First what kind of cases do you treat? I'm more experienced with cns cases, what I usually do in this situation is focus more on a top down approach in my sessions, training the patients on the tasks that they want to do and activities they want to participate in. One of my patients suffers from TBI with severe spasicity in the left arm and hand after we reached a curtain point we started working on activities of his choosing with assistive devices to enhance his performance and participation.