NEUROMUSCULAR & NERVOUS SYSTEMS

Interventions.
This category refers to neuromuscular/nervous systems interventions (including types,
applications, responses, and potential complications), according to current best
evidence, as well as the impact on the neuromuscular/nervous systems of interventions
performed on other systems in order to support patient/client management for
rehabilitation, health promotion, and performance across the lifespan.

Neuromuscular/nervous systems physical therapy

interventions and their applications for rehabilitation, health
promotion, and performance according to current best
evidence
Brandt-Daroff Habituation exercises
Move patient from sitting to the provoking position and hold for 30 seconds after symptoms
decrease. Return to sitting, and wait for symptoms to disappear. Move the patient to the mirror
position.
Repeat this process 10-30 times daily. The treatment should be continued until no symptoms are
produced over 2 consecutive days. 95% rate of cure within 3 to14 days of treatment.

Liberatory Maneuver
Quickly move the patient to the provoking position and hold for 2-3 minutes. Then move to the
mirror position through sitting. Hold for up to 5 minutes. If no symptoms are elicited, shake
patient with small amplitude oscillations. After this treatment the patient is to remain upright
with the head in a neutral position, a soft cervical collar should be used. The patient should not
bend over. This positional restriction is maintained for 48 hours. Usually only one treatment is
required. Success rate is 70%
Canalith Repositioning Maneuver
Rapidly move the patient from sitting into the Hallpike-Dix position ( supine with neck extended
30 degrees and involved ear down 45 degrees), hold this position 2-3 minutes. Rotate the head so
the patient is with the opposite ear down 45 degrees, maintain this position until vertigo stops.
Roll body on to the involved side, and hold for 2-3 minutes. Slowly sit up. Following this
treatment the patient should remain upright and use a cervical collar. The patient should not bend
over. These positional restrictions should be maintained for 48 hours post treatment. In addition
the patient should not sleep on their involved side for 5 more days. The result is reported to be 92
%.
Treatments for UVL and BVL
Cawthorne-Cooksey exercises
I.
In bed
1.Eye movements: a. Look up and down, b. Look to right and left,

Look at a finger moving from 3 feet to 1 foot from the patients

face.
2. Move the head, slow at first, then rapid and finally with eyes
closed
II.

a. Bend forward the bend backwards b. Turn side to side

In sitting
1. Move the head, slow at first, then rapid and finally with eyes

closed

III.

a. Bend forward the bend backwards b. Turn side to side

2. Shoulder shrugging and circling
3. Bending forward picking up objects from the ground
Standing
1.Eye movements: a. Look up and down, b. Look to right and left,
Look at a finger moving from 3 feet to 1 foot from the patients
face.
2. Move the head, slow at first, then rapid and finally with eyes

closed
a. Bend forward the bend backwards b. Turn side to side
3. Bending forward picking up objects from the ground
4. Move from sitting to standing with eyes open, then with eyes
shut

IV.

5. Throw a small ball hand to hand at eye level

6. Throwing a small ball hand to hand under knee
7. From sitting, stand up, turn around, then sit down
While walking
1. Play catch while walking in a circle
2. Walk across a room with eyes open then closed
3. Walk up and down a slope with eyes open then with eyes closed
4. Walk up and down stairs with eyes open the with eyes closed
6. Do sport or game that involves stooping, aiming and stretching

Vestibular Adaptation Exercises

Scan with eyes in all planes, progress by increasing speed
of scan
Move head while eyes are fixed upon a target
Move the body while fixing gaze upon a target (spotting)
Gait Training
Straight over level surfaces
Turning on level surfaces
Straight over inclined surfaces
Turning upon inclined surfaces

Anatomy and physiology of the neuromuscular/nervous

systems as related to physical therapy interventions, daily
activities, and environmental factors
Tone - Can differentiate Upper motor neuron verses lower motor neuron.
Upper motor neuron verses lower motor neuron
Factor

Upper motor neuron

Lower motor neuron

Deep tendon reflexes

Hyperactive

Flaccid

Special reflexes

Hyper active

Flaccid

Dermotone

Hyper or hypoesthetic

Hyperesthetic
Hypoesthetic

Peripheral nerve sensory

area

Hyper or hypoesthetic

Flaccid

Myotome

Initially flaccid
Late hypertonicity
develops

Flaccid

Motor nerve

Initially flaccid
Late hypertonicity
develops

Flaccid

Electromyography (EMG)

