Electroencephalography as a Clinical Tool in Early Stroke Rehabilitation

Background

Throughout my time in the UNC Doctor of Physical Therapy program, I have been exposed to many areas of clinical practice and it has been a privilege to learn about the assessment and treatments that physical therapists can provide to a wide spectrum of conditions. I appreciate the variety of clinical rotations that we are able to have and I am especially grateful for my acute care rotation at UNC Hospitals during my second year. I was able to practice my skills across all of the different floors and units, from oncology, trauma, to coronary care, but I quickly became fascinated with neurology as my favorite specialty in the hospital. With UNC being a nationally recognized stroke center, I commonly worked with patients who had suffered from strokes. Through this experience, I observed the many functional differences across patients based on their stroke type and location. As well, I was able to witness the exciting progress that patients were able to make over time, from having limited active motion to taking steps. I was amazed to see neuroplasticity and motor recovery at work in these early stages and wanted to learn more about what can be done to help this population.

Last fall, I joined Jessica Cassidy’s research project on Neuroimaging in Early Stroke Rehabilitation and it has been a remarkable journey. This longitudinal study took place at the UNC Hillsborough Hospital, following individuals with stroke admitted to the inpatient rehabilitation facility. Participants completed clinical and neuroimaging measures at admission and 3-month follow-up, then this data was analyzed to better understand the relationship between changes in the brain and motor recovery. I focused on resting-state electroencephalography (EEG) and upper extremity motor recovery. My goal for my Capstone project was to share our findings with clinicians to support stroke rehabilitation.

Statement of Need

In the United States, stroke occurs in over 795,000 individuals each year, which is a leading cause of disability. Further, a majority of stroke survivors over age 65 have reduced mobility and residual functional deficits.¹ Stroke rehabilitation is an essential component for recovery and return to daily life. After hospitalization, many stroke survivors go to acute inpatient rehabilitation facilities, where they receive intensive treatment from physical therapists, occupational therapists, and/or speech language pathologists.

Because stroke is a heterogenous condition, it can be challenging for clinicians to determine outcomes, interventions, and goals based on clinical measures alone.² While structural neuroimaging techniques are well-established, functional measures such as EEG are still being investigated for clinical use.³ However, emerging evidence is demonstrating that EEG can be clinically useful in stroke rehabilitation through identifying biomarkers that are associated with functional characteristics and outcomes.^4,5 The use of EEG has the potential to impact clinical-decision making in stroke rehabilitation by guiding recovery expectations and tailored interventions. My area of focus in the Neuroimaging in Early Stroke Rehabilitation study specifically sought to add to this growing knowledge base.

Purpose

This study aimed to determine:

1. How resting-state EEG measures change over time from inpatient admission to discharge in individuals after stroke
2. How brain activity measures compare to healthy controls
3. Whether there is a relationship between brain activity measures and behavioral measures

Of special interest was if EEG measures at inpatient admission can predict future outcomes in behavior to determine motor recovery.

The purpose of my Capstone was to disseminate my findings from this research study for healthcare workers, researchers, and students. My products are intended to demonstrate the information that EEG can provide and how these findings can be applied to clinical practice.

Products

I have created presentation slides and an abstract as my Capstone products focusing on resting-state EEG. The presentation was developed for an intended audience of clinicians to share our research findings. I presented my slides at the UNC Hillsborough Hospital to the therapy team as part of a comprehensive Research Brown Bag with other members of the Cassidy Plasticity Lab. It was nice to come full-circle and share what our research produced with the staff that allowed our study to occur. Additionally, I wrote an abstract to be submitted for the APTA Combined Sections Meeting next year. These products reflect an introduction to EEG and what it can offer to stroke rehabilitation. In this study, we found that delta coherence across the bilateral primary motor cortices is associated with motor impairment and corticospinal tract injury. Delta coherence was also found to be predictive of change in functional status from admission to discharge.

