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Case Example 1: Mrs A

Mrs A (78 y) came into hospital on Friday afternoon with what she described as some weakness and clumsiness of her right hand.

The physiotherapist saw her on Monday (day 3). PREP was started by obtaining a SAFE score. Mrs A scored 4/5 for each of shoulder abduction and finger extension (movement through full range against gravity, but is weaker than normal). A SAFE score of 8/10 was documented.

Mrs A was prescribed a home exercise programme and discharged later that day. She spent about 40 minutes doing practice with the right hand each day for nearly three weeks.

At 12 weeks after stroke, Mrs A was using her right arm ‘as normal’ for nearly all tasks. This was reflected in assessments of her right arm function (Action Research Arm Test score 56/57) and impairment level (Fugl-Meyer Upper Limb Scale score 61/66). At 6 months, she reported that she used her right arm for nearly all the activities that she used to use it for, and the quality of use was nearly the same as before the stroke (Motor Activity Log score 94%). Mrs A reached her potential for a ‘complete’ recovery.


Case Example 2: Mr B

Mr B (62 y) was admitted to the hospital with a stroke. He couldn’t move his left arm and hand.

PREP was started. On day 1 he had a SAFE score of 0/10 (no movement in shoulder abduction or finger extension). On day 2 his SAFE score was 2/10 (he had a flicker of activity in both shoulder abduction and finger extension, giving him scores of 1/5 for each). On day 3 he had a SAFE score of 5/10, as he had full movement against gravity but not resistance in shoulder abduction (3/5) and some movement with gravity eliminated in finger extension (2/5).

Mr B and his rehabilitation team were given verbal and written information that Mr B had the potential to be using his arm and hand in most day to day activities within 12 weeks. Although there was some weakness, motor pathways to the arm and hand were functionally intact.

To reach his potential, arm and hand rehabilitation should focus on improving function by increasing strength, coordination and fine control. Mr B should use his affected arm and hand for safe daily activities and try to minimise compensation with the stronger arm and hand. Repetitive practice of movement and everyday tasks should help.

Mr B spent three weeks on the rehabilitation ward at the hospital.

At 12 weeks after the stroke Mr B was using his left arm for many day to day activities. This was reflected in assessments of his left arm function (Action Research Arm Test score 47/57) and impairment level (Fugl-Meyer Upper Limb Scale score 57/66). At 6 months, he reported that he used his left arm for about half the activities he was using it for before the stroke, and its use was more slow and effortful than before the stroke (Motor Activity Log score 71%). Mr B reached his potential for a ‘notable’ recovery.


Case Example 3: Mr C

Mr C (81 y) was admitted to the hospital with a stroke that produced weakness of the right arm and hand.


PREP was started. On day 3 after stroke, the physiotherapist scored his shoulder abduction and finger extension movements as 0 and 2, and calculated a SAFE score of 2/10. In other words, Mr C had no movement at his shoulder and a small amount of extension in his fingers (but not full range without gravity).

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Mr C went on to have TMS on day 6 after stroke. Responses were able to be measured in the muscles of the affected arm (presence of motor evoked potentials, i.e. MEP+). These responses indicated that the stroke-affected side of the brain was able to send a message via motor pathways to the stroke-affected arm. This is good news, since the presence of these responses is usually related to a better recovery.



Mr C and his rehabilitation team were given verbal and written information that Mr C had the potential to be using his arm and hand in most day to day activities within 12 weeks.

To reach his potential, arm and hand rehabilitation should focus on improving function by increasing strength, coordination and fine control. Mr C should use his affected arm and hand for safe daily activities and try to minimise compensation with the stronger arm and hand. Repetitive practice of movement and everyday tasks should help.

Mr C spent six weeks on the rehabilitation ward at the hospital.

At 12 weeks after the stroke Mr C was using his right arm (dominant) for quite a few tasks. This was reflected in assessments of his right arm function (Action Research Arm Test score 37/57) and impairment level (Fugl-Meyer Upper Limb Scale score 44/66).

At 6 months, he reported that he used his right arm for many daily activities, but overall it was slightly slower or more effortful than before the stroke (Motor Activity Log score 67%). Mr C reached his potential for a ‘notable’ recovery.