Fasciculation

Demylineization
Initial amplitude when
needle pierces the
sarcomere

Synergy patterns
Brunnstorm described two synergy patterns in patients with hemiplegia.
This is not to be confused with tone that is consistent with all upper motor neuron
lesions. Strong components of a synergy are indicated by a +. These are the first
components to be present and their spacisity can impede patient function. The - sign
indicates a weak component. The components without a sign are in-between the + and
-.
Upper Extremity Synergies
JOINT

FLEXION

EXTENSION

Scapulothoracic

Retraction and/or elevation

Protraction

Upper Extremity Synergies

JOINT

FLEXION

EXTENSION

Glenohumeral

-Abduction to 90E
-External rotation

+Adduction
+Internal rotation

Elbow

+Flexion

-Extension

Radio ulnar

Supination

+Pronation

Wrist

Flexion

-Extension

Fingers

Flexion

Flexion

Lower Extremity Synergies

JOINT

FLEXION

EXTENSION

Hip

+ Flexion, abduction, external

rotation

-Extension (limited to the neutral

or 0E position),
+Adduction,
-Internal rotation

Knee

Flexion to 90E

+Extension

Ankle

+Dorsi flexion

+Plantar flexion

Subtalar

Inversion

+Inversion

Toes

Dorsi flexion (extension)

Plantar flexion (flexion), great toe

may extend

(Rothstein et al, 1991, p.424 - 425).

Brunstrum also defined a method of treatment dependent on the use of
facilitation or inhibition techniques to modify spacisity. Stages one through four are well
accepted, but stage four through five are more of an continuum as coordination
improves with both the facilitation and inhibition of the synergy improving.
Brunstrum Spacisity Stages
STAGE
One

MOVEMENT
None

SPASTICITY
Absent

EVALUATION METHOD
No voluntary movement is
present; little or no resistance to
passive movement

Brunstrum Spacisity Stages

Two

Weak
Developing
associated
movements in
synergy; little or
no active finger
flexion

When movement is attempted,

there are associated movements
in synergy (in the upper extremity
seen first with flexion)

Three

All movements
are in synergy;
mass grasp in
hand

Full upper extremity synergy; hip,

knee, and ankle flexion are
coupled in either sitting or
standing

Four

Some deviation Decreasing

from synergies;
lateral
prehension and
semi voluntary
finger
extension

The patient in this stage can:

(1) place his hand behind his
back;
(2)flex at the glenohumeral joint
with his elbow extended;
(3) pronate and supinate his
forearm while the elbow is flexed
to 90E;
(4) sit and dorsiflex his foot while
keeping the foot on the floor;
(5) sit and slide his foot on the
floor by flexing his knee past 90E.

Five

Almost free
Further decrease
from synergies; from stage four
palmar
prehension and
voluntary mass
extension of
digits

The patient in this stage can

perform the tests for stage four
with greater ease and:
(1) abduct at the glenohumeral
joint with the elbow extended;
(2) flex at the shoulder joint past
90E with the elbow extended;
(3) pronate and supinate the
forearm with the elbow extended;
especially with abduction at the
glenohumeral joint; (4) stand nonweight-bearing with the affected
limb, flex the knee, and extend at
the hip;
(5) stand with the heel forward,
knee extended, and dorsiflex the
ankle.

Marked

Brunstrum Spacisity Stages

Six

Free of
Only during
synergy,
active rapid
slightly
movements
awkward; all
types of
prehension
(grasps) can be
controlled;
individual finger
movements
present

The patient in this stage can:

perform the tests for stage five
with greater ease and:
(1) stand and abduct the hip;
(2) sit, reciprocally contract the
medial and lateral hamstring
muscles, causing inversion and
eversion.

Behavioral scales
Rancho Los Amigos scales were developed from traumatic brain injury patients.
Eight level Rancho Los Amigos scale
The Behavioral Function Levels of Rancho Las Amigos
The questions in this area deal with the treatment setting, the approach used to deliver
treatment, prognosis and functional expectations.
The Scale may show improvement, or a patient may plateau at a level.
The faster the progression, the less the residual effect will be.
When a patient is tired or stressed expect them to score at a decreased level.
I - No response
Patient appears to be in a deep sleep and is com pletely unresponsive to any stimuli.
Setting - Acute hospital or if they are chronic a SNF.
Goals of Treatment - Establish any response through stimulation.
Developmentally this level corresponds to a newborn of less than 28 weeks of
gestation.

