What is Cervicogenic Headache?

By Bijal Shah

Cervicogenic headache is a secondary headache with the primary cause being a pathology in the neck. This means a problem in the neck is causing a headache as a symptom.

The cervicogenic headache typically starts from the back of neck/back, travels up to the front of the head. It usually is on one side of the head. And therefore, this type of headache is a referred pain to the head.Cervicogenic Headache

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Three Ways to Predict Stroke Recovery functionally

By Bijal Shah

Stroke is the fifth leading cause of death in the US and a leading cause of disabilities. There are two main different types of strokes. As we know, the neurological recovery and returning of functions after stroke mainly depend on the type and severity of the stroke. There are a few other outcome predictors like age, prior level of function, and how long it took for a patient to receive medical treatment, etc, that can also assist us in determining the outcomes. But none of these predictors can tell us the level of function a person will achieve in six months or in a year post-stroke. The goal of this post is to discuss how to predict the functional recovery of a patient after a stroke!!

Since I have been in physical therapy, I have been looking for a tool that can predict an outcome for a patient after an injury. Almost every field in medicine is able to predict some sorts of outcomes for their patients after a disease or an injury. Unfortunately, the therapist did not have that ability.

The ability to predict outcomes after any injury is crucial. This not only helps the patient to set the expectations right but also assists in preparation for the discharge. The level and independence at discharge determine the house modification, assistance required, and so on.

Knowing the functional outcomes assists us in :

  • Developing an appropriate plan of care
  • Providing appropriate nursing and therapy assistance
  • Explain and educate the patient as well as families how to prepare for post-discharge
  • To provide appropriate assistance to the patient and families to deal with the loss they may suffer
  • To set the right expectations

You will be surprisingly happy when I tell you that you can really predict a functional return of your patient within 7 days of a post-stroke!! Yes, you read that correctly, a therapist can predict functional recovery of 6 months or 1 year in the first 7 days of stroke onset. Isn’t that COOL!!!

So here how it goes!

Currently, there are two algorithms that can help you determine the functional recovery of the upper limb for a patient after a stroke. They are called PREP algorithms.

SAFE score:

Both PREP algorithms use the SAFE score of a paretic upper extremity. The SAFE score is a total score of manual muscle testing of shoulder abduction and finger extension.

As we know, manual muscle testing score ranges from 0 (no trace of contraction) to 5 (full range of motion, against gravity, against maximal resistance). So the maximum possible SAFE score is 10.

PREP Algorithm in Stroke Recovery:

The algorithm begins with a simple bedside assessment of upper limb impairment and progresses to neurophysiological and neuroimaging assessments if required. The SAFE score is recommended 72 hours after stroke.

stroke recovery

The term for recovery determines the amount of recovery a person will have after 12 weeks of rehabilitation. That also assists therapists to develop appropriate goals and plans of care.

You can find the full definitions of recovery and the type of goals a therapist can have at tbe end of the article. 

PREP2 Algorithm in Stroke Recovery:

This algorithm predicts upper limb functional outcome at 3 months post-stroke. The most beneficial thing about this algorithm is that it takes age into the account. Also, we do not have to rely on a strong diagnostic tool like MRI to predict the outcome with this algorithm.

Therefore, PREP 2 not only makes it easy for clinicians to use but also makes it realistic in a day to day clinical setting to utilize such an important tool.

Just like original PREP, PREP 2 also starts with a SAFE score on day 3 post-stroke.

Along with the SAFE score, a clinician may have to use Transcranial Magnetic stimulus (TMS) to determine Motor Evoked Potential (MEP) status in the paretic upper limb.

If the MEP can not be elicited, a clinician will go further into the algorithm to use the NIHSS score on the third-day post-stroke.

Stroke recovery

You can PREP 2 attachment where I discuss the definition of the recovery. Additionally, I have included NIHSS and Berg scale.

So What about Recovery in Ambulation?

As you just read, the PREP algorithm only talks about upper limb recovery after a stroke. It does not assist a therapist in determining if community ambulation is going to be a realistic goal or not.

Another research done using the Berg balance scale (BBS) during the first week of stroke onset, helps us to determine just that!! The Berg balance score done at the admission during inpatient rehabilitation stay significantly predicts independence with ambulation.

As we know, BBS is a 14 items scale, with a total score of 56. The cut-off score of 29 on admission predicts that an individual will be a community ambulator. While a cut-off score of 12 at admission predicts a non-ambulatory to regain unassisted ambulation.

As I mentioned earlier, I have attached a full BBS with the slides.

Hope this information helps you to develop your plan of care and answers any questions your patient or families have! As always, if you have any questions, please feel free to reach out to me.


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  1. Stinear, M.C., Barber A.P., Petoe, M., Anwer, S., & Byblow, D.W.. The PREP algorithm predicts potential for upper limb recovery after stroke. Brain: 135 (8); 2527-2535.
  2. Stinear, M.C., Byblow, D. W., Ackerley, J.S., smith M., Borges, M.V., Barber, A.P. PREP2: biomarker-based algorithm for predicting upper limb function after stroke: Annals of Clinical and Translational Neurology; 2017, 4(11): 811-820.
  3. Maeda,N., Irabe,Y., Murakami, M., Itotiani, K., Kato, J. Discriminant analysis for predictor of falls in stroke patients by using the Berg Balance Scale. Singapore Med J. 2015; 56 (5): 2880-283
  4. Louie, D.R., Eng, J.J. Berg Balance Scale Score at Admission Can Predict Walking Suitable for Community Ambulation at discharge from Inpatient Stroke Rehabilitation. Journal of Rehabilitation Medicine 2018: 50(1); 37-44.
  5. Smith MC, Ackerley SJ, Barber PA, Byblow WD, Stinear CM. PREP2 Algorithm Predictions Are Correct at 2 Years Post Stroke for Most Patients. Neurorehabil Neural Repair. 2019 Aug; 33(8):635-642. Epub 2019 Jul 3.
  6. Louie, R.D., & Eng, J.J. Berg Balance Scale Score at Admission Can Predict Walking Suitable for Community ambulation at discharge From Inpatient Stroke Rehabilitation. Journal of Rehabilitation Medicine 2018;50 (1).
  7. https://www.sralab.org/rehabilitation-measures/berg-balance-scale
  8. https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf
  9. https://www.sralab.org/rehabilitation-measures/national-institutes-health-stroke-scale
  10. https://www.sralab.org/rehabilitation-measures/berg-balance-scale

