Key messages
• Psycho-behavioural treatments probably reduce seizure frequency slightly, but we do not know their effect on people's quality of life.
• Mind-body treatments (such as yoga) may slightly reduce seizure frequency, and may make little or no difference to quality of life.
• In general, treatment effects were inconsistent across studies and the strength of evidence varied.
What is epilepsy?
Epilepsy is a common condition that affects the brain and causes seizures. In a seizure, the brain's electrical signals are suddenly disrupted or become too active.
What is the role of non-medicinal treatments in epilepsy?
Most people with epilepsy take daily anti-seizure medication to help control seizures. One-third of people with epilepsy don't respond well to medication alone: seizures persist. Additional, non-medicinal treatments may help people with epilepsy manage the mental, emotional, and lifestyle effects of the condition. We divided these treatments into six broad categories, based on how each treatment is designed to work:
• psycho-behavioural treatments, which aim to change a person's behaviour;
• mind-body treatments, such as muscle relaxation and yoga;
• self-management treatments, which aim to help people better understand and manage their condition;
• physical exercise, such as cardiovascular or aerobic training;
• nurse-led service delivery approaches, where epilepsy-specialist nurses deliver health care;
• other service delivery approaches, such as care support via telephone or multidisciplinary team support.
What did we want to find out?
We wanted to find out if treatments in these categories were better than the usual epilepsy care that adults receive at:
• reducing the number of seizures people experience;
• improving their health-related quality of life (HRQoL).
We also wanted to know if these treatments led to any unwanted, harmful events.
What did we do?
We searched for studies that compared two different types of non-medicinal treatments or any of these types of help to usual care. We focused on people aged 16 years old or older. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size.
What did we find?
We found 36 studies involving 5834 people with epilepsy. The studies included different groups of people: most involved people with any type of epilepsy (26 studies); six studies focused on those with severe epilepsy or epilepsy that did not respond to medication; and four studies included people with additional health issues like depression or learning difficulties.
The studies were conducted globally: 21 in high-income countries, seven in upper-middle-income, and eight in lower-middle-income countries.
Main results
Seizure frequency
• Two studies showed that psycho-behavioural interventions are likely to reduce the number of seizures in the six months after the intervention started.
• Mind-body methods, such as muscle relaxation or yoga, may reduce seizure frequency slightly.
• Three studies showed that self-management methods may not reduce the number of seizures per month. However, three other studies showed they are likely to help more people become seizure-free. The overall effect remains uncertain.
• We are very uncertain about how physical exercise affects seizures.
• One study showed that service delivery led by specialist epilepsy nurses did not reduce seizure frequency in the short term.
• The results from other service delivery approaches were mixed.
Quality of life
• We are very unsure if psycho-behavioural interventions improve people's quality of life.
• Mind-body and exercise approaches may make little to no difference to people's quality of life.
• Self-management methods may improve quality of life slightly. This benefit was not shown in all the studies.
• Three studies showed that physical exercise may result in no difference to quality of life in the short term.
• Nurse-led service delivery approaches probably make no difference to quality of life.
• One service delivery approach showed likely improvements to some aspects of quality of life.
Other outcomes
There was very limited evidence about the effects of these treatments on helping people learn more about epilepsy, medication use, general health, and social and psychological function. Importantly, none of the interventions caused any harm or worsened seizure control or quality of life.
What are the limitations of the evidence?
In general, we have low or very low confidence in many of the results because the studies were very different from each other. They tested different types of treatments, were carried out in different ways and places, and measured seizure frequency and quality of life differently. Many studies were small and had problems in how they were designed or reported.
Most of the evidence relates to the short-term effects of the treatments, up to six months. Evidence for longer-term effects is very limited, and we are very uncertain about this evidence. The results of this Cochrane review are complex. Lots of the results were mixed, some positive, some negative, and with different strengths of evidence.
How current is the evidence?
The evidence is current to August 2023.
อ่านบทคัดย่อฉบับเต็ม
Epilepsy is a common condition, affecting around 660 per 100,000 people worldwide. Despite treatment with anti-seizure medications, one-third of people do not achieve seizure control. There is a need to focus on models of service delivery and therapies that target cognitive, psychological, and behavioural aspects to improve seizure control and quality of life.
วัตถุประสงค์
To assess the effects of service delivery, behavioural, and self-management inventions on seizure control and health-related quality of life in adults with epilepsy.
วิธีการสืบค้น
We used the Cochrane Register of Studies, MEDLINE, and two other databases, together with reference checking and contact with study authors, to identify the studies included in the review. The latest search date was 21 August 2023.
เกณฑ์การคัดเลือก
We included randomised controlled trials (RCTs) or quasi-RCTs of any design (double/single-blinded, unblinded; parallel, cross-over, or cluster) involving participants with a mean age of 16 or older. Eligible interventions included behavioural, self-management, or service-delivery approaches. Behavioural and self-management interventions had to report seizure control as an outcome.
