Using and supporting PREP2 Predictions

Purpose
PREP2 provides a rehabilitation focus for each prediction category to help guide upper limb therapy, but it doesn’t prescribe the type of therapy. The objective of this section is to provide a summary of information that may be useful when considering the therapy plan for patients.

Overview
PREP2 predictions and the upper limb rehabilitation focus should be recorded in the clinical notes. The information provided for each prediction is summarised in the table below, and a PDF of the information for the patient and their family and the clinical team can be downloaded from here: PREP2 Prediction Information.

If you are currently implementing PREP2 with a phased approach, then you may not need to read all of the material below just yet. Phase 1 of implementing PREP2 involves obtaining and using Excellent and Good predictions. Phase 2 of implementing PREP2 involves obtaining and using all four predictions.

Category	Prediction	Upper limb rehabilitation focus	Information
Excellent	This patient is most likely to regain very good function within the next 3 months. They can expect to be using their upper limb fairly normally for most activities of daily living.	Promote Normal Function	Improve strength, coordination and fine control. Avoid compensation. A programme of self-directed upper limb activities may be beneficial (click here for a downloadable copy).
Good	This patient is most likely to regain fairly good function 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.	Promote Function	Improve strength, coordination and fine control. Repetitive practice of movement and everyday tasks should help. If patients have an initial SAFE score < 5, rehabilitation can initially focus on assisting the return of voluntary muscle activity. Compensation with the other hand should be minimised.
Limited	This patient is most likely to have some function within the next 3 months. They can expect to regain some movement and possibly grasp function, though recovery of dextrous hand function is unlikely.	Promote Movement	Improve strength, active range of motion, and joint flexibility. Adapt activities to incorporate both upper limbs when necessary to achieve a task. Bilateral practice
Poor	This patient is most likely to regain minimal movement within the next 3 months. They are unlikely to recover useful upper limb function, though may be able to use their weaker hand as a stabiliser in bimanual tasks.	Promote Compensation	Focus on preventing secondary complications such as pain, spasticity, and shoulder instability. Reduce disability by helping the patient learn to compensate with their other upper limb for activities of daily living.

When using PREP2 predictions to focus rehabilitation, it is important to remember some key points about the predictions, therapy, and communication.

Predictions

What does PREP2 predict?
PREP2 predicts one of four categories of upper limb outcome at 3 months post-stroke based on the Action Research Arm Test (ARAT) score. It predicts the patient’s capacity to complete tasks such as those in the ARAT. It does not predict the extent to which the patient will use their hand and arm to complete these types of tasks in their daily living. While PREP2 doesn’t directly predict the extent of real-world upper limb use, the four categories do relate to the amount and quality of real-world upper limb use reported by patients. So it appears that the prediction categories do map on to different levels of real-world performance. It’s also important to note that people with high impairment can still achieve high levels of functional independence and participation in meaningful activities, through adaptation and compensation for any ongoing impairments they experience.

Predictions are for the arm and hand only
Predictions relate to the functional capacity 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. People with Limited and Poor predictions for their upper limb are likely to have lots of other things to work on in rehabilitation such as their walking, communication and swallowing.

Predictions are based on the patient’s current status, and are not a guarantee, as some people recover more or less than expected
The predictions made by PREP2 are accurate for 75% of patients at 3 months post-stroke. For the remaining 25%, the prediction tool is too optimistic for about two-thirds of people. Most of these patients are people with an Excellent prediction who actually have a Good outcome. We think that erring on the side of optimism is preferable to the alternative, to avoid reducing patient motivation. Note that patients with a Limited or Poor prediction are not able to have a Good or Excellent outcome, as the damage to their motor pathways prevents them from regaining fine motor control. PREP2 predictions are most accurate for these groups, with 85% accuracy for Limited predictions, and 90% accuracy for Poor predictions. The remaining 15% of patients with a Limited prediction don’t do as well as expected, and have a Poor outcome. The remaining 10% of patients with a Poor prediction do a little better than expected and have a Limited outcome. PREP2 predictions are correct for 80% of patients at 2 years post-stroke, which is very reassuring.

