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).