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When is the best time to get the SAFE score?

We count the day of the stroke as day 0, the next day as day 1, and so on. If a patient reaches 8/10 by day 3, then they have a Complete prognosis. If a patient reaches 5/10 within 3 days, but is less than 8/10 at day 3, then they have a Notable prognosis.

Here are some examples:
Mr Smith
Day 0 (day of symptom onset), SAFE = 6
Day 1 (day after symptom onset), SAFE = 8, so we can give him a Complete prognosis right now, even though it’s only day 1. This is assuming he doesn’t deteriorate over the next couple of days, in which case we’d have to re-assess him. But assuming he’s stable, we expect him to remain at 8 or above, so he has a Complete prognosis.

Mrs Brown
Day 0 (day of symptom onset), unable to get a SAFE score, as they were admitted late that night and no staff were available
Day 1 (day after symptom onset), SAFE = 2
Day 2, SAFE = 4
Day 3, SAFE = 5. Now we can give her a Notable prognosis, as she has achieved a 5 on day 3, just in time.

Mr Jones
Day 0 (day of symptom onset), unable to get a SAFE score, it was a Sunday and no staff were available
Day 1 (day after symptom onset), SAFE = 2
Day 2, SAFE = 3
Day 3, SAFE = 4, so we can’t give him a Notable prognosis, and we remain unsure of his prognosis if we don’t have TMS available. All we do know for sure is that he’s not in the Complete category.
If someone did a SAFE score on him the next day (Day 4), and his SAFE = 5, we can’t ‘upgrade’ him to Notable at this time, because the 72 hour time window has passed. It’s tempting, but we wouldn’t have much confidence in the prediction.

Is it possible for the hand and arm to recover better than predicted?
Yes. The prediction made by PREP is the minimum level of recovery that can potentially be achieved within 12 weeks after stroke. It's pleasing to see that some people do recover more hand and arm function than predicted by PREP. This could be due to a range of reasons, which we are continuing to explore with our research.

Can the hand and arm keep improving beyond 12 weeks after stroke?
Yes. The brain can continue to change in response to practice and experience, throughout life. Therefore it's possible for improvements to be made beyond 12 weeks after stroke. However, most people make most of their recovery of movement within the first 12 weeks after stroke. This is because of the unique biological conditions in the brain during this time. Improvements can be made after this time, however they are usually smaller, slower to develop, and require more effort.

What type of upper limb therapy will ensure that people reach their predicted recovery?
PREP helps patients and therapists to focus on appropriate rehabilitation goals, but it can't prescribe the type of upper limb therapy. PREP may also help us define a minimum dose of therapy needed to ensure people reach their predicted recovery.
For example, we have found that people with potential for a complete recovery of hand and arm function are more likely to achieve this if they do at least 2 weeks of self-directed therapy. This is why we have developed a Home Exercise Programme, to be prescribed for people in the complete category by a physiotherapist or occupational therapist.

Why do some people not recover hand and arm function as well as predicted?
There may be a range of reasons why some people don't reach their predicted potential for recovery within 12 weeks. For example, they may not be able to do as much rehabilitation as other patients, due to problems with their thinking, attention, communication, mood, and energy levels. They may also have other health problems that make it difficult to engage in rehabilitation. We are continuing to explore these factors with our research.

If a person had no responses to Transcranial Magnetic Stimulation 7 days after stroke, but responses returned at a later time, would they then have 'notable' potential for hand and arm recovery?
If a person has no responses to TMS 7 days after stroke, this indicates a greater degree of stroke damage to the descending motor pathways. This means that even if they do recover responses later, they are unlikely to have the potential to make a notable recovery of hand and arm function.

How important is the TMS? Can we skip this step and go straight to the MRI?
The TMS step is important. We have found that people can have responses to TMS even though they have an FA asymmetry index > 0.15. The TMS shows that the remaining descending motor pathways are still functioning, even though the MRI indicates a greater degree of structural damage to the pathways. This means that these patients still have potential for a notable recovery. If the TMS step was skipped, the MRI would put these patients in the none category, which would underestimate their potential for recovery. If the pathways are functioning (MEP+), then it doesn't seem to matter what they look like on the MRI scan.


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