II - Generalize Response
Patient reacts inconsistently and non-purposefully to stimuli in a nonspecific manner.
Responses are limited and often the same regardless of the type of stimulus presented.
Responses may be physiological changes (HR or BP), gross body movements, and/or
vocalization.
Setting - Acute hospital or if this is a chronic condition a SNF.
Goals of Treatment - Establish a consistent response to stimuli.

Developmentally this level corresponds to a normal newborn.

III - Localized Responses
Patient reacts specifically, but inconsistently to stimuli.
Responses are directly related to the type of stimulus that are presented.
The patient may follow simple commands in an inconsistent, delayed manner, such as
closing eyes or squeezing hand.
Setting - Acute Hospital or if this is a chronic condition a SNF
Goals of Treatment - Develop consistency in specific response to a specific stimulus.
Developmentally this level corresponds to a normal baby (3 months).
IV - Confused-Agitated
Patient is in heightened state of activity. Behavior is bizarre and non purposeful relative
to immediate environment. They do not not discriminate among persons or objects and
is unable to cooperate directly with treatment efforts. Verbalizations frequently are
incoherent and/or inappropriate to the environment, confabulation may be present.
Gross attention to environment is very brief, selective attention is often nonexistent.
Patient lacks short-term and long-term recall.
Setting - This patient represents a special situation in that they need to be in a sensory
deprived environment, if chronic, a long term psychiatric institution. This patient must
be treated in a quiet environment where all forms of stimuli are controlled.
Goals of Treatment - Establish a longer attention span with respect to specific activities.
Developmentally this level is similar to a 18 month old to 3 years.
V - Confused-Inappropriate Patient is able to respond to sim ple commands fairly
consistently. However, with increased complexity of commands or lack of any external
structure, responses are non purposeful, random, or fragmented. Demonstrates gross
attention to the environment, but is highly distractible and lacks ability to focus attention
on a specific task. With structure, may be able to converse on a social automatic level
for short periods of time. Verbalization is often inappropriate and confabulatory.
Memory is severely impaired (repetition may allow a patient to retain memory of a
simple task or skill). They often show inappropriate use of objects, and may perform
previously learned tasks with structure, but is unable to learn new information.
Setting - Rehabilitation Hospital. A highly structured environment is needed for
treatment with reduced stimulation. SNF if this becomes a chronic level since they are
dependent in self care.
Goals of Treatment - Establish automatic function with less distraction. Treatment
requires one on one attention as they cannot function in a group setting.

Developmentally this corresponds to ages 3 years to 7 years.

VI - Confused-Appropriate Patient shows goal-directed behavior, but is dependent on
external input or direction. Follows simple directions consistently and shows carry-over
for relearned problems, but appropriate to the situation. They are able to complete
simple multi step tasks. Past memories show more depth and detail than recent
memory.
Setting - Rehabilitation Hospital or group home if this becomes a chronic condition.
Goals of Treatment - Attempt introduction of more complex exercises. Start training for
carryover. They may be employed in controlled setting workshop.
Developmentally this corresponds to grade school aged children.
VII - Automatic-appropriate Patient appears appropriate and oriented within hospital
and home settings: goes through daily routine automatically, but frequently robot-like
with minimal to absent confusion and has shallow recall of activities. Shows carryover
for new learning, but at a decreased rate. Is able to initiate social or recreational
activities with structure, judgment remains impaired.
Setting - Outpatient treatment, may live at home with support.
Goal of Treatment - Competitive employment
Developmentally this corresponds to a child that is in junior high school.
VIII - Purposeful-appropriate Patient is able to recall and to integrate past and recent
events, and is aware of and responsive to environment. Show carryover for new
learning and needs no supervision once activities are learned. May continue to show a
decreased ability relative to premorbid abilities, abstract reasoning, tolerance for stress,
and judgment in emergencies or unusual circumstances.
Setting - Home, independent with consulting. Outpatient treatment
Goals of treatment - Competitive employment
Developmentally this level describes a teenager.
(Adapted from Rothstein et al, 1991,p.412-413).
There is a newer 12 level form that also might be on the exam
Cognitive Functioning
12 level Rancho Los Amigos Cognitive Functioning Scale
I - No Response: Patient appears to be in a deep sleep and is com pletely

unresponsive to any stimuli.