การรวบรวมและวิเคราะห์ข้อมูล
Our primary outcome was seizure frequency. Our secondary outcomes were: seizure severity, health-related quality of life (HRQoL), medication usage, knowledge, general health, social and psychological function, and adverse events. We classified outcomes as short-term (up to six months) or long-term (over six months). At least two review authors independently screened all papers, extracted data, assessed the risk of bias, and analysed data. We used GRADE to assess the certainty of the evidence.
ผลการวิจัย
We included 36 studies with 5834 randomised participants. Twenty-six studies included participants with a diagnosis of epilepsy, six studies included participants with severe or drug-resistant epilepsy, and four studies included participants with epilepsy and another comorbidity, including depression, psychosocial problems, or learning disabilities. We rated 16 studies as having an overall low risk of bias, 11 studies as high risk, and nine studies with an unclear risk of bias. Twenty-one studies were conducted in high-income countries, seven in upper-middle-income countries, and eight in lower-middle-income countries. We categorised interventions into psycho-behavioural, mind-body, self-management, physical exercise, nurse-led service delivery, and other service delivery interventions.
Seizure frequency
Two studies showed that psycho-behavioural interventions likely reduce seizure frequency at three to six months (mean seizure frequency reduction 4.42 per month, 95% confidence interval (CI) 6.41 per month lower to 2.43 per month lower; 64 participants; moderate-certainty evidence). However, this intervention may not improve seizure frequency immediately post-intervention.
Three studies showed that mind-body interventions may reduce seizure frequency slightly at six to eight weeks (mean seizure frequency reduction 3.28 per month, 95% CI 6.36 per month lower to 0.20 per month lower; 148 participants; low-certainty evidence). However, evidence from two studies suggests that such interventions have no effect on seizure control.
Evidence from three studies suggests that self-management interventions may not reduce seizure frequency between 20 weeks and six months (mean seizure frequency was 1.61 per month higher, 95% CI 6.08 per month lower to 9.29 per month higher; 222 participants; low-certainty evidence). However, three studies showed these interventions are likely to increase seizure freedom.
In the short term, the effect of physical exercise on seizure control is very uncertain. Evidence from one study suggests that a nurse-led service delivery intervention does not improve seizure frequency. No data were available for other service-based interventions.
The long-term data (> six months) for psycho-behavioural, self-management, and service-based interventions are limited. There are no long-term data available for mind-body, physical exercise, or nurse-led service delivery interventions.
Health-related quality of life
One study reported that psycho-behavioural interventions likely result in no difference in Quality of Life in Epilepsy Inventory (QOLIE)-10 total score at six months (mean total score was 0.89 higher, 95% CI 1.06 lower to 2.84 higher; 120 participants; moderate-certainty evidence). Overall, there is very uncertain evidence of the short- and long-term effect of psycho-behavioural interventions on HRQoL outcomes.
One study showed that mind-body interventions may result in no difference in QOLIE-31-P (31-item questionnaire with patient-weighted scoring system) total scores at six weeks (mean total score was 0.75 higher, 95% CI 5.49 lower to 6.99 higher; 60 participants; low-certainty evidence).
Two studies showed that self-management interventions probably do not improve the mean QOLIE-31 or QOLIE-31-P total scores at six months (mean scores 2.42 higher, 95% CI 2.58 lower to 7.42 higher; 393 participants; moderate-certainty evidence). However, one study showed that these interventions are likely to result in a slight improvement in QOLIE-10 total scores. Four studies showed that this intervention probably does not improve HRQoL outcomes. We are very uncertain about the effect of this intervention on long-term outcomes.
Three studies showed that physical exercise may result in no difference to HRQoL outcomes in the short term. Two studies showed that nurse-led service delivery interventions probably do not improve outcomes in the short or long term. One study showed that a service delivery-based intervention likely results in an improvement in HRQoL in the long term.
Other outcomes
Evidence for improvements in epilepsy knowledge, medication usage, general health, social and psychological function was very limited and showed no consistent differences between interventions and controls.
There were no reported adverse events related to the interventions.
ข้อสรุปของผู้วิจัย
There is no high-certainty evidence that service delivery, behavioural, and self-management interventions improve seizure control or quality of life outcomes for adults with epilepsy. There were wide variations in the size of the effect estimate, depending on how outcomes were measured. Furthermore, there was significant clinical heterogeneity amongst the populations studied, types of interventions delivered, study setting, and study design, which limit interpretation of the currently available evidence and its overall applicability. Further research is needed from well-designed studies using validated measures to assess long-term improvement in outcomes important to adults with epilepsy.
