When Seconds Matter: A PT’s Guide to Recognizing and Responding to Seizures

Unfortunately, seizures are common and about 1 in 10 people in the U.S. will have at least one in their lifetime. That means if you treat humans, you will eventually treat someone with a seizure history, and you may be present when one happens.

As PTs, our jobs are to:

• Recognize possible seizure events.

• Keep patients safe during and after a seizure.

• Understand the basics of seizure pathophysiology and classification so our plans of care make sense.

• Modify exercise, education, and the environment to reduce risk and support long-term function and participation.

Pathophysiology & Etiology: What’s Actually Happening

What is a seizure?

A seizure is a transient episode of abnormal, excessive, synchronous neuronal firing in the brain. This abnormal activity disrupts normal brain function and can cause changes in:

• Consciousness/awareness

• Movement (tonic stiffening, clonic jerking, automatisms)

• Sensation (tingling, visual changes, odd smells/tastes)

• Behavior, memory, and emotions

Epileptic seizures are one type of “paroxysmal spell” others include syncope, psychogenic non-epileptic events, movement disorders, and sleep phenomena. Not every “shaking spell” is epilepsy, and not every seizure equals “epileptic.”

Seizure threshold and why everyone can seize

Everyone has a seizure threshold, a continuum of susceptibility. A seizure occurs when excitation in neural networks overwhelms inhibition:

• Excitatory neurotransmitter: glutamate

• Inhibitory neurotransmitter: GABA

When there is excess excitation and/or reduced inhibition, groups of neurons can enter a state of paroxysmal depolarization, leading to synchronized discharges that we observe clinically as a seizure. The location of the abnormal activity determines the signs/symptoms (e.g., motor cortex → limb jerking; temporal lobe → déjà vu, fear, autonomic sensations).

Provoked vs unprovoked seizures

This distinction matters for prognosis and for how we document and communicate:

• Provoked (acute symptomatic) seizures
  Occur in close temporal relationship to an acute insult or metabolic issue. Examples:

  • Electrolyte abnormalities (hypo/hypernatremia, hypoglycemia, hypocalcemia)

  • Alcohol or benzodiazepine withdrawal

  • CNS infections (meningitis, encephalitis)

  • Stroke (ischemic or hemorrhagic)

  • Traumatic brain injury

  • Brain tumor or mass lesion

  • High fever (especially in kids – febrile seizures)

• Unprovoked seizures
  Occur without an acute precipitating event, or more than ~7 days after the acute injury (e.g., chronic post-stroke epilepsy). Recurrent unprovoked seizures suggest an underlying epileptic disorder.

Status epilepticus (SE): the true emergency

Status epilepticus is an ongoing epileptic condition that doesn’t stop on its own:

• Clinically:

  • A single generalized convulsion lasting >5 minutes or

  • Recurrent seizures without full return of consciousness between them

• Consequences:

  • Systemic: lactic acidosis, hyperthermia, respiratory compromise

  • Neurologic: ongoing electrical activity → neuronal injury and long-term deficits

As PTs, any seizure lasting >5 minutes = medical emergency → call EMS. You are not treating this in the clinic; you are recognizing it and activating the system.

Seizure Types: What Should We Be Watching For?

Clinically, we care most about:

• Where the seizure starts (focal vs generalized)

• Awareness (intact vs impaired)

• Motor vs non-motor features

• Safety risks (falls, head strike, aspiration)

Focal seizures (start in one area/one hemisphere)

Focal = localized onset. They can stay focal or spread to involve both hemispheres (“focal to bilateral tonic-clonic”).

a) Focal seizures with impaired awareness

• Patient appears “awake” but:

  • Stares into space

  • Doesn’t respond appropriately to commands

  • May perform automatisms (lip smacking, hand rubbing, picking at clothes, repeated words, wandering)

• Often followed by amnesia for the event

• From a PT perspective, you might see:

  • A patient suddenly stop participating in an exercise, staring, then doing repetitive movements

  • Unresponsiveness to verbal cues despite normal vitals and environment

b) Focal seizures without impaired awareness

• Awareness intact; patient can sometimes later describe the episode

• Possible symptoms:

  • Sudden emotional shifts: fear, joy, sadness without clear trigger

  • Sensory changes: tingling, flashes of light, smells/tastes, déjà vu

  • Autonomic symptoms: rising epigastric sensation, hot/cold, nausea

  • Motor signs: jerking or stiffening in a single limb or region

• These can be “auras” in people with epilepsy, often warning signs that a larger seizure may follow.