There can be a range of factors that mean a patient recovers less than expected, and therefore doesn’t achieve their predicted upper limb outcome. For example, their functional capacity might be limited by problems with cognition, vision, attention and communication. They may also have other health problems that make it difficult to engage in rehabilitation. We are continuing to explore these factors with our research. There is also a responsibility on the patient for practicing, and it is possible that a patient’s ‘potential’ may not be met if a patient chooses not to engage in their therapy. These factors might also mean that some patients take a little longer than 3 months to achieve their predicted outcome. It is worth considering further rehabilitation if a patient is continuing to experience meaningful upper limb recovery at 3 months.

Therapy

Everyone needs therapy
The role of rehabilitation is to help patients define and achieve a rewarding life after stroke. The aims of therapy lie on a continuum. At one end therapy helps the patient to recover what they have lost, and at the other end it helps them adapt and compensate for what can’t be recovered. Therapy for each patient will lie somewhere on this continuum, usually with a mixture of recovery and adaptation, so they are enabled to participate in the activities that are important to them. The predicted upper limb outcome will influence where upper limb therapy lies on the continuum. People with an Excellent or Good prediction will benefit from therapy weighted towards recovery, whereas people with a Limited or Poor prediction will benefit from therapy weighted towards adaptation and compensation.

Patients with a Good prediction can start from a position of profound weakness
About half of patients who need TMS are MEP+. This means that if a patient has a Day 3 SAFE score less than 5, they have a 50/50 chance of being MEP+ and the potential for a Good upper limb outcome. Therapy will need to accommodate this, and progress appropriately. Rehabilitation can initially focus on assisting the return of voluntary muscle activity, then progress to include interventions to improve strength, coordination, and fine control. Incorporating practice of everyday tasks should be encouraged and supported when possible. There are two versions of the written information for patients and families. One for patients who have a Good prediction based on their SAFE score and age, and another for patients who have a Good predicted based on the TMS test showing they are MEP+.

The therapist determines the type of therapy
PREP2 helps patients and therapists to focus on appropriate rehabilitation goals, but it can’t prescribe the best types of upper limb therapies to use with each patient. It is up to the therapist to decide, based on the patient’s current status, the skills and experience of the therapist, and the available resources. It is important that the patient is regularly reassessed using appropriate measures to monitor changes in their upper limb functional capacity over time, and to ensure that their therapy and goals are continuously updated in response to these changes. It might be helpful to give the patient several opportunities to discuss their progress throughout rehabilitation to ensure that everyone’s expectations of recovery remain aligned.

Treat what you see
A small proportion of people do better than expected. It is important to use objective assessment and your clinical judgment, and continue to progress a person who is still improving despite having met their predicted upper limb functional outcome. Consider a person with a Good prediction who is using their upper limb for most activities of daily living with some slowness, weakness and/or clumsiness. If they are continuing to show improvements in function and control it may be appropriate to engage them in further challenging therapy. Likewise, patients with Limited and Poor predictions who are showing return of movement in the hand or arm should be guided to adapt daily activities to incorporate these movements, wherever possible. Further intervention and education may help maximise independence.

Communication

What about hope?
It’s important to support your patient’s hope. Early after stroke, most people hope to be living independently and returning to the rewarding roles and activities they enjoyed before the stroke. The role of rehabilitation is to help patients define and achieve a rewarding life after stroke, and this is an ongoing process. One part of helping people re-establish their life after stroke is providing them with appropriate expectations for their hand and arm recovery. In giving people information about this, we might be able to help them recalibrate what they’re hoping for and how they hope to achieve it. This can be done with kindness, compassion, and patience, as they work through the process of constructing their new sense of self. We can always support our patient’s hopes for the future, and their process of defining and establishing their new life, regardless of their upper limb prediction.

