Epilepsia, 38(4):439-444, 1997
Lippincott-Raven Publishers, Philadelphia
0 International League Against Epilepsy
Patients’ Experiences of Injury as a Result of Epilepsy
Deborah Buck, *Gus A. Baker, Ann Jacoby, *David F. Smith, and *David W. Chadwick
Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne; and *Department of
Neurosciences, Walton Hospital, Liverpool, U.K .
Summary: Purpose: The increased risk of mortality among
people with epilepsy is well documented; people with epilepsy
are more likely than the general population to die as a result of
an accident. Data about incidence of nonfatal accidents and
associated factors are not so readily available, even though such
accidents are more common than fatal injuries. We report the
proportion of people who sustain various injuries during a sei-
zure and the key variables predicting injury.
Methods: Questionnaires were mailed to an unselected, com-
munity-based population of patients with epilepsy. The ques-
tionnaire included clinical and demographic details, previously
validated scales of psychosocial well-being, and questions
about seizure-related injuries.
Results: Of patients who had had at least one seizure during
the previous year, 24%sustained at least one head injury, 16%
People with epilepsy have an increased risk of mor-
tality as compared with the general population, and ac-
cidents and trauma appear to be a more common cause of
death in people with epilepsy than in the population as a
whole (1). Investigators have studied drowning during
seizures in particular, and people with seizures are sig-
nificantly more likely to die as a result of drowning than
are those without seizures (1,2). Relatively little has been
reported in the literature to date about the incidence and
nature of nonfatal seizure-related injuries, but one recent
survey (3) offers some information on the level of sei-
zure-related injury in a general population: Of 146,365
visits to four emergency departments, 0.4% were pre-
cipitated by seizures and 14% of these seizures resulted
in injury. In all, seizure-related injuries were sustained
by 63 patients, and some of the patients incurred multiple
injuries as a result of their seizures. Head contusions and
lacerations were the most common injuries sustained;
most injuries were minor, requiring little or no treatment.
That study and others showed that head injuries and
bums tend to be the most common types of seizure-
Accepted November 13, 1996.
Address correspondence and reprint requests to Ms. D. Buck at
Centre for Health Services Research, 21 Claremont Pl., University of
Newcastle upon Tyne, Newcastle upon Tyne NE2 4AA, U.K.
439
sustained a burn or scald, 10% a dental injury, and 6% some
other fracture. Seizure type, seizure severity, and seizure fre-
quency were key predictors of having sustained at least one of
these four seizure-related injuries. Key predictors of budscald
were seizure severity, seizure frequency and sex; those of head
injury were seizure severity and type; that of dental injury was
seizure severity; and those of some other fracture were seizure
severity, duration of epilepsy, and three or more drug-related
adverse effects.
Conclusions: These data help identify significant risk factors
associated with seizure-related injuries and so facilitate sen-
sible patient counseling about how the risks of such injuries can
be minimized. Key Words: Epilepsy-Accidents-Head in-
jury-Dental injury-Burns.
related injury (4,5). Factors associated with the likeli-
hood of sustaining an injury because of a seizure include
seizure type, seizure frequency, number of seizures dur-
ing lifetime, and patients’ sex (6-8).
We attempt to add to the limited evidence currently
available by reporting the incidence of bumdscalds, head
injuries, dental injuries or other fractures as a conse-
quence of having a seizure and on the relation between
this and several clinical and sociodemographic charac-
teristics. Given the findings of recent research, we con-
centrate on the following issues: the relation or relations,
if any, between seizure type, sex, and other variables,
particularly seizure severity, and the likelihood of sus-
taining an injury during a seizure.
METHODS
Study design
Subjects were eligible for the study if they had active
epilepsy [defined as having a history of seizures in the
past 2 years or being seizure-free but currently receiving
antiepileptic drug (AED) treatment]. Subjects were iden-
tified in one U.K. health region from the records of 31
general practices (primary physician practices), and se-
lection was stratified by health districts and practice size.
The study design and methods were described in detail
440 D. BUCK ET AL.

