PREP2 Basic: Predictions

Obtaining Excellent and Good predictions

Obtaining a prediction always starts with obtaining a SAFE score from the patient each day until you are able to determine a prediction category, or up to and including Day 3 post-stroke.

If the patient has a SAFE score of 5 or more on Day 3 after stroke, you can use the PREP2 prediction tool to make either an Excellent or Good prediction, depending on their age.

If a patient reaches 8/10 by Day 3, then they are most likely to have an Excellent functional outcome for their upper limb.

If a patient scores at least 5/10 on Day 3, but is less than 8/10, then they have an Excellent prediction if they are less than 80 years old, and a Good prediction if they are 80 years old or more.

If the patient has a SAFE score less than 5 on Day 3 after stroke, their Day 3 NIHSS score needs to be obtained and Transcranial Magnetic Stimulation (TMS) testing needs to be carried out between Day 3 and Day 7. If TMS is not (yet) available at your site, then PREP2 is discontinued for patients with a SAFE score less than 5 on Day 3, and a prediction cannot be made.

Delivering Excellent and Good predictions

You can see a video on delivering predictions here.

When delivering predictions remember:

Predictions are for the hand and arm only
Predictions relate to the functional outcome of the hand and arm at 3 months after stroke, and they are not for the whole person, or their whole life. It is important to keep this in perspective. It’s also important to use your judgement when considering the patient’s overall situation. For example, if the patient is not expected to survive their stroke, then it would probably be better not to provide them with a prediction, until you see whether they recover.

Good news may be bad news
Bad news is any news that drastically and negatively alters the patient’s view of their future. For many patients, recovery means a return to their normal life with a resumption of their previous activities. Sometimes anything less than back to normal is a disappointment. In the context of the PREP2 prediction tool this means that even a good prognosis can be bad news.

Predictions are not provided in absolute terms
For the Excellent and Good predictions we use phrases like ‘most likely’ ‘fairly normally’ and ‘most’. The information also clearly identifies the focus of the upper limb rehabilitation and reminds patients of their responsibility for practicing.

Start with what the patient thinks
It can be helpful to start by asking the patient what their understanding of the situation is, and using that as a way into your message. For example, “I’m here to talk about what you can expect for your hand and arm. What’s your understanding of how it’s doing and how it might recover?” You then listen to their response and build on it.

After delivering the prediction gauge the patient’s emotions and reaction. Surprise and relief are common when people hear more positive news than they were expecting. Sadness, disappointment, and anger are common when people hear more negative news than they were expecting. Empathetic statements can help, such as:

“How are you feeling about this news?”
“I understand if you’re feeling disappointed about this”
“This is really hard to hear”
“I’m sure you were hoping for better news than this”

Be clear, consistent and confident when delivering the prediction, consider your body language and show empathy. Summarise the main message and check for understanding.

Provide verbal information and written information
Reinforce your discussions with patients (and their families) by providing written information on their PREP2 prediction category: PREP2 Prediction Information

Things can change
It is important to remember that a new stroke or progression of stroke symptoms which results in worsening upper limb weakness means that the PREP2 prediction tool should be started again. Count the day of the new stroke or progression as Day 0. If the patient’s prediction category changes, you will need to convey the new prediction to the patient, their family and the clinical team.

More than one discussion might be needed
You need to be willing to have an ongoing dialogue with the patient and their family. They are going to think about what you have said and may want to talk about it again to check their understanding and ask new questions. It is also important that the wider clinical team can reinforce the PREP2 prediction and answer patients’ questions too. Education and training for staff who support PREP2 predictions is essential.

A consistent, coordinated approach is needed
Ensure that current and future clinical staff (including inpatient, outpatient and GP) are aware of the PREP2 prediction that has been shared with the patient. Staff may need to reinforce the PREP2 prediction, and support focussed rehabilitation. Clear documentation of a patient’s PREP2 prediction should be placed in the clinical notes. Download PREP2 Prediction Information for help with each PREP2 prediction category. It also may be useful to discuss PREP2 predictions at multidisciplinary team meetings etc. Ongoing education to staff, and other stakeholders, about PREP2 is important to allow a consistent and coordinated approach.

