Table 4.

Middle Training Visits

Session description	Debriefing of preceding Action Plan (“Practice doing each of the three tasks you chose for outside-of-training practice (preparing/eating food, personal hygiene/grooming/dressing, and housework/home maintenance) and assess in what ways you are making progress.”):
	T: “How did you do with your Action Plan? Did you discover or try any new activities since we last met? Are you noticing any changes with activities you tried earlier?”
	P: “I have been ironing daily and noticed that I can maneuver the shirts better and can pump the steam button faster with my thumb. I can now hold large pliers in my weaker hand—I am happy that I did not have to ask my wife to help me! I also worked with the weed eater for around 90 min. I think I only took about 4 breaks that were about 2–3 min. Shoulder was kind of sore the next day though, so I rested my arm.”
	Determination of tasks and sequence of activities for the session’s practice: hammering nails in 2×4 board, painting a wall with a brush, refilling mechanical pencil with lead, digging holes for plant with hand shovel, preparing wall for painting by sanding
	P: “I think sanding will be a good way to increase strength and endurance in my arm.”
	Self-efficacy rating for the priority task: 7/10
Task performance and dialogue	T: “How long do you think you can sand the wall?”
	P: “I am not sure, maybe a minute. But after sanding the wall, I want to use the screwdriver to put back the 3 screws in the wall and place back the soap holder.”
	[TASK PERFORMANCE: P sanded wall 6 ft high (head level), and suggested timing the activity to provide a measure of accomplishment.]
	T: “That is really nice because you are directing the progression of the activity.”
	[TASK PERFORMANCE: Over 3 trial attempts, P was able to increase time spent sanding wall without rest. He focused on speed of unscrewing and screwing 3 screws. Improved speed and reduced time to complete task from 3 min 12 sec to 2 min 5 sec over 3 trial attempts.]
	P: “Do you have any tape so I can tape around the door frame and molding? However, I think I can use my left hand [weaker hand] to trim the corners and ceiling without using the tape.”
	T: “Wow, you can trim without tape?” Unbelievable! How should we set up the challenge for this task?”
	P: “Measure the distance I am able to paint the top of the wall without touching the ceiling.”
	[TASK PERFORMANCE: P carried a 6-ft ladder to the wall, held the paint can/brush in the affected hand, and climbed the ladder.
	P was able to increase accuracy of trim job from 61 inches to 143 inches without touching the ceiling.]
	P: “Let’s try to paint the baseboards to make it harder.”
	T: “That is great! You just figured out how to increase the intensity of the task.”
	[TASK PERFORMANCE: P was able to trim the wall next to baseboard for a distance of 12 inches using the affected arm.]
	P: “I think I can do better. I am going to have to come up with a new strategy to paint the baseboards.”
	T: “Your painting skills are fantastic, what do you think?”
	P: “Pretty good, I may be able to get a job painting. It is an advantage to be able to paint with both hands.”
Elements/comments	Self-direction, problem solving, and intensity of training initiated by the participant; the therapist was supportive of the participant’s choices, building self-efficacy, and support for autonomy
	P initiated progression of the task and T supported autonomy by getting the paint tape and “going with the flow.” T remained in the background and allowed time for the P to identify, choose, and direct challenges for himself
	T was enthusiastic and celebrated the P’s efforts and ideas
	P/T celebrated the success of the activity
	All principles (1–8) and all elements of ASAP represented in the P/T exchange: intrinsic motivation, capacity building, and skill development

Abbreviations: ASAP, Accelerated Skill Acquisition Program; P, participant; T, therapist.