#

Complete absence of observable change in behavior when presented

visual, auditory, tactile, proprioceptive, vestibular or painful stimuli.

II - Generalized Response: Patient reacts inconsistently and non-purposefully to

stimuli in a nonspecific manner. Responses are limited and often the same
regardless of stimulus presented. Responses may be physiological changes, gross
body movements, and/or vocalization.
#
#
#
#
#

Demonstrates generalized reflex response to painful stimuli.

Responds to repeated auditory stimuli with increased or decreased
activity.
Responds to external stimuli with physiological changes generalized gross
body movement and/or not purposeful vocalization.
Responses noted above may be same regardless of type and location of
stimulation.
Responses may be significantly delayed.

III - Localized Responses: Patient reacts specifically but inconsistently to stimuli.

Responses are directly related to the type of stimulus presented. May follow simple
commands in an inconsistent, delayed manner, such as closing eyes or squeezing
hand.
#
#
#
#
#
#
#

Demonstrates withdrawal or vocalization to painful stimuli.

Turns toward or away from auditory stimuli.
Blinks when strong light crosses visual field.
Follows moving object passed within visual field.
Responds to discomfort by pulling tubes or restraints.
Responses directly related to type of stimulus.
May response to some persons (especially family and friends) but not to
others.

IV - Confused - Agitated: Patient is in heightened state of activity. Behavior in bizarre

and non-purposeful relative to immediate environment. Does not discriminate
among persons or objects; is unable to cooperate directly withy treatment efforts.
Verbalizations frequently are incoherent and/or inappropriate to the environment;
confabulation may be present. Gross attention to environment is very brief;
selective attention is often nonexistent. Patient lacks short-term and long-term
recall.
#
#
#
#

Alert and in heightened state of activity.

Purposeful attempts to remove restraints or tubes or crawl out of bed.
May perform motor activities such as sitting, reaching and walking but
without any apparent purpose or upon anothers request.
Very brief and usually non-purposeful moments of sustained alternative

#
#
#
#
#
#

and divided attention.

Absent short-term memory.
May cry out or scream out of proportion to stimulus even after its removal.
May exhibit aggressive or flight behavior.
Mood may swing from euphoric to hostile with no apparent relationship to
environmental events.
Unable to cooperate with treatment efforts.
Verbalizations are frequently incoherent and/or inappropriate to activity or
environment.

V - Confused - Inappropriate: Patient is able to response to simple commands fairly

consistently. However, with increased complexity of commands or commands or
lack of any external structure, responses are non-purposeful, random, or
fragmented. Demonstrates gross attention on a specific task. With structure, may
be able to Converse on a social automatic level for short period of time.
Verbalization is often inappropriate and confabulatory.
Memory is severely impaired; often shows inappropriate use of objects; may perform
previously learned tasks with structure but is unable to learn new information.
#
#
#
#
#
#
#
#
#
#
#
#
#

Alert, not agitated in response to external stimulation, and/or intention of

going home.
May become agitated in response to external stimulation, and/or lack of
environmental structure.
Not oriented to person, place or time.
Frequent brief periods of non-purposeful sustained attention.
Severely impaired recent memory, with confusion of past and present in
reaction to ongoing activity.
Absent goal directed, problem solving, self-monitoring behavior.
Often demonstrates inappropriate use of objects without external
direction.
May be able to perform previously learned tasks when structured and
cues provided.
Unable to learn new information.
Able to respond appropriately to simple commands fairly consistently with
external structures and cues.
Responses to simple commands without external structure are random
and non-purposeful in relation to command.
Able to converse on a social, automatic level for brief periods of time
when provided external structure and cues.
Verbalizations about present events become inappropriate and
confabulatory when external structure and cues are not provided.

VI - Confused-Appropriate: Patient shows goal-directed behavior but is dependent on

external input or direction. Follows simple directions consistently and shows carryover for relearned problems but appropriate to the situation; past memories show
more depth and detail than recent memory.

#
#
#
#
#
#
#
#
#
#
#
#
#

Inconsistently oriented to person, time and place.

