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Patient Selection
PREP categories could be useful inclusion or exclusion criteria for clinical trials. This would enable patients to be selected for trials based on the intervention's hypothesised mode of action.


Example 1: An intervention designed to promote use of the affected hand, and minimise compensation with the other hand, might be most effective for patients with notable potential for recovery.

Example 2: An intervention designed to increase activity in the stroke affected side of the brain might be most effective for patients in whom the ipsilesional corticospinal pathway remains functional. It could be useful to exclude patients in the limited and none PREP categories, as they are MEP-.

Example 3: An intervention designed to increase rehabilitation dose by supporting self-directed practice with the upper limb might be most effective for patients in the notable and complete PREP categories.




Patient Stratification
The figures below show that patients can have similar clinical scores soon after stroke, but make very different recoveries.



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This means that matching treatment and control groups on baseline clinical scores could result in one group having more patients with more potential for recovery than the other, just by chance. This could bias the outcome of the trial towards a positive or negative result. Matching treatment and control groups using PREP at baseline can match the groups for recovery potential, so that any subsequent differences in outcome are more likely to be due to treatment effects.

For example, see this study of an upper limb intervention that matched treatment and control groups using the PREP algorithm.

Bilateral priming accelerates recovery of upper limb function after stroke

This study matched treatment and control groups for upper limb recovery potential, and showed that bilateral priming accelerated recovery of function in the treatment group over the first 6 weeks after stroke. The two groups had similar upper limb function at 12 weeks, which was expected as the groups were matched for predicted function at 12 weeks.

Stinear CM, Barber PA, Petoe MA, Anwar S, Byblow WD. Bilateral priming accelerates recovery of upper limb function after stroke: A randomized controlled trial. Stroke. 2014;45:205-210

See the Resources page for links to publications on the PREP algorithm.



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