When I have done this activity with my clients, it has oftentimes been the first time they have realized they do have some functional use of their upper extremity. The visual feedback is an 'eye-opener' for them.
To downgrade: use a thicker writing utensil like a marker and build-up the shaft. Tape the paper to the table. Complete the task in standing.
Keep in mind that for the low-level hemiplegic arm, you will be likely be capturing proximal arm movement and not the distal, fine motor movement of the hand. That's okay. This still provides an excellent visual of progress for your client.
To upgrade: Use a thinner writing utensil like a pencil or pen. Make the task a bilateral activity by removing the tape from the paper. Complete the task in sitting. Try a vertical surface (like a whiteboard or a paper taped to a wall)
To change it up: use paint and canvas!
2. Wipe down counters
In the orthopedic world, these are called "table slides." I like this task for neuro-rehab because it's functional, effortlessly graded, and repetitions are easy to accomplish.
To downgrade: use hand-over-hand to guide your client through her entire active range of motion. Teach self guided hand-over-hand.
To upgrade: move from active-assisted range of motion to active range of motion without hand-over-hand assistance. Use a wet towel rather than a dry towel. Wipe down a vertical surface such as a window.
To change it up: 'dirty' the surface to create a visual. I like to use shaving cream.
3. Wring out a rag.
This task makes repetition super easy and motor-feedback is built into the task. I like this for working on coordination of grasp/release as well as improving wrist flexion and extension, particularly in coordination with hand grasp.
To downgrade: use a large basin or a sink to minimize the mess. Use a washcloth versus a hand towel.
To upgrade: add washable paint or soap to the rag and instruct your client to wring and wet until the rag is clean. Combine the task with washing dishes or wiping down the counter.
When you have the time for set-up and clean-up, cooking is a perfect neuro-rehab task. Of course, teaching the whole-task of cooking is an important and useful treatment tool, and should be customized to the dishes your client wants to prepare.
I like to use partial cooking tasks to achieve functional repetitive training for upper extremity rehabilitation.
Some specific and repetitive cooking tasks I have used are:
scoop and drop cookie dough
transferring beans from one container to another
flipping pages in a cook book
opening a variety of spice containers
To downgrade: use adaptive kitchen utensils such as the cutting board pictured. Provide hand-over-hand assistance as needed to achieve repetitive muscle activation and proprioception.
To upgrade: progress from partial cooking tasks to integrating those partial task into the whole-task of making a meal or side dish.
Keep in mind that simply doing the task of cooking is not therapeutic. You should complete an activity analysis and use your results to create a specific treatment based on your client's current abilities and goals.
I would love to learn what you are doing to help your clients complete functional activities. We're all in this together.