Presentation:

Snyder_CapstonePresentation

Abstract:

Snyder_CapstoneAbstract

Evaluation Component

Evaluation has been an ongoing process from when I began working on this research last fall semester. My advisor, Jessica Cassidy, has been incredibly helpful with providing me with feedback every step of the way. I also greatly appreciate the feedback and insight from my committee members, who are clinical leaders in stroke rehabilitation at Hillsborough. As part of my presentation at Hillsborough, I provided attendees with a feedback form to assess my effectiveness, which is attached below. Overall, the presentation was well-received and responses were positive.

Presentation Feedback Form:

Snyder_PresentationFeedbackForm

Self-Reflection

This was my first experience in research, but I learned so much within this past year about the ins and outs of what research entails. At the start of my research experience, I established the following objectives for myself:

• I will become familiar with EEG equipment and be able to collect EEG measurements and conduct behavioral tests with participants.
• I will gain interpersonal skills by interacting with participants through the consent process, conducting tests, and facilitating follow-ups.
• I will be involved in the data processing and interpretation of neuroimaging and clinical behavior tests.
• I will review stroke literature and neuroplasticity work to support my research learning.
• I will disseminate my research findings into a final product in the form of a presentation, abstract, and/or clinician guide.

At the conclusion of my project, I have met these goals. Last semester, I was able to get involved in multiple steps of the research process, including data collection, data processing, statistical analysis, and interpreting main findings. For data collection, I became competent with setting up the EEG system and administering the Action Research Arm Test for the clinical measure I chose to focus on. I spent extensive time in the lab processing our EEG data and preparing it for analysis. I also participated in bi-monthly Cassidy Plasticity Lab meetings where we engaged in discussion on current literature and I delivered a presentation on Brain Computer Interface research. I am excited to have been able to contribute to the growing body of evidence in stroke rehabilitation and hope that these promising findings can soon be implicated into clinical practice. I am proud of my progress and am thankful to have had this opportunity to holistically grow as a future physical therapist.

Acknowledgements

To Dr. Jessica Cassidy, PT, DPT, PhD for serving as my Capstone advisor and research mentor. Thank you for devoting so much time this past year to guiding me throughout the research process and helping me develop my project. Your support has been outstanding and you have left a tremendous impact on me as I enter my career. It has been a pleasure being a member of your research team.

To John M. Baratta, MD, MBA and Kelly Fletcher, PT, DPT, MHA, MRMC for serving as such valuable members of my Capstone Committee. I highly regard your expertise in the field of stroke rehabilitation and appreciate the time you took to review my project and provide insightful feedback on my products. 

To the Cassidy Plasticity Lab for welcoming me into the team and being so supportive. Thank you for all of your assistance and feedback as I learned the ropes of working in research. I am so grateful for the extra time you all took to listen, provide input, and go out of your way to help me complete this project. It was truly a team effort!

References from Post:

1. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation. 2022;145(8):e153-e639. doi:10.1161/CIR.0000000000001052
2. Stinear CM. Prediction of motor recovery after stroke: advances in biomarkers. Lancet Neurol. 2017;16(10):826-836. doi:10.1016/S1474-4422(17)30283-1
3. Boyd LA, Hayward KS, Ward NS, et al. Biomarkers of stroke recovery: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable. Int J Stroke. 2017;12(5):480-493. doi:10.1177/1747493017714176
4. Wu J, Srinivasan R, Quinlan EB, Solodkin A, Small SL, Cramer SC. Utility of EEG Measures Of Brain Function In Patients With Acute Stroke. J Neurophysiol. 2016;115(5):jn.00978.2015. doi:10.1152/jn.00978.2015
5. Cassidy JM, Wodeyar A, Wu J, et al. Low-Frequency Oscillations Are a Biomarker of Injury and Recovery After Stroke. Stroke. 2020;51(5):1442-1450. doi:10.1161/STROKEAHA.120.028932