Able to attend to highly familiar tasks in non-distracting environment for 30
minutes with moderate redirection.
Remote memory has more depth and detail than recent memory.
Vague recognition of some staff.
Able to use assistive memory aid with maximum assistance.
emerging awareness of appropriate response to self, family and basic
needs.
Moderate assist to problem solve barriers to task completion.
Supervised for old learning (e.g. self care).
Shows carry over for relearned familiar tasks (e.g. self care).
Maximum assistance for new learning with little or no carry over.
Unaware of impairments, disabilities and safety risks.
Consistently follows simple directions.
Verbal expressions are appropriate in highly familiar and structured
situations.

VII - Automatic-Appropriate: Patient appears appropriate and oriented within hospital

and home settings: goes through daily routine automatically, but frequently
robotlike with minimal to absent confusion and has shallow recall of activities.
Show carry-over for new learning but a decreased rate. With structure is able to
initiate social or recreational activities; judgement remains impaired.
#
#
#
#
#
#
#

#
#
#
#
#
#
#

Consistently oriented to person and place, within highly familiar

environments. Moderate assistance for orientation to time.
Able to attend to highly familiar tasks in a non-distraction environment for
at least 30 minutes with minimal assist to complete tasks.
Minimal supervision for new learning.
Demonstrates carry over of new learning.
Initiates and carries out steps to complete familiar personal and
household routine but has shallow recall of what he/she has been doing.
Able to monitor accuracy and completeness of each step in routine
personal and household ADLs and modify plan with minimal assistance.
Superficial awareness of his/her condition but unaware of specific
impairments and disabilities and the limits they place on his/here ability to
safely, accurately and completely carry out his/her household, community,
work and leisure ADLs.
Minimal supervision for safety in routine home and community activities.
Unrealistic planning for the future.
Unable to think about consequences of a decision or action.
Overestimates abilities.
Unaware of others needs or feelings.
Oppositional/uncooperative.
Unable to recognize inappropriate social interaction behavior.

VIII - Purposeful and Appropriate: Patient is able to recall and to integrate past and

recent events and is aware of and responsive to environment. Shows carry over
for new learning and needs no supervision once activities are learned. May
continue to show a decreased ability relative to pre-morbid abilities, abstract
reasoning, tolerance for stress, and judgment in emergencies or unusual
circumstances.
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#

Consistently oriented to person, place and time.

Independently attends to and completes familiar tasks for 1 hour in
distracting environments.
Able to recall and integrate past and recent events.
Uses assistive memory devices to recall daily schedule, to do lists and
record critical information for later use with stand-by assistance.
Initiates and carries out steps to complete familiar personal, household
community, work and leisure routines with stand-by assistance and can
modify the plan when needed with minimal assistance.
Requires no assistance once new tasks/activities are learned.
Aware of and acknowledges impairments and disabilities when they
interfere with task completion but requires stand-by assistance to take
appropriate corrective action.
Thinks about consequences of a decision or action with minimal
assistance.
Overestimates or underestimates abilities.
Acknowledges others needs and feelings and responds appropriately with
minimal assistance.
Depressed.
Irritable.
Low frustration tolerance/easily angered.
Argumentative.
Self-centered.
Uncharacteristically dependent/independent.
Able to recognize and acknowledge inappropriate social interaction
behavior while it is occurring and takes corrective action with minimal
assistance.

IX - Purposeful, Appropriate:
#
#
#

Able to handle multiple tasks simultaneously in all environments but may

require periodic breaks.
Able to independently procure, create and maintain own assistive memory
devices.
Independently initiates and carries out steps to complete familiar and
unfamiliar personal, household, community, work and leisure tasks but
may require more than usual amount of time and/or compensatory
strategies to complete them.
Anticipates impact of impairments and disabilities on ability to complete
daily living tasks and takes action to avoid problems before they occur but

#
#
#
#
#
#

may require more than usual amount of time and/or compensatory

strategies.
Able to independently think about consequences of a decision or actions
but may require more than usual amount of time and/or compensatory
strategies to select the appropriate decision or action.
Accurately estimates abilities and independently adjusts to task demands.
Able to recognize the needs and feelings of others and automatically
respond in appropriate manner.
Periodic periods of depression may occur.
Irritability and low frustration tolerance when sick, fatigued and/or under
emotional stress.
Social interaction behavior is consistently appropriate.

Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A. Patricia
Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital. 1972.
Revised 11/15/74 by Danese Malkmus, M.A., and kathryn Stenderup, O.T.R.