previously by Jacoby et al. (9). The total practice popu- APPENDIX 1

lation was 177,703 among the 31 practices, with 1,341 Questions Asked About Drug-Related Adverse Effects
people (0.8%) identified as having active epilepsy, of Have you had any problems or side effects which you think may
whom 151 were children aged <16 years and 159 were have been caused by the drugs you take for your epilepsy? If
yes:
adults who were severely learning disabled or physically During the last month, have you had any of the problems or side
disabled. For these 1,341 patients, clinical information effects listed below?
about their epilepsy was abstracted from the medical
records held by the general practices. Information was Unsteadiness
Tiredness
collected on the first and most recent seizure, etiology of Restlessness
epilepsy, classification of seizure types, and the presence Feelings of aggression
of any health problems other than epilepsy (mental or Nervousness and/or agitation
Headache
neurological handicap, psychiatric disorder, and other Hair loss
chronic medical disorder). Problems with skin. e.g., acne, rash
Questionnaires inquiring about their quality of life Double or blurred vision
Upset stomach
(QOL) and the quality of services they received in re- Difficulty in concentrating
spect of their epilepsy were mailed to eligible adult pa- Trouble with mouth or gums
tients. Questionnaires were not sent to the 158 adults Shaky hands
Weight gain
with learning disabilities on the grounds that such pa- Dizziness
tients would have had difficulty in completing them and I Sleepiness
that the value of proxy information about QOL issues is Depression
Memory problems
questionable (10); we were requested by the consulting Disturbed sleep
doctor not to approach 1 severely physically disabled
patient; and 56 adult patients who, although they were
eligible, proved untraceable because the medical records
were out of date. Parents of children with epilepsy were
sent a parallel QOL questionnaire, but this did not in-
clude questions about seizure-related injuries. In all, 975 APPENDIX 2
adults received a questionnaire, of whom 696 returned it Questions Asked About Seizure-Related Injuries
(71% response rate). There was no difference between In the last 12 months, have you suffered any of the following
the responders and nonresponders for current seizure ac- injuries as a result of having a seizure?
tivity, but those who did not respond were more likely to a) A burn or a scald?
have a shorter duration of epilepsy and a younger age of
onset. There was no difference between the responders If yes, did this require:
a simple dressing
and those deemed ineligible in relation to seizure _activ- admission to hospital
ity, but those in the ineligible group were more likely to skin grafting
have multiple seizure types and reported significantly b) A head injury?
higher rates of additional health problems. Information
on the clinical and demographic characteristics of re- If yes, did this result in:
stitches to scalp wound
sponders, nonresponders, and those considered ineligible overnight observation in hospital
was published previously (9). a skull fracture
The questionnaire was designed to obtain information an operation to remove blood clot from head
on patients’ psychosocial functioning, the history and c) A dental injury?
clinical nature of their epilepsy, and their medical care,
If yes, did this result in:
including AED therapy and presence of any associated loss of teeth
adverse effects, which was measured with a validated, a fractured jaw
patient-based adverse drug event profile (11). For this admission to hospital
major dental surgery
profile, patients were asked whether they had experi-
enced any of 19 drug-related adverse effects always or d) Any other fracture?
often, sometimes, rarely, or never in the last 4 weeks If yes, which bone?
(Appendix 1). Patients were also asked whether they had,
in the last 12 months, sustained any burns or scalds, head e) In the last year, have you had a seizure while bathing or
swimming?
injuries, dental injuries, or other fractures as a result of a
seizure and also whether they had had any seizures while If yes, did this happen:
bathing or swimming (Appendix 2). at home
elsewhere
Major clinical factors in which we were interested