Generalized seizures (involve both hemispheres from onset)

a) Absence seizures (often in children)

• Brief stare, “spacing out”

• May have eye blinking or subtle automatisms

• Last 5–10 seconds; can occur many times per day

• PT red flag: child “checking out” repeatedly mid-task, unresponsive to name, then instantly resumes activity with no confusion.

b) Tonic seizures

• Sudden stiffening of muscles (back, arms, legs)

• Frequently causes falls if standing

c) Atonic seizures (“drop attacks”)

• Sudden loss of muscle tone, often in legs → collapse

• High fall and head injury risk; helmets sometimes used.

d) Clonic seizures

• Rhythmic jerking movements, often in face, arms, or neck

e) Myoclonic seizures

• Sudden brief jerks or twitches (often arms/shoulders)

• Awareness typically preserved

f) Tonic-clonic seizures (“grand mal”)

• Most recognizable pattern:

  1. Tonic phase: body stiffens, often a cry, patient falls

  2. Clonic phase: rhythmic jerking of limbs

  3. Possible tongue biting, urinary incontinence

  4. Followed by postictal period: confusion, fatigue, headache, agitation

• This is the classic scenario where PTs need strong first-aid skills (more on that below).

Seizure Phases: What You Might See Before & After

Understanding phases helps with both recognition and documentation.

1. Prodrome (hours to days before)

   • Vague changes: irritability, mood changes, sleep disruption, “something feels off”

   • May or may not be present

2. Aura (technically a focal aware seizure)

   • Déjà vu or jamais vu

   • Strange smell/taste, rising stomach sensation

   • Sudden fear, panic, or “weird feeling”

   • Visual changes, tingling, dizziness

3. Ictal phase (actual seizure)

   • From the first clear symptom to the end of the seizure

   • Presentation depends on seizure type (staring, automatisms, jerking, stiffening, collapse, etc.)

4. Postictal phase (recovery)

   • Minutes to hours

   • Patients may have:

     • Confusion, slowed responses

     • Headache, fatigue, nausea

     • Focal weakness (e.g., Todd’s paralysis)

     • Emotional changes: anxiety, fear, sadness, frustration (Patients may even become combative)

As PTs we should protect, observe, and document each of these phases when possible.

Epilepsy: What It Is and How It’s Defined

Seizure vs epilepsy

• Seizure: a single event (provoked or unprovoked) caused by abnormal excessive neuronal activity.

• Epilepsy: a chronic brain disease characterized by an enduring tendency to have recurrent unprovoked seizures and by the neurobiologic, cognitive, psychological, and social consequences of that condition.

Traditionally, epilepsy diagnosis required:

• ≥2 unprovoked seizures >24 hours apart.

The revised ILAE definition also includes:

• 1 unprovoked seizure plus a ≥60% risk of another (e.g., characteristic EEG, structural lesion known to be epileptogenic, or defined epilepsy syndrome).

Epilepsy may be considered “resolved” after:

• 10 years seizure-free, with the last 5 years off antiseizure medications (for many syndromes).

What To Do If Your Patient Has a Seizure

Think: PROTECT – OBSERVE – ACT – RECOVER – DOCUMENT

General seizure first aid (for most settings)

During the seizure:

1. Stay calm and stay with the person.
   Your calm behavior helps everyone else stay safer.

2. Keep the area safe.

   • Move equipment, sharp objects, and furniture out of the way.

   • In the gym, that may mean clearing dumbbells, bands, walkers, and chairs.