If we avoid the difficult conversations about the patient’s predicted upper limb outcome, we leave the patient to work it out for themselves. It can be upsetting for people to realise that their outcome is less than they had hoped for. If this occurs after they’ve left our care they have to make sense of this realisation without our support. Having the difficult conversations near the beginning of rehabilitation allows you to provide your patient with the support and guidance they need. It also means you have time to talk with your patient about the possibilities for their future, as they start to redefine themselves with a sense of hope. This will involve multiple conversations over time, as they and their family adjust to life after stroke.

People adjust at different rates
Patients and their family and friends go through a period of adjustment and recalibration after stroke. And this process occurs at different speeds for different people. A patient might move towards redefining themselves quite quickly, while a person close to them spends a bit longer hoping for a return to their life before stroke. This can sometimes create tension and challenges within relationships. It’s good to remember that PREP2 predictions are likely to influence this process of adjustment not just for the patient, but for all those close to them as well. You might need to have several discussions about the future with the patient and their loved ones, as they each make these adjustments in their own ways and in their own time.

It’s good to avoid labels
Notice that the written information given to patients and families avoids using the words Excellent, Good, Limited, or Poor as this might create the impression the prediction is for their whole recovery instead of just their hand and arm. It’s important to avoid ‘labeling’ patients and using these terms in conversations with patients and families. Instead, it’s better to give them and their families a verbal and written description of what they can expect.

Share PREP2 information
It is important that as a patient moves through different services (inpatient, outpatient, community, GP) that PREP2 information travels with them. Clear documentation of a patient’s PREP2 prediction in the clinical notes, discharge summaries, and handover documentation will allow a consistent and coordinated approach to the upper limb management, and avoid confusion around the patient’s expectations for their recovery of upper limb function. Sharing PREP2 information at MDTs and ward rounds etc. will be useful. It is also important to make sure that all other people working with the patient are aware of the PREP2 prediction tool, and what the prediction means, so that they are able to support the patient with the prediction whilst working with them.

Referral for psychological input might be appropriate
It is important to be conscious of the effect that prognostic information might have on a person’s expectations for their recovery. Referral for psychological support should be considered for any patient who is having emotional/adjustment difficulties following a stroke. This is particularly important for patients with a Limited or Poor prediction.

Cultural and spiritual support can be helpful
Patients and families might find it helpful to talk about the prediction and what it means for them with people who can provide appropriate cultural and spiritual support. This is particularly important for patients with a Limited or Poor prediction. You may wish to suggest or facilitate getting in touch with cultural and spiritual support staff available in your setting, or in the patient’s community.

Case Examples

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.

Key points:

Mr Stewart is starting from a position of moderate weakness in the hand and arm, but is predicted to be back to fairly normal movement of the upper limb within 12 weeks
The rehabilitation focus should be to promote normal function
Goal setting should consider the abilities he needs for his work, to care for his toddler, and interests such as the gym, keeping in mind that he is likely to have fairly normal function of the hand and arm within 12 weeks.
A facilitated therapeutic approach may be required initially to improve strength coordination, and fine control. Going forward repetitive practice of every daily tasks should help. As he improves, Mr Stewart is likely to be appropriate for prescription of a home exercise programme.
When appropriate Mr Stewart should be encouraged to avoid compensation with the left hand, and should try to use his right hand for safe daily activities where possible. This should be supported by the wider clinical team during day to day activities on the ward such as showering, dressing, feeding etc.

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.

Key points:

Mr Leong is starting from a position of mild/moderate weakness in the hand and arm, and is predicted to be using his upper limb for most activities of daily living within 12 weeks, though function may remain affected by slowness, weakness or clumsiness.
The rehabilitation focus should be to promote function
Goal setting should consider the abilities he needs for his activities of daily life, and his hobbies such as fishing, keeping in mind 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.
Therapeutic interventions should aim to improve strength, coordination, and fine control. Repetitive practice of every daily tasks should help. As he improves, Mr Leong may be appropriate for prescription of a home exercise programme.
From an early stage, Mr Leong should be encouraged and supported to minimise compensation with the right hand (which may be more likely as he is right-hand dominant) and incorporate the left hand into activities where possible.

