Table 1 Summary of common scenarios leading to decreased impaired arm involvement during real life

The immediate rewards of engaging in compensatory behaviors are more apparent and achievable than for engaging restorative behaviors

Patient becomes confused and feels encouraged to engage in both compensatory activities and restorative behaviors. Patient becomes satisfied with the level of independence attained either through caregivers (proxy control) or through the compensatory strategies.

The effort (or cost) to engage in restorative behaviors is beyond their ability.

Patient stops using the impaired arm due to the frustration encountered during attempts to use the arm. The effort to engage in restorative behavior is prohibitive and therefore achieving bilateral arm use is perceived as an unrealistic goal.

Patient perceives that the activities are too challenging and therefore impossible to achieve or too easy and therefore irrelevant.

Patient loses range of motion, muscle strength, dexterity and other motor abilities due to factors such as abnormal muscle activation and force generation.

Patient loses sensory feedback in the impaired limb.

Patient has a frontal lobe lesion and diminished motivation.

The effort to engage in restorative behaviors is not seen as resulting in getting their perceived needs met.

Patient perceives that continuing in rehabilitation is unproductive because it will not help in regaining previous roles in life.

The reasons (or incentives) given to encourage them to engage in restorative behaviors are not sufficient.

Patient believes their discharge from the hospital signals the end of recovery and believes the standard predictions that there is minimal to no recovery after 6 months.

Patient loses the ability to focus on treatment activities because of neurological deficits and must be reminded to do it.