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For Stroke Recovery PREP algorithm.

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Presentation on theme: "For Stroke Recovery PREP algorithm."— Presentation transcript:

1 for Stroke Recovery http://prepforstrokerehab.wikispaces.com/home PREP algorithm

2 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

3 Part 1Why use the PREP algorithm? Part 2How to use the PREP algorithm Part 3How to tailor rehabilitation Why is the upper limb import ant? What ’ s wrong with clinic al experi ence?

4 Why is the upper limb import ant? 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 facto r we can help with

5 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

6 Does experi ence help us answer her questi on? 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 exper ience Predicted ARAT score at 6M < 10 10 – 56 57 Overall The Action Resear ch Arm Test measur es upper limb functi on The maximum score for normal functio n is 57 Therapists predicted a category for each patient Correct predictions 86% 47% 61% 59% Overa ll, thera pists were right 59% of the time But…were no better than chance for this catego ry Experienced therapists can predict very poor and normal function, but struggle to predict which patients will be somewhere in between

7 Patients who initially have similar upper limb function can have very different recoveries Stinear et al., 2012, Brain, 135(8):2527-2535 Measu res were made from 2 weeks after strok e Each line repr esen ts an indi vidu al Patients can look the same at first, but recover differently The Action Researc h Arm Test measure s upper limb functio n

8 It would be good if we could make accurate predictions for individual patients MANAGE PATIENT E X P E C T A T I O NS TAILOR REHABILITATION GOALS This would help us to... USE TIME AND RESOURCES TO BRING THE BEST OUTCOME FOR THE PATIENT

9 Predictions based on clinical experience can be inaccurate A systematic approach may be more accurate How can we answer her questi on? Will my hand get better ?

10 Part 1Why use the PREP algorithm? Part 2How to use the PREP algorithm Part 3How to tailor rehabilitation Is it easy to use PREP? Is PREP really any better than clinic al experi ence?

11 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 presentNotable Asymmetry index < 0.15 Limited Asymmetry index > 0.15 None Predicted recovery of upper-limb function at 12 weeks SAFE score ≥ 8Complete 72 hours 5 days 10 days 5, 6 or 7 < 5 PREP algorithm

12 72 hours PREP algorithm Notable 5, 6 or 7 Stinear et al., Brain, 2012, 135(8):2527-2535 Stinear, Lancet Neurology, 2010, 9(12):1228-1232 The first step is to calcul ate the SAFE score SAFE = Should er Abduct ion and Finger Extens ion 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… ≥ 8Complete Predicted recovery of upper-limb function at 12 weeks SAFE score …the patien t is predic ted to make a comple te recove ry If the SAFE score is 5, 6 or 7 within 72 hours of stroke… …the patien t is predic ted to make a notabl e recove ry If the SAFE score is less than 5, you need the next step…

13 Notable SAFE score ≥ 8Complete 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 painless TMS 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 algorithm Stinear et al., Brain, 2012, 135(8):2527-2535 Stinear, Lancet Neurology, 2010, 9(12):1228-1232

14 Notable SAFE score ≥ 8Complete Predicted recovery of upper-limb function at 12 weeks 72 hours 5, 6 or 7 TMS < 5 5 days MEP present Muscle respon ses are record ed with EMG, and are called MEPs If the TMS produces a response… …the patie nt is predi cted to make a notab le recov ery PREP algorithm Stinear et al., Brain, 2012, 135(8):2527-2535 Stinear, Lancet Neurology, 2010, 9(12):1228-1232

15 Notable SAFE score ≥ 8Complete Predicted recovery of upper-limb function at 12 weeks 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 PREP algorithm Stinear et al., Brain, 2012, 135(8):2527-2535 Stinear, Lancet Neurology, 2010, 9(12):1228-1232

16 Notable SAFE score ≥ 8Complete Predicted recovery of upper-limb function at 12 weeks 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 pathway s are in the posteri or limb of the interna l capsule More asymme try in these pathwa ys means more damage PREP algorithm Stinear et al., Brain, 2012, 135(8):2527-2535 Stinear, Lancet Neurology, 2010, 9(12):1228-1232

17 Notable SAFE score ≥ 8Complete Predicted recovery of upper-limb function at 12 weeks 72 hours 5, 6 or 7 TMS < 5 5 days MEP present MEP absent 10 days Asymmetry score < 0.15 Limited Asymmetry score > 0.15 None MRI Low asymm etry means the patie nt has limit ed poten tial High asymm etry means the patie nt has no poten tial PREP algorithm Stinear et al., Brain, 2012, 135(8):2527-2535 Stinear, Lancet Neurology, 2010, 9(12):1228-1232

18 The PREP algorithm can make accurate predictions for individual patients Does the PREP algor ithm work? This is the same graph you saw earli er Now the patie nts are categ orise d by the algor ithm

19 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% 69% 87% 83% How does it compar e to experi enced therap ists? This is the table you saw earli er Here ’ s what we see for PREP There are 4 catego ries, rather than 3 for the therap ists

20 SAFE 5 - 7 17% SAFE score > 8 44% Unknown TMS 35% MEP +ve 15% Unknown MRI 20% Unknown FAAI <0.15 13% >0.15 7% 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 predic tion for around 60% of patien ts TMS is need ed for the rest MRI is neede d for aroun d 20% of patie nts A predict ion can ’ t be made for a small percent age of people who can ’ t have TMS or MRI More advanced tests (TMS, MRI) are only used as required, for some patients

21 Part 1Why use the PREP algorithm? Part 2How to use the PREP algorithm Part 3How to tailor rehabilitation So how do we use the predic tions? Does PREP improv e outcom es?

22 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 ≥ 8 72 hours 5 days 10 days 5, 6 or 7 < 5 PREP algorithm Stinear et al., Brain, 2012 Stinear, Lancet Neurology, 2010 How are these predictions used to focus rehabilitation?

23 Rehabilitation focus Notable Limited None Complete Promote normal use Promote function Promote movement Promote compensation

24 Complete Promote normal use Rehabilitation focus 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?

25 Complete Promote normal use Rehabilitation focus 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 websit e has a progra mme to downlo ad for free

26 Promote function Rehabilitation focus 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

27 Promote movement Rehabilitation focus 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

28 Promote compensation Rehabilitation focus 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

29 Rehabilitation focus Notable Limited None Complete Promote normal use Promote function Promote movement Promote compensation Notice that everyone needs therapy… …it ’ s just the focus that changes, dependi ng on the degree of damage to key motor pathway s

30 Part 1Why use the PREP algorithm? Part 2How to use the PREP algorithm Part 3How to tailor rehabilitation What have we learne d?

31 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 project You 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.comhttp://prepforstrokerehab.wikispaces.com

32 She is predicted to be using her affected right hand and arm for most activities within 12 weeks Where does this leave Mrs McInty re? She is in the notable category, so her rehabilitation focus is to promote function How do we know? SAFE score = 2 TMS = MEP + No MRI needed

33 12 weeks after stroke:ARAT score = 38 /57 MAL score = 7.6 /10 How is she doing at 12 weeks? Upper limb funct ion is in the notab le range This Motor Activit y Log score means she ’ s using her right hand, with some difficu lty Mrs McIntyre has returned to work part-time

34 Associate Professor Cathy Stinear Dr Suzanne Ackerley Professor Alan Barber Professor Winston Byblow Ms Anna McRae Dr Samir Anwar Professor Rhema Vaithianathan Research led by: With special thanks to the patients and their families for taking part… …as well as the therapis ts and clinicia ns helping to test the algorith m


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