Epilepsia, Vol. 38, No. 4, 1997

 EPILEPSY-RELATED INJURIES
TABLE 1. No. of patients experiencing injuries and the
severitv of injuries
Type and nature of injury No. of patients
Head injury (n = 297)”
Stitches to scalp wound
Overnight observation in hospital
Skull fracture
Operation to remove blood clot from head
Burnlscald (n = 302)“
Simple dressing
Admission to hospital
Skin grafting
Dental injury (n = 290)”
Loss of teeth
Fractured jaw
Admission to hospital
Major dental surgery
Other fracture (n = 278)”
Seizure while bathinghwimming (n = 313)”
At home
Elsewhere
a Number of patients responding to a particular question
included seizure type, seizure frequency (none in the past
year, less than one a month, one or more a month), du-
ration of epilepsy, and patient-perceivedseizure severity,
as measured by a previously validated scale (12). This
scale comprises two subscales: The first is concerned
with patients’ perception of control (“percept”)* which
is principally determined by the predictability of sei-
zures, and the second deals with the events occurring
during and immediately after seizures (“ictal”).*
Data were analyzed with the SPSSx statistical package
for social sciences (13). Tests of significance were made
by the chi square and t tests. Because excessive use of
hypothesis testing has been criticized and confidence in-
tervals (CI) are now considered often more informative
than p-values (14), difference in proportions and 95% CI
are also reported. Key predictors of seizure-relatedinjury
were identified by stepwise logistic regression [odds ra-
tios (OR) and 95% CI are also reported].
RESULTS
Our results relate only to patients who had had at least
one seizure in the previous 12 months (n = 344). Sixty-
five percent of patients reported no injuries, 22% re-
ported one, 9% reported two, 3% reported three, and 1%
reported four. Patients’ experience and the nature of in-
juries are shown in Table 1 together with the incidence of
incurred seizures, while bathing or swimming.
We examined factors associated with the occurrence
of such injuries, using both univariate and multivariate
* Examples of items in the percept subscale are: “How often have
you had an aura or warning with your attacks?” and “When you have
had attacks, how often have they occurred together in clusters, with
quite long periods between each cluster?” Examples of items in the
Ltal subscale are: “When you had your attacks, how often did you fall
-
to the ground?” and “When YOU recovered from vour attacks. how
confused did you feel?”
441
analysis. Univariate analysis showed that patients with
tonic-clonic seizures, at least one seizure a month, at
least three drug-related adverse effects, and those who
70 were female were more likely to experience a burn or
15 scald (Table 2). The only factor significantly associated
23 with an increased likelihood of incurring a head injury,
2
1 including a fracture to the head, or some other fracture
48 was having at least three drug-related adverse effects
42 (Table 2). Having tonic-clonic seizures or the combina-
4
1 tion of tonic-clonic and other seizures and at least three
28 drug-related adverse effects significantly increased the
22 chances of sustaining dental trauma (Table 2 ) . Tonic-
2
1 clonic seizures, the occurrence of at least one seizure a
6 month, and at least three drug-related adverse effects
16 were the factors related to the likelihood of having at
44
38 least one of these four types of injury (Table 2). In ad-
4 dition, patients having at least one seizure a month and
those reporting at least three drug-related adverse effects
were significantly more likely than the rest to experience
a seizure while bathing or swimming (Table 2).
Mean scores on the seizure severity scale were higher
for those reporting burndscalds [for the ictal subscale,
+5.7 (95% CI 3.4-8.0); for the percept subscale, +1.9
(95% CI 0.7,3.1)], for those reporting a head injury [ictal
+5.3 (3.3,7.3), percept +1.7 (0.6,2.8)], for those reporting
a dental injury [ictal +7.5 (4.6,10.4), percept +0.9
(-0.7,2.5)], and for those reporting some other fracture
[ictal+5.8 (2.0,9.6), percept +4.0 (2.0,6.0)] than for those
not reporting such injuries. Mean scores on the seizure
severity scale were also higher on the ictal though not on
the percept subscale for those reporting seizures while
bathing/swimming than for the rest [+2.4 (-0.05,4.9) and
+0.5 (-0.8,1.8)] respectively.
Multivariate analyses (stepwise logistic regression)
were used to identify independently significant predic-
tors of a particular type of injury and of sustaining any
injury. The following explanatory variables were tested
for inclusion in the models: whether receiving mono-
therapy or polytherapy, the presence or absence of drug-
related adverse effects, the number of adverse effects,
seizure type, seizure frequency, seizure severity, duration
of epilepsy, sex, and age. Table 3 shows the key predic-
tive variables, together with the OR and CI. Seizure se-
verity, type, and frequency were the best predictors of all
types of injury; seizure frequency and number of drug-
related adverse effects were the best predictors of attacks
occurring while bathing or swimming. Table 4 summa-
rizes the findings of the univariate and multivariate
analyses and highlights
- - the variables that were signifi-
cantly associated with seizure-related injury across one
Or both types Of
DISCUSSION
In considering the results of our study, its limitations
must be recognized. There were no control data, the
Epilepsia, Vol. 38, No. 4, 1997
442 D. BUCK ET AL.

