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The PREP algorithm is currently used at the Auckland District Health Board within a research study called TRIO (Targeted Rehabilitation, Improved Outcomes). The study has been approved by the regional ethics committee (NTX 11/08/070) and is a registered clinical trial (ACTRN 12610000314022).
The study provides patients, their families and their rehabilitation teams with information about their potential for arm and hand recovery after their stroke. This information is then used to help tailor rehabilitation for the individual.

You can download a slide show about the PREP algorithm, and how to use it for tailoring upper limb rehabilitation. This slide show is designed as an educational resource for individuals and clinical teams.



WHO is PREP for?
PREP is designed for patients who are older than 18 years and have had a recent stroke (excluding cerebellar stroke) that has caused weakness in the arm and hand. PREP may not be suitable for patients who have severe aphasia or cognitive impairment that limits their ability to understand the tests involved, or if there are contraindications to TMS or MRI.


WHAT does PREP involve for the clinician?

Step 1

Clinicians document a SAFE score in the clinical notes within the first 72 hours after stroke (or until a SAFE score of 8 or more is achieved). A SAFE score is calculated by scoring shoulder abduction and finger extension with Medical Research Council Grades. Each movement is graded between 0 (no movement) – 5 (normal movement through a full range of motion against resistance). The two scores are added to form a SAFE score out of 10.

You can use the grades below, and avoid using + and - signs to keep things simple.
0 = no palpable muscle activity
1 = palpable muscle activity, but no movement
2 = limited range of motion without gravity
3 = full range of motion with gravity, but not resistance
4 = full range of motion with gravity and resistance, but weaker than the other side
5 = normal power

If the fingers have unequal strength, use a majority rule. If three fingers have the same score, use this score. If two fingers have a lower score than the other two fingers, use the lower score.

If the SAFE score is ≥ 8
A patient is classified as having the potential for a complete recovery of their upper limb. A home exercise programme is prescribed by the physiotherapist or occupational therapist. Information is provided to the patient, their family and the rehabilitation team. Clinicians should share this information at handover to different rehabilitation services.

If the SAFE score is 5, 6 or 7
A patient is classified as having the potential for a notable recovery of their upper limb. Rehabilitation should focus on repetitive practice of movement and functional tasks with the affected hand and arm, and minimising compensation with the good hand and arm, and the trunk. Information is provided to the patient, their family and the rehabilitation team. Clinicians should use this information to guide rehabilitation and share it at handover to different rehabilitation services.

If the SAFE score is less than 5, proceed to Step 2.

Step 2

TMS (Transcranial magnetic stimulation) is used to test the functioning of motor pathways between the stroke-affected side of the brain and the affected arm. The presence of motor evoked potentials (MEP+) indicates functional motor pathways, and patients are classified as having potential for a notable recovery of their upper limb. Rehabilitation should focus on repetitive practice of movement and functional tasks with the affected hand and arm, and minimising compensation with the good hand and arm, and the trunk. Information is provided to the patient, their family and the rehabilitation team. Clinicians should use this information to guide rehabilitation and share it at handover to different rehabilitation services.


MEP positive.jpgMEP negative.jpg


If motor evoked potentials are absent (MEP-), proceed to Step 3.

Step 3

An MRI scan is undertaken at 10 – 14 days after stroke for patients who are MEP-. The MRI takes around 30 minutes and is used to look at the structural integrity of the posterior limb of the internal capsule (PLIC) on each side of the brain. Diffusion-weighted imaging is used to calculate the fractional anisotropy asymmetry index. (See Article).

MRIScan.jpg
If the asymmetry index ‍‍‍‍‍is < 0.15,‍‍‍‍‍ patients are classified as having potential for a limited recovery of their upper limb. 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. Information is provided to the patient, their family and the rehabilitation team. Clinicians should use this information to guide rehabilitation and share it at handover to different rehabilitation services.


If the asymmetry index is ≥ 0.15, the potential for upper limb recovery is none. Rehabilitation should focus on prevention of secondary complications, such as pain, spasticity and shoulder instability. It is also important to reduce disability by helping the patient learn to complete activities of daily living with the stronger hand and arm. Information is provided to the patient, their family and the rehabilitation team. Clinicians should use this information to guide rehabilitation and share it at handover to different rehabilitation services.

Rehabilitation Team InformationInformation for the clinical notes and at handovers is available for each prediction. This information can be viewed, downloaded, and printed by clicking on the links below:Complete
Notable
Limited
None

Home Exercise Programme
- Appropriate exercises should be prescribed by a physiotherapist or occupational therapist, for patients with potential for complete recovery of the hand and arm. Unprescribed use of this programme by patients may result in injury.


Patient Information
Information is available for patients in each predicted recovery potential group. This information can be printed and given to patients and their families, by clicking on the links below:
Complete
Notable
Limited
None



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