Mr Sharma (56 y)
Clinical information: Left hemisphere LACI
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.

Key points:

Mr Sharma is starting from a position of severe weakness in the hand and arm, but is predicted to be using his upper limb for most activities of daily living within 12 weeks, though function may remain affected by slowness, weakness and/or clumsiness.
The rehabilitation focus should be to promote function
Goal setting should consider the abilities he needs for work and travel, keeping in mind that it’s most likely he will be able to use his right arm for most day to day activities though a full recovery to 100% is unlikely.
Therapeutic interventions should initially focus on assisting the return of voluntary muscle activity in the hand and arm. As he regains movement, interventions should aim to improve strength, coordination, and fine control. Repetitive practice of every daily tasks should help. As he continues to recover Mr Sharma may be appropriate for prescription of a home exercise programme.
Mr Sharma should be encouraged and supported to minimise compensation with the left hand and incorporate the right hand into functional activities as the hand and arm improve.

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.

Key points:

Mr Fisher is starting from a position of severe weakness in the hand and arm, and is predicted to regain some movement within 12 weeks and possibly grasp function, though recovery of dextrous hand function is unlikely.
The rehabilitation focus should be to promote movement.
Goal setting should consider the abilities he needs for returning home, and for a possible return to work. An interdisciplinary approach should be taken to be ensure realistic goals are set. For goals involving his right upper limb, it’s important to keep in mind that it’s most likely he will need to use his left hand to help with some activities. Some work-related activities such as typing require fine control of the arm and hand and this may be a difficult activity given his upper limb prediction.
Therapeutic interventions should aim to improve strength, active range of motion, and joint flexibility of the right hand and arm. Therapy could include practice of adapted daily activities that incorporates both hands when necessary
Mr Fisher should be encouraged and supported to use adapted daily activities during his day, whenever possible.

Mrs Parata (58 y)
Clinical information: Left hemisphere TACI
PREP2 information: SAFE score = 0, MEP-, NIHSS = 9
PREP2 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.

Key points:

Mrs Parata regain some movement within 12 weeks but is unlikely to recover useful upper limb function, though may be able to use their weaker hand as a stabiliser in bimanual tasks.
The rehabilitation focus should be to promote compensation.
Goal setting should consider the abilities she needs to maximise independence and return home if possible. An interdisciplinary approach should be taken to be ensure realistic goals are set. For goals involving the upper limbs, it’s important to keep in mind that it’s most likely she will need to use her left (non-dominant) hand for most activities, though she may be able to use the right hand as a stabiliser.
Therapeutic interventions should aim to maintain the flexibility of the right 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 arms where possible.

Frequently asked questions

If someone asks “I am having TMS testing soon, could you remind me what it is testing and what it might feel like?” what should I say?
It may be best to get a staff member trained in using or supporting TMS to answer this question for the patient. But in general terms, you could cover the following main points:

TMS provides a safe way of testing whether the movement pathways from your brain to your affected hand and arm are working or not at this time.
TMS is a comfortable experience for most people.
During testing the TMS operator will hold a coil against the side of your head, over your hair.
The main things you’ll notice are a click noise each time the device it is activated, and a light tap on your scalp, but this won’t be painful.

Is it possible for the hand and arm to recover better than predicted?
Yes. The predictions made by PREP2 are accurate for 75% of patients at 3 months post-stroke. For the remaining 25%, about one-third have a better outcome than expected. Most of these are patients with a Good prediction go onto have an Excellent outcome, and about 10% are people with a Poor prediction who do a little better than expected and have a Limited outcome. Note that patients with a Limited or Poor prediction are not able to have a Good or Excellent outcome, as the damage to their motor pathways prevents them from regaining fine motor control. PREP2 predictions are correct for 80% of patients at 2 years post-stroke, which is very reassuring. It’s pleasing to see that some people do recover more hand and arm function than predicted by PREP2. This could be due to a range of reasons, which we are continuing to explore with our research.