PREDICTIONS

The following information below can be downloaded here.

Delivering an Excellent prediction

As you might expect delivering an Excellent prediction is relatively straightforward. The difficulty in this situation is not that you are giving them negative information but that they might not think it is credible information. You can help to overcome this difficulty by being confident in the way you provide the prediction.

These patients are:

<80 years old with a Day 3 SAFE score of 5 or more
80+ years old with a Day 3 SAFE score of 8 or more

Information for the patient and their family:

Your hand and arm are most likely to make an Excellent recovery within the next 3 months
You can expect to be able to use your hand fairly normally for most day to day activities
The focus of your rehabilitation will be on improving your strength, coordination and fine control
You will need to practice using your hand and arm to help improve it
It’s important to avoid using your other hand to compensate
This prediction is based on your current status, and is not a guarantee, as some people recover more or less than expected

Information for the clinical team:

This patient is most likely to have an Excellent upper limb outcome within the next 3 months
They can expect to be using their upper limb fairly normally for most activities of daily living
Upper limb rehabilitation can focus on promoting normal function by improving strength, coordination and fine control, and avoiding compensation
A programme of self-directed upper limb activities may be beneficial
This prediction is based on the patient’s current status, and is not a guarantee, as some people recover more or less than expected

Delivering a Good prediction

Discussing a Good prediction is still usually a positive experience. Some patients might be disappointed that their hand and arm are likely to still have some problems in 3 months, whereas other patients might be pleasantly surprised.

These patients are:

80+ years old with a Day 3 SAFE score of 5, 6 or 7
Any age with a Day 3 SAFE score < 5 and MEP+ on TMS testing at Day 3 – 7 post-stroke. Good predictions for these patients will usually be shared after TMS testing by a staff member with PREP2 Advanced training.

Information for the patient and their family:

Your hand and arm are most likely to make a Good recovery within the next 3 months
You can expect to be able to use your hand for most day to day activities, though it may still be affected by slowness, weakness or clumsiness
The focus of your rehabilitation will be on improving your strength, coordination and fine control
You will need to practice using your hand and arm to help improve it
It’s important to avoid using your other hand to compensate
This prediction is based on your current status, and is not a guarantee, as some people recover more or less than expected

Information for the clinical team:

This patient is most likely to have a Good upper limb outcome within the next 3 months
They can expect to be using their upper limb for most activities of daily living, though function may remain affected by slowness, weakness or clumsiness
Upper limb rehabilitation can focus on promoting normal function by improving strength, coordination and fine control, and minimising compensation
If patients have an initial SAFE score < 5, rehabilitation can initially focus on assisting the return of voluntary muscle activity
This prediction is based on the patient’s current status, and is not a guarantee, as some people recover more or less than expected

Essential reading

Watch Basic Delivering PREP2 Predictions for how to deliver PREP2 predictions.

Frequently asked questions

When do I share the PREP2 prediction with the patient?
You can share the prediction once it has been determined, and provided the patient is ready to hear it. This is usually within the first 3 days for an Excellent or Good prediction obtained using the SAFE score and the patient’s age.

What do I say if I give a patient a Good prediction and they say, “I don’t think you’re right, I think my hand will get 100% better”?
Our responsibility is to be respectful of the patient and their views, without compromising the validity or credibility of information that is being provided. Our responsibility is to compassionately and respectfully provide information in a way that the patient and their family can understand if they choose to. It is not our responsibility to make them believe us.

What happens if the patient has another stroke during their admission?
A new stroke or progression of stroke symptoms which results in worsening upper limb weakness means that the PREP2 prediction tool should be started again. Count the day of the new stroke or progression as Day 0. If the patient’s prediction category changes, you will need to convey the new prediction to the patient, their family, and the clinical team.

