PREP2 Support: Case examples

 

Here are examples of queries that may be raised by patients, and key points to consider when providing support.

Mr Stewart (38 y)

Clinical information: Left hemisphere PACI
PREP2 information: SAFE score = 5
PREP2 prediction: Excellent
Additional information: Mr Stewart works in a call centre. He enjoys going to the gym. He has a toddler that lives with him on weekends. He is right-handed.

Query to you: “They have said that I will get nearly all my arm and hand movement back, but when? I need to go back to work soon.”

Key points:

    • The timeframe for the predictions is within 12 weeks, so Mr Stewart should be back to fairly normal movement of the hand and arm within this time, but we are unable to be more specific than that.
    • The prediction gives ‘potential’ for recovery, and it is not guaranteed. Mr Stewart should be supported to follow the advice of his clinical team and participate in his recommended rehabilitation.
    • Mr Stewart should be supported to avoid compensation with the left hand, he should try to use his right hand for daily activities where possible.
    • Return to work can depend on several factors, not just upper limb recovery. Mr Stewart’s therapists (and medical team) are in the best position to provide specific advice on return to work.

 

Mr Leong (80 y)

Clinical information: Right hemisphere LACI
PREP2 information: SAFE score = 7
PREP2 prediction: Good
Additional information: Mr Leong lives with his wife. He enjoys fishing and reading. He is right-handed.

Query to you: “Are there other exercises I can do to get a full recovery?”

Key points:

    • Mr Leong has a Good prediction, rather than excellent, because he is 80 years old
    • You could reinforce that it’s most likely he will be able to use his left arm for most day to day activities, though a full recovery to 100% is unlikely as he may still have some slowness, weakness or clumsiness.
    • Mr Leong’s therapists will be aware of his prediction for upper limb functional recovery, will help him set goals, and will prescribe him the most appropriate exercises to help him reach his potential. He should be supported to discuss his exercises with his therapists, and try to participate fully in his recommended rehabilitation.
    • Mr Leong could be encouraged to discuss his interest in fishing with his therapists, so this can be considered when goal setting and developing his rehabilitation plan.
    • Mr Leong should be supported to avoid compensation with the right hand, incorporating the left hand into activities where possible.

 

Mr Sharma (56 y)

Clinical information: Left hemisphere PACI
PREP2 information: SAFE score = 0, MEP+
PREP2 prediction: Good

Additional information: Mr Sharma works as an engineer in a large company. He regularly travels overseas. He is right-handed.

Query to you: “They say I will be able to move my arm again, but I can’t at all now. Are they telling me the truth? I don’t want to get my hopes up.”

Key points:

    • Mr Sharma has no movement at present, but was MEP+ on TMS testing which indicates functional motor pathways between the stroke-affected side of the brain and the affected arm. He therefore has potential for a Good functional outcome for his right hand and arm.
    • You can reinforce that although he has no movement in the right hand and arm at present, the tests of his hand and arm indicate that the connections between his brain and hand can still work. So he has the potential to be able to use this arm for most day to day activities within 12 weeks, though it may still have some slowness, weakness or clumsiness.
    • Mr Sharma should be supported to follow the recommendations of his therapists and try to participate fully in his rehabilitation. He should be reassured that his therapists will monitor the arm and hand closely and help him incorporate it into functional activity as it improves.

 

Mr Fisher (64 y)

Clinical information: Left hemisphere PACI
PREP2 information: SAFE score = 0, MEP-, NIHSS = 5
PREP2 prediction: Limited
Additional information: Mr Fisher has some word-finding difficulties. He has a supportive wife, and together they own and operate a small business. He is keen to return to work.

Query to you from his wife: “Will he be able type on the computer?”

Key points:

    • Mr Fisher has the potential for Limited functional recovery of his right hand and arm as he was MEP- on TMS testing (which indicates the motor pathways between the stroke-affected side of the brain and the affected arm were not functional when tested), but he has a NIHSS less than 7 on day 3 after stroke (which indicates a mild/moderate rather than severe stroke).
    • You can reinforce that although he has no movement at present, based on tests of his hand and arm he has the potential to regain some movement within 12 weeks, possibly some hand opening and closing, though fine control is likely to remain challenging and he is likely to need to use the other hand to help with some activities.
    • As typing requires fine control of the hand and arm this may be a difficult activity given his upper limb prediction. However, he should be supported to discuss return to specific activities (such as typing) with his therapy team (physical therapist, occupational therapist, and speech language therapist) who are able to help him set realistic goals.

 

Mrs Parata (58 y)

Clinical information: Left hemisphere TACI
PREP2 information: SAFE score = 0, MEP-, NIHSS = 9
PREP 2 prediction: Poor

Additional information: Mrs Parata is currently unable to walk and her communication is impaired by dysarthria. She lives alone and has a supportive daughter who lives nearby. She is right-handed.

Query to you (from her daughter): “I’ve been told Mum is unlikely to be able to use her right hand and arm, what about if you give it lots and lots of therapy and we practice with her too?

Key points:

    • Based on assessments the motor pathways between the stroke-affected side of the brain and the right hand and arm have been significantly damaged by the stroke. Mrs Parata may regain some movement within 12 weeks, and may be able to use her weaker hand to stabilise objects, but is unlikely to recover fine finger control.
    • Spending “lots and lots” of time on specific movement therapy for the right upper limb will unfortunately not alter the prediction. But you can reinforce that there is still a focus for hand and arm rehabilitation, which is to maintain the flexibility of the hand and arm, prevent shoulder instability or pain, and help Mrs Parata to learn to perform day to day activities with her left hand, or both hands where possible.
    • It would be good to reinforce that there are other areas for rehabilitation to also focus on, such as mobility and communication.
    • It is good that that Mrs Parata’s daughter is keen to help her Mum rehabilitate. For the upper limbs, she could be supported to help care for the right hand and arm to prevent secondary complications and optimise the use of the left hand and arm. There is likely to be a lot of other areas of rehabilitation (such as mobility and communication) that Mrs Parata’s daughter could be involved in too.