TABLE 2. Factors related to likelihood of sustaininn iniuries

Type of injury"
Seizure while
Other Dental At least one of bathing or
Burdscald Head injury fracture injury the four types swimming
Factor (n = 292) (n = 289) (n = 271) (n = 280) (n = 309) (n = 304)
Seizure type (i)
GTCS (%) 27 28 3 10 41 8
GTCS + other (%) 19 28 9 14 40 17
Other only (a) 10 20 4 5 27 14
Chi-square, p-value 7.27, <0.05 2.29, = 0.3 2.52, = 0.3 6.48, <0.05 6.23, <0.05 2.21, = 0.3
dpb(95% CI) 13 (5 to 21) 8 (-2 to 18) 2 (-3 to 7) 7 (1 to 13) 14 (4 to 24) 2 (-6 to 10)
Seizure type (ii)'
Single (%) 14 22 4 6 26 12
Combination (%) 19 28 9 14 43 17
Chi-square, p-value 1.13, = 0.3 1.37, = 0.2 2.49, = 0.1 5.74, <0.05 3.54, = 0.06 1.23, = 0.3
dp (95% CI) 5 (-4 to 14) 6 (-4 to 16) 5 (-1 to 11) 8 (1 to 15) 10 (-1 to 21) 5 (-3 to 13)
Seizure frequency
<1 a month (%) 9 21 4 6 26 7
At least 1 a month (%) 24 27 7 13 43 21
Chi-square p-value, 12.7, <0.001 1.46, = 0.2 0.97, = 0.3 3.8, = 0.6 9.39, <0.01 12.65, <0.001
dp (95% CI) 15 (7 to 23) 6 (-4 to 16) 3 (-2 to 8) 7 (0 to 14) 17 (7 to 27) 14 (6 to 22)
No. of adverse effects
None (%) 10 18 4 6 28 10
1 to 2 (%) 9 23 2 7 29 10
2 3 (%) 28 32 11 17 41 23
Chi-square, p-value 18.1, <0.001 6.3, <0.05 6.97, <0.05 8.25, c0.05 11.52, c0.01 10.13, <0.01
dpd (95% CI) 18 (8 to 28) 11 (-1 to 23) 8 (2 to 14) 11 (3 to 25) 19 (7 to 31) 13 (-5 to 31)
Sex
F (%) 22 25 7 11 37 18
M (%I 11 23 5 9 32 11
Chi-square, p-value 6.68, c0.01 0.15, = 0.7 0.50, = 0.5 0.37, = 0.5 1.15, = 0.3 3.11, = 0.08
dp (95% CI) 11 (3 to 19) 2 (-8 to 12) 2 (-4 to 8) 2 (-5 to 9) 5 (-5 to 15) 7 (0 to 14)

" Figures in parentheses are the lowest base number on which percentages are calculated; they exclude small numbers of patients who did not
respond to particular questions.
Difference in proportions (dp) with 95% confidence intervals (CI) between patients experiencing tonic-clonic seizures only or in combination with
other types of seizures and those experiencing other types only.
The two categories in this computed variable indicate whether patients had just one type of attack or at least two different types.
Difference in proportions between those reporting three or more drug-related adverse effects and the rest.