Can the hand and arm keep improving beyond 12 weeks after stroke?
Yes. The brain can continue to change in response to practice and experience, throughout life. Therefore it’s possible for improvements to be made beyond 12 weeks after stroke. However, most people make most of their recovery of movement within the first 12 weeks after stroke. This is because of the unique biological conditions in the brain during this time. Improvements can be made after this time, however they are usually smaller, slower to develop, and require more effort.

Why do some people not recover hand and arm function as well as predicted?
There may be a range of reasons why some people don’t reach their predicted upper limb functional outcome. For example, their function might be limited by problems with their cognition, attention, and communication. They may also have other health problems that make it difficult to engage in rehabilitation. We are continuing to explore these factors with our research. There is also a responsibility on the patient for practicing, and it is possible that a patient’s ‘potential’ may not be met if a patient chooses not to engage in their therapy.

Can you get away with no therapy for a patient with an Excellent prediction?
PREP2 was developed and validated with patients receiving therapy as required, including those with an Excellent prediction. Therefore, at a minimum therapists should provide education, including information about use and avoiding compensation, and consider prescribing self-directed hand and arm exercises.

Do patients with a Poor prediction still need upper limb therapy?
Yes. Patients with a Poor prediction are given a focus for their upper limb rehabilitation, and together with their therapy team they can set goals that are realistic and worthwhile. Therapy can include interventions and education to help prevent secondary complications, such as shoulder pain. Therapy also has a very important role in helping the patient to learn to compensate with their other hand (or use both hands where possible) for activities of daily living. This will help a patient maximise their independence, and may be particularly pertinent if the weaker hand was their dominant hand.

How does prediction information travel with the patient?
Your organisation should have a method to formally document PREP2 predictions. Most often predictions are recorded in the clinical notes, but there may also be other methods on electronic records systems. Ask a colleague or a member of your PREP2 implementation team if you are unsure. It is important for PREP2 prediction information to be handed over to ongoing services, and discussed with the appropriate new staff.

I’m part of the community rehabilitation team, and my patient is coming up to 3 months post-stroke. They want to know if they’ve achieved their predicted outcome. What should I say?
The only way to really know is by doing the Action Research Arm Test, and seeing whether their score lies in the range for their predicted outcome. However, this test isn’t part of routine clinical practice in many settings. If it’s unavailable, then it may help to consider whether their current upper limb functional capacity fits the overall description of that prediction. If their function is less than expected, and they are still experiencing meaningful improvements in their hand and arm, it would be worth considering further upper limb therapy to see if they can achieve their predicted outcome. A small number of patients simply take a little longer to get there. If their function is less than expected, but they are not experiencing any further improvements, it will be important to remind the patient that the prediction was not a guarantee, and that they may not achieve the outcome that was predicted. Unfortunately some patients don’t do as well as expected, and this might be related to other factors that limit their upper limb capacity, such as sensory loss, vision loss, apraxia, and musculoskeletal conditions. In this case, this patient’s goals might need to be reconsidered, and therapy might need to be reoriented towards finding ways to optimise functional independence within the limits of the impairment the patient is experiencing.

What do I do if I have a question about PREP2?
You could discuss your PREP2 query with another therapist or a member of your organisations PREP2 implementation team. You could also look at the PRESTO website for more information and resources on PREP2.

Quizzes

Click below for practice quizzes to assess your learning on the PREP2: Using and Supporting Predictions section.

Once a practice quiz has been completed with at least 70% correct you will be emailed a link to the final quiz for either Part 1 or 2.

If you pass a final quiz with at least 80% correct you will be emailed a certificate of completion for that quiz. You will need certificates for both Part 1 and Part 2 to be certified for the PREP2: Using and Supporting Predictions section. There is no limit to the number of attempts for the practice or final quizzes.

PREP2: Using and Supporting Predictions – Part 1

PREP2: Using and Supporting Predictions – Part 2