Frequently, patients who have had a stroke also experience loss of function in the upper extremity. Unfortunately, there is no gold standard for remediating the upper extremities. Constraint-induced movement therapy (CIMT) has been shown to be effective. Yet, there is a criterion for eligibility. Additionally, CIMT requires extensive time and may show limitations. For instance, Dromerick et al., (2009) identified that massed practice with CIMT had an inverted dose-response effect after 3-months. 

To understand when to prioritize upper extremity rehabilitation, use the most recent edition of the Prediction Recovery Potential (PREP2) as an indicator of how much focus should be given to the affected upper extremity. The PREP 2 has excellent prediction using a manual muscle test and the combined scores of shoulder abduction finger extension (SAFE) that are >8. Age is also accounted for within the PREP2 algorithm. Using the PREP2 can help determine the likelihood of functional recovery for the affected hand and influence how much time an OT wants to focus on remediation versus compensation. See the image below for a detailed illustration of the PREP2 algorithm.  

Prioritizing the affected hand can also be done using the grade four inclusion criteria for CIMT, which includes the rule of 10. This rule includes 10 degrees of thumb abduction, 10 degrees of wrist extension, and 10 degrees of extension for any two fingers (Kwakkel et al., 2015). Shoulder flexion, abduction, or scaption should also be greater than or equal to 45 degrees. Together, these methods for prioritizing the upper extremities can help an OT decide their interventions to promote the most gain for their patients. 

An OT should challenge the hand through shaping strategies that are task-specific and incrementally progressive with the challenge to grasp and dexterity. Tasks should be occupation-based, focused, and/or centered to increase salient, patient-centered care. Error-based learning is recommended for the upper extremity, and error augmentation can be implemented with task variability. An OT can use Hornby et al.'s (2015) skill acquisition chart below to identify when to assist or when to augment errors. An OT can either use latency or excessive time for task completion, or they can use the rule of making the same error at least 2-3 or 3-5 times before providing the least to most assistance. Patients should make their own goals related to the occupation-based shaping task to increase salience and volition. Use the Volition Tool to determine how much help a patient needs with self-selected task-specific goals. Similar to intensified self-care, the OT-based HIT for task-specific upper extremity shaping should include blocked and massed practice for skill acquisition, increased variability, and practice of random rotation to transfer, master, and generalize skills.