for stroke recovery prep algorithm

for Stroke Recovery

http://prepforstrokerehab.wikispaces.com/home

PREP algorithm

The PREP algorithm predicts potential for recovery of upper limb function after stroke, for individual patients

This presentation will explain how the PREP algorithm works and how it can be used in stroke rehabilitation

Part 1 Why use the PREP algorithm?Part 2 How to use the PREP algorithmPart 3 How to tailor rehabilitation

Why is the upper limb important?

What’s wrong with

clinical experience?

Why is the upper limb important?

Age

Initial stroke severity (NIHSS)Upper-limb paresis

Independence at 6 months is predicted by:Veerbeek et al., Stroke, 2011, 42(5):1482-1488

This is the only factor

we can help with

A clinical scenario

that may be familiar…

Will my hand get better ?

Mrs McIntyre, 63 years, works on a computer

Right-sided weakness

Ischaemic stroke 10 days ago

Grossly 1/5 (MRC grading) in the upper limb

Does experience

help us answer her question?

Experienced therapists were asked at 72 hours to predict how well the hand and arm would function at 6 months Nijland et al., 2013, Physical Therapy, 93(4):460-469

All had more than 20 years

experiencePredicted ARAT score at 6M

< 10

10 – 56

57

Overall

The Action Research Arm Test measures upper limb

functionThe maximum score for normal

function is 57

Therapists predicted a category for each patient

Correct predictions

86%

47%

61%

59%

Overall, therapists were right 59% of the

time

But…were no better

than chance for this

category

Experienced therapists can predict very poor and normal function, but struggle to predict which patients will be somewhere in between

Patients who initially have similar upper limb function can have very different recoveries

Stinear et al., 2012, Brain, 135(8):2527-2535

Measures were made

from 2 weeks after

stroke

Each line represent

s an individual

Patients can look the same at first, but recover differently

The Action Research Arm Test measures

upper limb function

It would be good if we could make accurate predictions for individual patients

MANAGE PATIENT

EX

PE

C TA

T IO

NS

TAILOR REHABILITATION GOALS

This would help us to...

USE TIME AND RESOURCES TOBRING THE BEST

OUTCOMEFOR THE

PATIENT

Predictions based on clinical experience can be inaccurateA systematic approach may be more accurate

How can we answer her question?

Will my hand get better ?


Is it easy to use PREP?

Is PREP really any

better than clinical

experience?

The next few slides will explain each step of the PREP algorithm, and then how it can be used to focus rehabilitation goals

TMS

MRI

MEP absent

MEP present Notable

Asymmetry index < 0.15 Limited

Asymmetry index > 0.15 None

Predicted recovery of upper-limb function

at 12 weeks

SAFE score ≥ 8 Complete72 hours

5 days

10 days

5, 6 or 7< 5

PREP algorithm

72 hours

PREP algorithm

Notable

5, 6 or 7

Stinear et al., Brain, 2012, 135(8):2527-2535Stinear, Lancet Neurology, 2010, 9(12):1228-1232

The first step is to calculate the SAFE

score

SAFE = Shoulder Abduction and Finger Extension

Add the MRC grades for these two movements together, for a SAFE score out of 10

If the SAFE score is 8 or more within 72 hours of

stroke…

≥ 8 Complete

Predicted recovery of upper-limb function at

12 weeks

SAFE score

…the patient is

predicted to make a

complete recovery

If the SAFE score is 5, 6 or 7 within 72 hours of

stroke…

…the patient is

predicted to make a notable recovery

If the SAFE score is less than 5, you

need the next step…

Notable

SAFE score ≥ 8 Complete

Predicted recovery of upper-limb function at 12 weeks

72 hours

5, 6 or 7

TMS

< 5

5 days

TMS stands for Transcranial Magnetic Stimulation, which is safe and painlessTMS tests whether a message can get through, from the brain to the hand and arm

The second step is to use TMS around 5 days after

stroke

PREP algorithmStinear et al., Brain, 2012, 135(8):2527-2535Stinear, Lancet Neurology, 2010, 9(12):1228-1232

Notable



72 hours

5, 6 or 7

TMS

< 5

5 days MEP present

Muscle responses

are recorded with EMG, and are

called MEPs

If the TMS produces a response…

…the patient is predicted to make a notable recovery


Notable



72 hours

5, 6 or 7

TMS

< 5

5 days MEP present

If the TMS does not

produce a response…

…you need the third step


Notable



72 hours

5, 6 or 7

TMS

< 5

5 days MEP present

MRI

MEP absent

The MRI scan provides a detailed image of the pathways that carry movement commands

The third step is an

MRI scan 10 to 14 days after stroke

10 days

The pathways are in the

posterior limb of the

internal capsule

More asymmetry

in these pathways

means more damage


Notable



72 hours

5, 6 or 7

TMS

< 5

5 days MEP present

MEP absent

10 daysAsymmetry score < 0.15 Limited

Asymmetry score > 0.15 None

MRI

Low asymmetry means the patient has

limited potential

High asymmetry means the patient has

no potential


The PREP algorithm can make accurate predictions for individual patients

Does the PREP

algorithm work?

