tissue injuries from falls, and inter-episode anxiety
- Quality of life: Between seizures, massage improves quality of life by reducing stress (a known seizure trigger), improving sleep, and managing musculoskeletal complaints
- Session planning: Discuss seizure frequency, last episode, known triggers, and emergency medications (rectal diazepam, intranasal midazolam) before each session. Keep the client's emergency contact information accessible
- Positioning: Ensure the client can be safely managed if a seizure occurs on the table. Bolsters and face cradle must not create an airway hazard
CMTO Exam Relevance
- Know the classification: focal vs. generalized seizures. Absence vs. tonic-clonic
- Status epilepticus (>5 minutes) is a medical emergency
- Differentiate epileptic seizures from psychogenic non-epileptic seizures (PNES) — PNES has no EEG abnormality
- Environmental trigger audit is a key massage therapy responsibility
- Antiseizure medication side effects (fatigue, dizziness, osteoporosis) modify treatment approach
Key Takeaways
- It is strictly inappropriate to massage during a seizure. Discuss a first aid protocol with the client before beginning any session.
- Audit the treatment room for seizure triggers: flashing lights, flickering fans, specific scents, and certain music can provoke episodes.
- Status epilepticus (seizure lasting more than 5 minutes) is a life-threatening medical emergency requiring immediate 911 activation.
- Antiseizure medications cause fatigue, dizziness, and reduced bone density. Allow extra time for position transitions.
- Massage improves quality of life by managing post-seizure soreness, reducing stress (a known seizure trigger), and improving sleep.
- Psychogenic non-epileptic seizures (PNES) have no EEG abnormality and relate to psychological stressors — an important differential.