Therapy E-visit : A new type of service Therapist can provide

By Bijal Shah

As I write this article, the world is changing every minute. What was being considered standard a few days ago, is not so standard anymore. The way health care professionals learn to practice for decades all around the world is not the norm anymore. And this change brings many questions and many opportunities!!

Therapy E Visit

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How to use Exercise Bike effectively and safely

By Bijal Shah

The exercise bike is a very popular way of getting your workout checked off for the day. Most of the exercise bikes provide different exercise programs that include cardio, resistance training, weight loss training as well as the manual setting for beginners. Some newer models also include anaerobic exercise setting or high-intensity training. Thus, exercise bikes give users the flexibility to choose the desired work out session for the day, comfort to perform the work out any time of the day, as well as ability to perform the session in own homes. No worries about snow days or rainy days, one can still continue this important healthy habit and be proud of himself for doing it!

exercise bike

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ALS: A Comprehensive Rehabilitation Guide

By Bijal Shah

ALS is otherwise also known by its full name amyotrophic lateral sclerosis. It is a type of progressive neurodegenerative disease that affects upper and lower motor neurons in the brain and the spinal cord. It comes from the Greek language where “A” means no. “Myo” refers to muscle, and “Trophic” means nourishment – “No muscle nourishment.” The motor neurons are responsible for initiating voluntary muscle movements. They also act as a bridge between the brain and the muscles for crucial communication. So, as the name suggests, when a muscle does not have any nourishment, it “atrophies” or wastes away. As the motor neurons degenerate, it leads to a hardened area in the brain or scarring which is also known as “sclerosis”. Continue reading “ALS: A Comprehensive Rehabilitation Guide”

Tips to Develop Good Relationship between Therapist and Assistant

By Bijal Shah

Working in the healthcare industry is tough. Being a therapist is even tougher. You are constantly being challenged by a patient and their families for active participation. Your manager looks at you to complete your pending paperwork. The other team members might be pushing a patient for discharge. And you have a team member (PTA or PT) who gives you hard time for the plan of care, or your techniques, the school went to or any other small thing that he or she can talk about. Yes, I am talking about that therapist or therapist assistant who constantly finds a problem in you or your ideas. This article discusses how to improve the relationship between the therapist and assistant.

PT- PTA relationship

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5 Tips to Improve Your Communication Skills As a Health Care Professional

By Bijal Shah

Communication is crucial in health care. The form of communication can be immediate, FYIs, or education to patient and or family members. Effective and timely communication builds trust among team members, patient and care providers. Here are a few tips for effective communication.


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Managing chronic pain without addiction – A guide to Pain Management without Opioids

By Bijal Shah

Pain is defined as a feeling or sensation that is not pleasant or comfortable. Pain can be mild, moderate or severe.  It can bearable or unbearable. It may or may not disrupt one’s daily life or functional level. But the truth is, no one wants to live in pain. In addition, no one should put their health at risk in an effort to be pain-free.   I will focus on some very effective and non-pharmacological pain management techniques in this post.

Pain Management

Since 1999, Americans have increasingly been prescribed opioids. This includes painkillers (like Vicodin, OxyContin, Opana, and methadone), and combination drugs (like Percocet). In some situations, prescription opioids are an appropriate part of medical treatment. However, opioid risks include depression, overdose, and addiction, plus withdrawal symptoms when stopping use. As a result, people addicted to prescription opioids are 40 times more likely to become addicted to heroin. Continue reading “Managing chronic pain without addiction – A guide to Pain Management without Opioids”

A Physical Therapist Guide to Treat and Manage Congestive Heart Failure (CHF)

By Bijal Shah

Congestive heart failure is a series of conditions when cardiac output cannot meet the metabolic demand of the body. Approximately 5 million people in the United States have been diagnosed with Congestive Heart Failure (CHF). More than half a million people are diagnosed annually. Heart failure is mainly due to a structural or functional defect in the heart. The aim of this article is to talk about the role of physical therapy and the importance of an exercise regime in patients with congestive heart failure.Congestive Heart Failure

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A comprehensive guide to different types of transfer in Physical Therapy

By Bijal Shah

There are many types of transfer a clinician can guide a patient to perform.  As physical therapists, we come across different people with different limitation and abilities. While providing a PT treatment or assessing the patient, our goal (along with patients and families) is to make our patients independent in the majority of functional tasks.

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Tips on Prescribing Exercise as a Physical Therapist

By Bijal Shah

How a physical therapist decides/prescribes the exercise for a patient to make meaningful changes.  You may be wondering, exercise prescription??  We have heard about prescribing medication but not exercises, right?  Why do I bother to spread awareness that exercises, just like medications also have a prescription? Yes, you read that right.  We, physical therapists, don’t just come up with exercises and resistance that patients need to do.  Its also not just a guess when we say the frequency and intensity of exercises like 10 repetitions for twice a week.  Exercise is a prescription; just not written on a prescription pad!  exercise prescription Continue reading “Tips on Prescribing Exercise as a Physical Therapist”