This is the same

graph you saw earlier

Now the patients

are categorised by the

algorithm

The algorithm outperforms experienced therapists

Therapists

Predicted ARAT score at 6M

< 10

10 – 56

57

Overall

Correct predictions

86%

47%

61%

59%

PREP

Predicted ARAT score at 3M

< 10

10 – 24

25 – 49

50 – 57

Overall

Correct predictions

100%

100%

69%

87%

83%

How does it compare to experienced therapists?

This is the table you saw earlier

Here’s what we see for PREP

There are 4 categories, rather than

3 for the therapists

SAFE 5 - 717%

SAFE score > 844%

Unkn

own

TMS35%

MEP +ve15%

Unkn

own

MRI20%

Unkn

own

FAAI <0.1513%

>0.157%

The PREP algorithm is efficient, as predictions can be made for more than half of patients with a simple bedside test

Efficiency

The SAFE score can make a

prediction for around

60% of patients

TMS is needed for the

rest

MRI is needed

for around 20% of patients

A prediction can’t be made

for a small percentage of people who can’t have TMS or MRI

More advanced tests (TMS, MRI) are only used as required, for some patients


So how do we use the predictions?

Does PREP improve

outcomes?

Notable

Limited

None

Predicted recovery of upper-limb function

Complete

at 12 weeks

TMS

MRI

MEP absent

MEP present

Asymmetry index < 0.15

Asymmetry index > 0.15

SAFE score ≥ 872 hours

5 days

10 days

5, 6 or 7< 5

PREP algorithmStinear et al., Brain, 2012Stinear, Lancet Neurology, 2010

How are these predictions used to focus rehabilitation?

Rehabilitation focus

Notable

Limited

None

Complete Promote normal use

Promote function

Promote movement

Promote compensation



These patients have a 90% chance of making a complete recovery of hand and arm function within 12 weeks after stroke

These patients are typically mildly affected and often have a short length of stay

So won’t they get

better just by using

their hand?



These patients need to be prescribed a home exercise programme, or their chances of making a complete recovery will decrease from 90% to 60%

The PREP website has

a programme to download

for free

Promote function


It will also be important to minimise compensation with the other hand

Rehabilitation can focus on improving strength, coordination, and fine motor control

Notable

These patients have potential to be using their affected upper limb for most activities of daily living within 12 weeks after stroke

Promote movement


Daily activities will require significant modification, and the affected upper limb can be incorporated in daily activities, when safe to do so

Rehabilitation can focus on improving strength and increasing active range of motion

Limited

These patients will have some movement in their affected upper limb by 12 weeks after stroke



It will be useful to promote compensation with the other hand for daily activities

Rehabilitation can focus on preventing complications such as pain, spasticity, and shoulder instability

None

These patients are expected to have minimal movement in the affected upper limb by 12 weeks after stroke


Notable

Limited

None


Promote function

Promote movement


Notice that

everyone needs

therapy…

…it’s just the focus that changes,

depending on the degree of

damage to key motor

pathways


What have we learned?

Summary

Some people have more potential for upper limb recovery than others

The PREP algorithm can make accurate predictions for individual patients

The PREP algorithm is being implemented as part of a research projectYou can find out more here:

– And clinical judgement can be inaccurate

– The SAFE score can make a prediction for around half of patients

– For the rest, you need to know something about the extent of damage to key motor pathways in the brain

– http://prepforstrokerehab.wikispaces.com

http://prepforstrokerehab.wikispaces.com/

She is predicted to be using her affected right hand and arm for most activities within 12 weeks

Where does this leave

Mrs McIntyre?

She is in the notable category, so her rehabilitation focus is to promote function

How do we know?

SAFE score = 2TMS = MEP+

No MRI needed

12 weeks after stroke:

ARAT score = 38 /57MAL score = 7.6 /10

How is she doing at 12

weeks?

Upper limb function is

in the notable range

This Motor Activity Log score means

she’s using her right hand, with some difficulty

Mrs McIntyre has returned to work part-time

Associate Professor Cathy StinearDr Suzanne AckerleyProfessor Alan BarberProfessor Winston ByblowMs Anna McRaeDr Samir AnwarProfessor Rhema Vaithianathan

Research led by:

With special thanks to the patients and

their families for taking part…

…as well as the therapists and

clinicians helping to test the algorithm

for stroke recovery prep algorithm

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