Case Example 4: Mr D

Mr D (74 y) came to the hospital after a stroke, he was unable to move his left arm or hand at all.

PREP was started. On day 3 after stroke the occupational therapist recorded a SAFE score of 0/10. There was no muscle activation for left shoulder abduction or left finger extension.

Mr D MEP.png


Mr D had TMS on day 7 after stroke. Responses weren’t able to be detected in the muscles of the affected arm, there were no MEPs at the forearm (ECR) or hand (FDI). So at that time the motor pathways from the stroke-affected side of the brain to the left forearm and hand were not functioning.





On day 13 he had an MRI to review the stroke-affected motor pathways, by comparing them to the pathways on the other side of the brain. The MRI showed relatively good symmetry of these pathways (FA asymmetry index = 0.09).Mr D MRI.jpg

Mr D and his rehabilitation team were given verbal and written information that Mr D had the potential for some return of movement in his affected hand and arm within 12 weeks, because the motor pathways to the arm and hand had some residual structural integrity (MRI). But activities involving the upper limb would require significant modification, as the pathways weren't functioning that well (TMS).

To reach his potential, arm and hand rehabilitation should focus on reducing impairment by strengthening the affected upper limb and improving active range of motion. Promoting adaptation and incorporation of the affected upper limb in daily activities should be considered wherever possible. Practice that incorporates the use of both hands may be useful.

Mr D spent eight weeks as an inpatient on the rehabilitation ward at the hospital.

At 12 weeks after the stroke Mr D was using his left arm for lifting some larger items, sometimes using the right hand to assist. He had difficulty with completing fine tasks as his dexterity was reduced. This was reflected in assessments of his left arm function (Action Research Arm Test score 26/57) and impairment level (Fugl-Meyer Upper Limb Scale score 42/66).

At 6 months, he reported that he used his left arm for some daily activities that he had used it for before the stroke, most activities took longer and required more effort than before the stroke (Motor Activity Log score 57%). Mr D reached his potential for a ‘limited’ recovery.


Case Example 5: Miss E

Miss E (58 y) came to the hospital after a stroke, she was unable to move her right arm or walk.

PREP was started. On day 3 after stroke the physiotherapist recorded a SAFE score of 0/10. There had been no return of movement.


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Miss E had TMS on day 6 after stroke. Responses weren’t able to be detected in the muscles of the affected arm, there were no MEPs at the forearm (ECR) or hand (FDI). So at that time the motor pathways from the stroke-affected side of the brain to the left forearm and hand were not functioning.







On day 14 she had an MRI to review the stroke-affected pathways, by comparing them to the pathways on the other side of the brain. The MRI showed marked asymmetry of the motor pathways (FA asymmetry index = 0.20).


Mrs E MRI.jpg

Miss E and her rehabilitation team were given verbal and written information that Miss E had the potential to have minimal movement in her affected hand and arm within 12 weeks. Education was supported with pictures of her brain, with an explanation of the stroke and its impact on the motor pathways. As the motor pathways to the arm and hand were not functionally (TMS) or structurally (MRI) intact, upper limb rehabilitation should focus on prevention of secondary complications, such as pain, spasticity and shoulder instability. It is also important to reduce disability by promoting compensation, which will involve learning to complete activities of daily living with the stronger hand and arm.

Miss E spent nine weeks as an inpatient on the rehabilitation ward at the hospital.

At 12 weeks after the stroke Miss E had not had any return of movement that could be used to assist with performing daily activities. However, she was able to wash and dress herself, and make her bed and a simple meal with her left hand and some adaptive equipment. She could apply her own sling to support the arm (helping to prevent shoulder pain) when she was up and about. The level of right arm recovery was reflected in assessments of arm function (Action Research Arm Test score 3/57) and impairment level (Fugl-Meyer Upper Limb Scale score 15/66).

At 6 months, she reported she was using the left arm instead of the right arm for most activities now, but that she didn’t have any pain and had good flexibility in the left arm which helped with getting dressed (Motor Activity Log score 8%). She was able to walk by herself, but needed a stick to steady herself when outdoors. Miss E reached her potential for a ‘none’ recovery.


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