From
Rehabilitation of the Head Injured Adult: Comprehensive Physical Management.
Professional Staff
Association, Rancho Los Amigos Hospital, Downey, CA. 1979 with permssion.
Reference
www.neuroskills.com/thi/rancho.html www.brainjury.com/recovery.html

The Braintree Hospital Cognitive Continuum is another commonly used cognitive scale
in rehabilitation. It is more common in occupational and speech therapy. It is focused
more to being able to educate the patient.
Braintree Hospital Cognitive Continuum
Level

Description

1. Arousal

The patient has difficulty initiating attention to purposeful

tasks. The patients behavior is purposeless, reflexive,
inconsistent, and dependent in all functional areas. Patient
may show some visual tracking and is usually not vocal.

2. Attention
Low level

The patient initiates attention but has dif ficulty sustaining

attention. Patient is able to follow one-step commands but
inconsistently. The patient may function automatically in
over learned behaviors. Patient does not initiate activities,
and may wonder if let unsupervised.

High level

The patients main deficit area is in sustaining and switching

attention. The patient is distractible and perseverative. He
or she may recall pieces of information but is unable to
integrate information.

3. Discrimination

Patient is able to sustain and to switch attention sufficiently

to integrate small amounts of information. Patient initiates
activities but may still show some perseveration and
impulsivity. Behavior can be partly modified by feedback.
Recall over time is improved.

4. Organization
Low level

High level

5. Higher - level
Cognitive function

Patient can integrate multiple pieces of information for a

task but tends to be concrete and have difficulty sequencing
the task. Patient can begin simple problem solving.
Patient can use selective attention to perceive stimuli or
task elements accurately, select a strategy, and reach a
solution. Patient continues to be concrete, has trouble
generalizing and carrying over learning from one setting to
another. In stressful situations, shows breakdown in
cognitive function.
The patient is able to do complex problem solving but is
limited owing to limited flexibility, insight, social behavior,
and endurance. The patient is susceptible to breakdown of
behavior outside of a structured setting (e.g., school or
work). In stressful situations, shows preserved cognitive
functions. Cognitive processing is slow.

From Braintree Hospital Cognitive Continuum, Braintree, MA, with permission.

Coordination Tests
Coordination Tests (in alphabetical order)
Test

Description

Alternate heel to knee; heel to toe

From a supine position, the patient is asked to

touch is knee and big toe alternately with the
heel of the opposite extremity.

Alternate nose to finger

The patient alternately touches the top of his

nose and the tip of the therapists finger with
the index finger. The position of the therapists
finger may be altered during testing to assess
ability to change distance, direction, and force
of movement.

Drawing a circle

The patient draws an imaginary circle in the air

with either upper or lower extremity (a table or
the floor also may be used). This also may be
done using a figure-eight pattern. This test
may be performed in the supine position for
lower extremity assessment.

Finger to finger

Both shoulders is abducted to 90 degree with

the elbows extended. The patient is asked to
bring both hands toward the midline and
approximate the index fingers from opposing
hands.

Finger to nose

The shoulder is abducted to 90 degree with the

elbow extended. The patient is asked to bring
the tip of the index finger to the tip of the nose.
Alterations may be made in the initial starting
position to assess performance from different
planes of motion.

Finger to opposition

The patient touches the tip of the thumb to the

tip of each finger in sequence. Speed may be
gradually increased.

Finger to Therapists finger

The patient and therapist sit opposite each

other. The therapists index finger is held in
front the patient. The patient is asked to touch
the tip of the index finger to the therapists
index finger. The position of the therapists
finger may be altered during testing to assess
ability to change distance, direction, and force
of movement.

Fixation or position holding

Upper extremity: The patient is asked to hold

the knee in an extended position.

Heel on shin

From the supine position, patient slides the

heel of one foot up and down the shin of the
opposite lower extremity.

Mass grasp

An alternation is made between opening and

closing fist (from finger flexion to full
extension). Speed may be gradually increased.

Secondary effects or complications from physical

therapy and medical interventions on the
neuromuscular/nervous systems

Secondary effects or complications on the

neuromuscular/nervous systems from physical therapy
and medical interventions used on other systems

Motor control as related to neuromuscular/nervous

systems physical therapy interventions

Motor learning as related to neuromuscular/nervous

systems physical therapy interventions