Delivering predictions after TMS
Please watch the following 30-minute video on delivering predictions:
Sharing a PREP2 prediction is different after TMS
Sharing a prediction after TMS can feel different because of when the prediction is delivered and how much weakness the patient has at that time. Patients with a Day 3 SAFE score ≥ 5 usually receive their Good prediction on Day 3, when they already have some movement. Patients with SAFE < 5 often wait until Days 3–7 for their prediction, after TMS testing, which means they’ve experienced uncertainty about how their hand and arm might recover for a longer period of time.
Patients who need TMS testing are usually given information about all possible outcomes beforehand. This helps them prepare for either a Good or Limited/Poor prediction and reduces surprise when the result is delivered.
The level of weakness at the time of prediction delivery also affects how patients interpret the result. Those with SAFE ≥ 5 often find a Good prediction easier to understand. Those with SAFE < 5 may have moderate to severe weakness, sometimes with no visible movement, which can make a Good prediction seem harder to believe. A clear explanation, along with showing them EMG traces that have MEPs, can help them understand why the prediction is credible.
The level of weakness also shapes early rehabilitation planning. For patients with SAFE < 5, initial therapy may focus on helping voluntary muscle activity return before progressing to strength, coordination, and fine control.
This final section is designed to help you become familiar with delivering PREP2 predictions after TMS. Read through each prediction to build your understanding, then move to the Case Examples page to practice and reflect with a partner.
A handout of the following information can be downloaded here.
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.
When the patient has significant other impairments such as sensory loss, vision loss, and apraxia, it might make it more difficult for them to use their hand and arm in daily activities 3 months after stroke, resulting in a Good outcome at the lower end of the ARAT score range for this category. In this situation, it’s important to focus on providing upper limb rehabilitation that maximises the patient’s function despite these impairments.
Information for the patient and their family when TMS was used to obtain the prediction:
The TMS assessment shows that the pathways between your brain and your arm are working
This means your hand and arm have the potential to regain fairly good movement within the next 3 months
You have the potential to be able to use your hand and arm for most day to day activities, although it may still be affected by slowness, weakness or clumsiness
The focus of your rehabilitation will shift from helping you regain movement to improving your strength, coordination, and fine control
You will need to practice using your hand and arm to help it improve
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 have potential 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
Delivering a Limited prediction
Discussing the Limited prediction with the patient is about identifying that they will regain some movement (positive statement), but that fine finger control is unlikely. These patients are usually quite impaired at this stage (SAFE score < 5). They will have had TMS testing and and have been told that the connections to their hand and arm aren’t working very well. So, it might not be completely unexpected to hear that their recovery will be limited, though it is always a disappointment. The good news is that their stroke is at the moderate to milder end of the NIHSS scale and they will be able to regain some movement, possibly including grasp function.
These patients:
are any age
have a Day 3 SAFE score less than 5
are MEP- on TMS testing at 3 – 7 days post-stroke
have a Day 3 NIHSS score < 7
Information for the patient and their family:
The TMS assessment shows that the pathways between your brain and your arm have been damaged
You can expect to regain some limited arm movement within the next 3 months
You might also regain some hand opening and closing, though fine finger control is unlikely
You will probably need to use the other hand to help with some activities
The focus of your rehabilitation will be on maintaining and improving the strength and flexibility of your hand and arm, and helping you to adapt activities to incorporate this hand and arm wherever possible
You will need to practice using your hand and arm to help it improve.
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 Limited upper limb outcome within the next 3 months
They can expect to regain some movement and possibly grasp function, though recovery of dextrous hand function is unlikely
Upper limb rehabilitation can focus on improving strength, active range of motion, and joint flexibility, and adapting daily activities to incorporate both upper limbs when necessary to achieve a task
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 Poor prediction
As with all other predictions, the patient who receives a Poor prediction is also told what the focus of the rehabilitation will be. This makes it clear that they will be treated, and hopefully allays their concerns that their Poor prediction means we might give up on them. The team are not giving up it’s just that the goals should change so they are realistic and worthwhile. Therapy can focus on learning to compensate well with the non-affected hand and arm so they can manage everyday tasks, such as tying shoelaces with one hand, single-handed buttons, unscrewing jars etc. This will minimise their disability and help them to live as independently as possible, despite their upper limb impairment. It is possible that they do better than expected, but this means a limited recovery (not good or excellent).
These patients:
are any age
have a Day 3 SAFE score < 5
are MEP- on TMS testing at 3 - 7 days post-stroke
have a Day 3 NIHSS score of ≥ 7
Information for the patient and their family:
The TMS assessment shows that the pathways between your brain and your arm have been damaged
You may regain some movement in your arm within the next 3 months
You might be able to use your weaker hand to stabilise objects, but fine finger control is unlikely
The focus of your rehabilitation will be on maintaining the flexibility of your hand and arm, preventing shoulder instability or pain, and helping you learn to perform day to day activities with your other hand or both hands where possible
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 Poor upper limb outcome 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
Upper limb rehabilitation can focus on preventing secondary complications such as pain, spasticity, and shoulder instability, and reducing disability by helping the patient learn to compensate with their other upper limb for activities of daily living
This prediction is based on the patient’s current status, and is not a guarantee, as some people recover more or less than expected
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FAQs
What happens if the patient has another stroke during their admission?
What if I give a Limited or Poor prediction and it is wrong?
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.
The research has shown that we don’t see any people with a Limited or Poor predictions who have a Good or Excellent outcome by 3 months or even by 2 years. The predictions are delivered using careful language, with phrases such as “most likely” and “unlikely”, rather than talking in absolute terms. This can help a patient understand that it is a prediction and not a guarantee. It is worthwhile noting that therapists are advised to use their clinical judgment and continue to progress a person who is still improving beyond their predicted upper limb functional outcome.