What do I do if the patient is aphasic?
Consult the patient’s speech language therapist to discuss the best strategies for effective communication with your patient. If a patient is severely aphasic, and this limits their ability to understand the tests involved, then delivering PREP2 predictions may not be appropriate, although the information will still be of value to their family and the therapy team.

What do I do if the patient doesn’t speak English?
It is possible that family may be able to assist with translation, but using an interpreter may be required. Using an interpreter is regarded as best practice as it is possible that family may not directly translate the information as it is intended, potentially leading to misunderstanding.

Case Examples

Here are two case examples (Mrs Apia and Mr Borich), illustrating how the SAFE score can be used to predict upper limb functional outcomes.

Think about how you’d approach discussing the PREP2 prediction with each patient and their family, and discuss with a colleague.

Mrs Apia (78 y)

Mrs Apia was admitted to the hospital on Friday afternoon with weakness and clumsiness of her right hand as a result of stroke.

The therapist saw her on Monday (Day 3). PREP2 was started by obtaining a SAFE score. Mrs Apia scored 4/5 for each of shoulder abduction and finger extension (movement through full range against gravity and resistance, but is weaker than the other side). A SAFE score of 8/10 was documented.

Mrs Apia was therefore predicted to have an Excellent upper limb outcome as she had a SAFE score greater than 5 and was less than 80 years old.

Mrs Apia and her clinical team were given verbal and written information that she would most likely have an Excellent functional outcome for her upper limb. She was prescribed a home exercise programme and discharged later that day. She spent about 40 minutes per day doing practice with her right hand for nearly three weeks.

At 12 weeks after the stroke, Mrs Apia was using her right hand ‘as normal’ for nearly all tasks. This was reflected in assessments of her right arm function (Action Research Arm Test 56/57) and impairment level (Fugl-Meyer Upper Extremity Scale score 61/66).

At 6 months after the stroke, she reported that she used her right hand and arm for nearly all the activities that she had previously used it for, and the quality of use was nearly the same as before the stroke (Motor Activity Log score 94%). Mrs Apia achieved the predicted Excellent functional outcome for her upper limb.

Mr Borich (83 y)

Mr Borich was admitted to the hospital with a stroke. He couldn’t move his left hand and arm. PREP2 was started.

On Day 1 he had a SAFE score of 0/10 (no palpable muscle activity in left shoulder abduction or finger extension).
On Day 2 his SAFE score was 2/10 (he had palpable muscle activity in both shoulder abduction and finger extension, but no movement, 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 Borich was predicted to have a Good upper limb outcome as he was more than 80 years old and had a SAFE score of at least 5, but less than 8. Mr Borich and his rehabilitation team were given verbal and written information that he would most likely have a Good functional outcome for his upper limb, and be using his hand arm in most day to day activities within 12 weeks, though function may remain affected by slowness, weakness or clumsiness.

To reach his potential, hand and arm rehabilitation focused on improving function by increasing strength, coordination and fine control. Mr Borich was advised he should use his affected hand and arm for safe daily activities and try to minimise compensation with the stronger hand and arm.

Mr Borich spent three weeks in inpatient rehabilitation.

At 12 weeks after the stroke Mr Borich was using his left hand and arm for many day to day activities. This was reflected in assessments of his left arm function (Action Research Arm Test 47/57) and impairment level (Fugl-Meyer Upper limb Scale score 57/66).

At 6 months after the stroke, he reported that he used his left hand and arm for more than half of the activities he was using it for before the stroke, but it was more slow and effortful than before the stroke (Motor Activity Log score 71%). Mr Borich achieved the predicted Good functional outcome for his upper limb.

Quiz

Click here for a practice quiz to assess your learning on the PREP2 Basic: Obtaining and Delivering Predictions section.

Once the practice quiz has been completed with at least 70% correct you will be emailed a link to the final quiz for this section.

If you pass the final quiz with at least 80% correct you will be emailed a certificate of completion for the PREP2 Basic: Obtaining and Delivering Predictions section. There is no limit to the number of attempts for the practice or final quiz.