3. Protect their head and airway.

   • If they are falling or lose tone, gently ease them to the ground.

   • Turn them onto their side with mouth pointing toward the floor if possible (recovery position → helps keep airway clear and reduces aspiration risk).

   • Put something soft under their head (jacket, towel).

4. Loosen anything around the neck (ties, collars) and remove glasses.

5. Time the seizure.

   • Look at a clock or timer on your watch/phone.

   • Document: start time, duration, and characteristics.

6. Do not:

   • Do not hold them down or try to stop movements.

   • Do not put anything in their mouth (they will not “swallow their tongue”; objects can fracture teeth or obstruct the airway).

   • Do not give water, food, or pills during or immediately after the event.

   • Do not give rescue breathing during the convulsive phase; most people start breathing on their own once it stops.

After the seizure:

7. Keep them on their side until breathing is normal and they’re more alert.

8. Re-orient and reassure.

   • Explain who you are, where they are, and what happened.

   • Expect confusion, fear, emotional lability, fatigue.

9. Check for injuries.

   • Head strike, tongue biting, shoulder dislocation, fractures from falls.

10. Offer help contacting a family member or friend if they are alone.

Exercise & PT: What is Generally Safe?

Most people with epilepsy benefit from exercise, including improved mood, sleep, and cardiovascular health. As a baseline:

• Choose lower-risk environments if seizures are poorly controlled:

  • Avoid unsupervised swimming or heights.

  • Be cautious with treadmills, free weights overhead, and cycling outdoors until you understand seizure control and triggers.

• Start with gradual intensity increases and monitor:

  • Dizziness, visual changes, déjà vu, rising stomach sensations, or “strange” feelings that may be auras.

• Teach self-monitoring and early stopping if prodromal signs appear.

• For patients with frequent or poorly controlled seizures:

  • Use spotters, gait belts, and safety harnesses when appropriate.

  • Practice fall recovery and safe positioning as part of their program.

Psychosocial & safety education

• Address fear of movement or activity avoidance; many patients self-restrict more than needed.

• Review environmental safety at home and in the community:

  • Showers vs baths, avoiding locking bathroom doors, cooking safety, helmets when appropriate.

• Encourage patients to:

  • Follow local driving regulations related to seizures.

  • Seek mental health support for depression/anxiety.

Parting Words

• Not all “spells” are epilepsy, but seizures are common enough that you must recognize and respond appropriately.

• Pathophysiology matters: seizures occur when excitation overwhelms inhibition in networks of neurons; threshold can be lowered by illness, sleep loss, substances, or structural brain disease.

• Classify what you see in simple terms:

  • Focal vs generalized

  • Awareness intact vs impaired

  • Motor vs non-motor

• Status epilepticus (>5 minutes or repeated without recovery) is a medical emergency → call EMS.

• In the event of a seizure: protect, don’t restrain; clear the area, time the event, roll to the side, call for help if criteria are met.

• As a PT, you play a major role in:

  • Risk reduction (sleep, stress, triggers, safe exercise)

  • Safety in the clinic and at home

  • Education and advocacy for patients living with seizure disorders.

References

1. Lovik K, Murr NI. Seizure. [Updated 2023 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430765/

2. Sarmast ST, Abdullahi AM, Jahan N. Current Classification of Seizures and Epilepsies: Scope, Limitations and Recommendations for Future Action. Cureus. 2020;12(9):e10549. Published 2020 Sep 20. doi:10.7759/cureus.10549

3. Centers for Disease Control and Prevention. First Aid for Seizures. 2024 May 15. Available at: https://www.cdc.gov/epilepsy/first-aid-for-seizures/index.html. Accessed November 23, 2025.

4. Mayo Clinic Staff. Seizure: Symptoms and Causes. Mayo Clinic. Updated 2024. Available at: https://www.mayoclinic.org/diseases-conditions/seizure/symptoms-causes/syc-20365711. Accessed November 23, 2025.

Disclaimer

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.