What are the guidelines for returning to sport after a first seizure?

Guidelines for Return to Sport After First Seizure

After a first seizure, athletes should not return to sports until they have been seizure-free for at least 24 hours, have been evaluated by a healthcare professional, and have followed a stepwise return-to-play protocol taking a minimum of 5 days to complete. 1, 2

Initial Management After First Seizure

• First aid providers should activate Emergency Medical Services (EMS) for individuals experiencing a first-time seizure 3
• During a seizure, first aid providers should:
  • Help the person to the ground and place them in the recovery position 3
  • Clear the area around them to minimize risk of injury 3
  • Stay with the person throughout the seizure and recovery period 3
• Do not restrain the person or put anything in their mouth during a seizure 3

Medical Evaluation Requirements

• All athletes who experience a first seizure must be evaluated by a healthcare professional before returning to sports participation 1, 2
• The evaluation should include:
  • Assessment of seizure type and potential causes (infection, trauma, metabolic abnormalities, underlying neurological conditions) 3
  • Determination of risk factors for recurrent seizures 2, 4
  • Consideration of whether the seizure was provoked or unprovoked 4

Return-to-Sport Protocol

A stepwise approach to return to sports after a first seizure is recommended:

1. Complete rest (24+ hours): No physical activity until at least 24 hours after the seizure and the athlete is completely asymptomatic 1, 2
2. Light aerobic activity: Walking, swimming, or stationary cycling at low-to-moderate intensity 2, 4
3. Sport-specific exercise: Sport-specific drills without risk of head impact or injury 2, 4
4. Non-contact training: More complex drills, may begin light resistance training 2, 4
5. Full practice: After medical clearance, participate in normal training 2, 4
6. Return to competition: Normal game participation 2, 4

• Each stage should last a minimum of 24 hours 2, 4
• If any symptoms return during any stage, the athlete should stop activity immediately and return to the previous stage after being symptom-free for 24 hours 2, 4

Sport-Specific Considerations

The International League Against Epilepsy (ILAE) Task Force on Sports and Epilepsy categorizes sports into three risk groups:

1. Low-risk sports (generally safe): Most team sports, track and field, swimming with supervision 4
2. Moderate-risk sports (caution needed): Cycling, skiing, contact sports like football or soccer 4
3. High-risk sports (not recommended after first seizure): Scuba diving, free climbing, motor sports 1, 4

Special Considerations

• Water sports and swimming are considered safe if the athlete is directly supervised at all times 1, 2
• Sports involving heights (gymnastics, rock climbing, horseback riding) require additional precautions 1
• Contact sports including football, hockey, and soccer have not been shown to induce seizures, but require proper supervision 1, 2
• Physical activity may actually decrease seizure frequency in many individuals with epilepsy 2, 5

Common Pitfalls to Avoid

• Unnecessarily restricting all physical activity due to fear or misinformation 2, 6
• Allowing return to high-risk activities too soon after a first seizure 1, 4
• Failing to recognize that most people with well-controlled seizures can safely participate in most sports 2, 5
• Not providing adequate supervision for activities with moderate risk 1, 4

Follow-up Recommendations

• Regular follow-up with healthcare providers to monitor seizure status 2, 4
• Education of coaches, teammates, and family members about seizure recognition and first aid 3, 1
• Consideration of seizure triggers (sleep deprivation, stress, dehydration) that may be relevant in athletic settings 5, 4