study was retrospective in design, and information about
seizure type was gathered from patients themselves (by
questionnaire) rather than from their doctors: we can not
be entirely certain about the observed relations between
injuries and the factors that appear to contribute to them.
Despite these limitations, our findings contribute to the
sparse body of literature on nonfatal seizure-related in-
juries. Furthermore, the study is unique in that the
sample was large, community-based, and thus unselected
(with the exception of people with a severe disability)
and represents people with epilepsy of varying severity.
Although much evidence shows that risk of mortality,
including sudden unexpected death, is increased among
people with epilepsy (15-20), few data about seizure-
related injuries are available even though such injuries
are far more common than fatal accidents. In the present
study, injuries sustained during seizures were reported by
one third of patients who had had at least one seizure in
the previous year. In this group, almost one quarter of
patients sustained a head injury, with approximately one
third being admitted to the hospital for overnight obser-
vation as a consequence. This number is higher than that
in the study of Kirby and Sadler (3), who in their unique
general population survey reported that 11% of 560 sei-
zures experienced by 63 people resulted in head injury.
Theirs was a prospective survey in which the data were
obtained from four adult emergency room records. If we
consider only the proportion of our study patients whose
head injuries were severe enough to warrant admission to
hospital (8%of all those who answered the question), our
findings more closely resemble those of Kirby and
Sadler (3).
Our finding that seizure type was a key predictor of
sustaining a head injury supports earlier research such as
that of Nakken and Lossius (6), who reported that atonic
and tonic-clonic seizures were the types most commonly
resulting in some sort of injury. In the present study,
seizure severity was also a key predictor of sustaining an
injury to the head (and of experiencing at least one type
of injury).
Burns and scalds were the next most commonly re-
ported injury. Together with severity and frequency of
seizures, sex was a key predictor of having had a burn or
scald, with women being twice as likely as men to have

Epilepsia, Vol. 38, NO. 4, 1997

 EPILEPSY-RELATED INJURIES 443

TABLE 3. Stepwise logistic regression: general population, possibly because those with epilepsy
Factors predictinE injury are more conscious of or less exposed to possible dan-
95% Confidence gers (22). Nevertheless, we noted that a sizable propor-
Injury/factor Odds ratioa intervalsb tion of people with active epilepsy sustained injuries as a
Burn/scald direct consequence of seizures and were experiencing
Seizure severity (ictal) 1.3 1.1-1.4 seizures while bathing or swimming. Although we did
At least one seizure a month 3.3 1.410.0
Sex (F) 2.2 1.1-4.6 not obtain details about the circumstances in which these
Head injury events occurred, we must recognize that many seizure-
Seizure severity (ictal) 1.3 1.2-1.4 related injuries, particularly bums and scalds, can be
Type of seizure (other only) 2.5 1.2-5.3
Dental injury avoided. Hampton et al. (4) report that many patients are
Seizure severity (ictal) 1.4 I .2-1.7 unaware of the risks of incurring seizure-related bums; in
Other fracture their study, they noted that only 5% of patients had been
Seizure severity (percept) 2.3 1.4-3.8
Duration of epilepsy 1.1 1.1-1.2 warned against this danger and call for a greater recog-
No. of adverse effects (3+) 4.1 1.2-14.3 nition by the medical profession of the link between
Any injury bums and seizures. Suggested preventative strategies in-
Seizure severity (ictal) 1.4 1.3-1.6
Seizure type (other only) 2.7 1.3-5.5 clude keeping to a minimum the use of electric irons and
At least one seizure per month 2.0 1.3-3.3 hand-held hair dryers; use of microwave ovens rather
Seizure while bathingkwimming than stovetop cookers, and installing thermostats to con-
At least one seizure a month 3.3 1.410.0
No. of adverse effects (3+) 2.0 1.141 trol water temperature in showers (8). Attention should
also be drawn to the potential dangers of bathing and
The subscales ictal and percept are described in the Methods section.
a Odd ratios >1 indicate that subjects with a given characteristic are
more likely to experience an injury.
TABLE 4. Summary of variables significantly associated
When 95% confidence intervals exclude 1, there was a statistically
significant association (p < 0.05) by a conventional chi-square test. with seiiure-related iniurv
Injury/associated variable UnivariateO Multivariateb

experienced such an injury. According to Spitz et al. (8) Burn/scald

Seizure type (tonic-clonic only or
many bums occur while people are involved in daily in combination)
living or self-care activities, which are more likely to be At least one seizure a month +
performed by women: This may explain why women Three or more adverse effects
sustain a bum more often than men. Spitz et al. specifi- Female sex +
Seizure severity (ictal) +
cally investigated seizure-related bums (8) and reported Seizure severity (percept)
that cooking on a stove was the most influential factor, Head injury (including fractures)
Three or more adverse effects
followed by showering, and the major risk factor for Seizure severity (ictal) +
bums was total number of seizures during adult life. In Seizure severity (percept)
our study, we did not collect parallel information about Type of seizure (other only) +
Other fractures
total number of seizures, but we did note that current Three or more adverse effects + +
seizure frequency (i.,e.,in the past year) was significantly Seizure severity (ictal) +
related to whether or not patients had sustained a burn or Seizure severity (percept) + +
scald. Duration of epilepsy +
Dental trauma
Our finding that seizure severity is an influential factor Seizure type (tonic-clonic only,
in the likelihood of having had an injury is not surpris- or in combination) +
ing: One of the 12 questions in the ictal subscale asks Three or more adverse effects +
Seizure severity (ictal) + +
how often people find they have injured themselves At least one of the four types of injury
(other than biting their tongues) after a seizure. The like- Seizure type (tonic-clonic only,
lihood of having some other fracture was also predicted or in combination) +
Type of seizure (other only) +
by duration of epilepsy and number of drug-related ad- Three or more adverse effects +
verse effects. Seizure severity and number of drug- Seizure severity (ictal) + +
related adverse effects are likely to be interdependent, Seizure seventy (percept) +
At least one seizure a month + +
since patients with more severe epilepsy often are treated Seizure while bathing or swimming
with higher doses and a greater number of drugs. As At least one seizure a month + +
Pedersen (21) notes, adverse effects of drugs can affect Three or more adverse effects + +
physical and mental alertness; therefore, even patients The ictal and percept subscales are described in the Methods section.
without seizures may be at increased risk of accidents. a Plus sign indicates significant relation following univariate analysis
(chi-square or t tests of significance).
It has been argued that people with epilepsy are actu- Plus sign indicates significant relation following multivariate
ally less likely to have an accident than are those in the analysis (stepwise logistic regression).

Epilepsia, Vol. 38, No.4, 1997

444 D.BUCK ET AL.
swimming unsupervised. In addition to such common-
sense precautions, patients should be offered individual-
ized counseling based on hard information when such
information is available.
Our findings lend support to previous research and
contribute to our limited knowledge of seizure-related
injuries. However, the need remains for a controlled
study to investigate incidence and type of injuries among
people with epilepsy as compared with a normal popu-
lation: In a recent study of driving accident rates among
people who have seizures (23), researchers concluded
that such persons were no more likely than the general
population to incur them. A prospective study may elicit
more valid and reliable data than a retrospective study,
which is inevitably subject to problems or recall error;
such a study is ongoing in nine European countries, and
the results will be available next year (24). Finally, more
detailed information about the precise causes of acci-
dents would ensure that better-focused advice is offered
to patients, so that the risk of accidents in this group can
be minimized.
Acknowledgment: W e thank the Wellcome Trust for help
and financial support, the patients who spared us their time to
participate, and Pauline Potts of the Centre for Health Services
Research for assistance with data analysis.
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