This presentaion provides introduction about therapeutic excersie

physiotherapy

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Introduction To
Therapeutic Exercises
Therapeutic exercise is a major & an
important part of the practice of physical
therapy. One of the most difficult tasks for any
physical therapist is to design & apply an
exercise program. Exercise presents both
benefits & risks. This balance can be easily
achieved towards the benefit side of the
equation with the optimal ex prescription.

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Definition Definition
ofof
Therapeutic Exercises Therapeutic Exercises
It is a It is a planned body movementsplanned body movements that aim to that aim to
improve & restore physical action.improve & restore physical action.
It is the It is the activityactivity that is performed or practiced to that is performed or practiced to
develop or improve a specific function or skill develop or improve a specific function or skill
for the sake of for the sake of developingdeveloping && maintaining maintaining
physical fitness.physical fitness.

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Goals of Goals of
Therapeutic ExercisesTherapeutic Exercises
1.1.The ultimate goal The ultimate goal is the achievement of an is the achievement of an
optimal level of symptom free movements optimal level of symptom free movements
during physical activities.during physical activities.
2.2.To To improve & restore physical functionimprove & restore physical function..
3.3.To To prevent loss of function & to enhance the prevent loss of function & to enhance the
pt’s functional capabilities.pt’s functional capabilities.
4.4.To To prevent & prevent & ↓↓impairment & disabilityimpairment & disability..
5.5.To To improve overall health status, fitness & improve overall health status, fitness &
sense of well-being.sense of well-being.

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Exercise Program PrerequisitesExercise Program Prerequisites
1. 1. Knowledge ofKnowledge of AnatomyAnatomy, , physiologyphysiology, pathology , pathology
& & kinesiologykinesiology..

2. 2. Understanding the different forms of exs. & Understanding the different forms of exs. &
how these exs. affect body systems.how these exs. affect body systems.
3. The ex. program should be 3. The ex. program should be individualized to individualized to
the special needs of the patient.the special needs of the patient.

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Designing Exercise ProgramDesigning Exercise Program
1.1.Start with a Start with a comprehensive examination of comprehensive examination of
the patient (pt.).the patient (pt.).
2.2.Determine the Determine the patient’s problems & patient’s problems &
functional disabilitiesfunctional disabilities . .
3.3.Set the Set the aims & objectives of the treatment aims & objectives of the treatment
(ttt) program.(ttt) program.
4.4.Select the Select the proper exercise program that can proper exercise program that can
solve the pt’s problem’ssolve the pt’s problem’s & & improve functional improve functional
capabilities.capabilities.

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5 . Periodically 5 . Periodically re-evaluate & examine the pt.re-evaluate & examine the pt.

6 . 6 . Modify the programModify the program according to the re- according to the re-
evaluation to evaluation to attain the optimal degree of attain the optimal degree of
improvement.improvement.
7. Clearly 7. Clearly identify the purpose & goal of the identify the purpose & goal of the
exercise program to the pt.exercise program to the pt.

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Therapeutic ExercisesTherapeutic Exercises
Passive Exercises Active Exercises
Relaxed Passive Movement
Forced Passive Movement
Static Exercises
Active Assisted Exercises
Active Free Exercises
Active Resisted Exercises
TherapTherap

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DefinitionsDefinitions
Passive ExercisesPassive Exercises::
movement is performed by an external force without movement is performed by an external force without
any voluntary contraction of the patient. External any voluntary contraction of the patient. External
force may be another person ,machine or the sound force may be another person ,machine or the sound
limb of the pt.limb of the pt.
Relaxed Passive Exercises:Relaxed Passive Exercises:
movement performed by an external force ,within the movement performed by an external force ,within the
pain free rangepain free range, , to maintain the ROM.to maintain the ROM.
Forced Passive MovementsForced Passive Movements : :
Movement performed by an external force, within Movement performed by an external force, within
the the tolerance of pain totolerance of pain to ↑ the limited ROM↑ the limited ROM..

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Active ExercisesActive Exercises::
Exercise in which movement is performed by the Exercise in which movement is performed by the
voluntary pt. effort ( voluntary pt. effort ( under pt. control ).under pt. control ).
Active Assisted ExercisesActive Assisted Exercises : :
Exercise in which mov. is performed by voluntary pt. Exercise in which mov. is performed by voluntary pt.
effort & with external assistance to complete the ROM.effort & with external assistance to complete the ROM.
Active Free ExercisesActive Free Exercises : :
Exercise in which mov. is performed by voluntary pt. Exercise in which mov. is performed by voluntary pt.
effort, through full ROM effort, through full ROM without the gravitywithout the gravity( gravity ( gravity
eliminated) eliminated) oror against gravity.against gravity.

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Active Resisted ExercisesActive Resisted Exercises : :
Exercises in which the mov. is resisted by an Exercises in which the mov. is resisted by an
external force.external force.
Types of Therapeutic ExercisesTypes of Therapeutic Exercises
Classification according to the Classification according to the aim & purpose of aim & purpose of
exercises into :exercises into :
1.1.Range of motion exRange of motion ex. which aim to maintain & . which aim to maintain & ↑ROM ↑ROM
( e.g. passive, active assisted, active ROM exercises ( e.g. passive, active assisted, active ROM exercises
) & other techniques of joint mobilization & soft ) & other techniques of joint mobilization & soft
tissue stretching .tissue stretching .
2. 2. Postural exPostural ex. to improve posture & correct faulty . to improve posture & correct faulty
posture .posture .

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3. 3. Muscle performance exMuscle performance ex. to . to ↑ m. strength, ↑ m. strength,
power & endurance e.g. resisted exs. & power & endurance e.g. resisted exs. &
endurance exs.endurance exs.
4. 4. Balance & coordination exercisesBalance & coordination exercises to improve to improve
balance & coordination .balance & coordination .
5. 5. Relaxation exRelaxation ex. to induce relaxation .. to induce relaxation .
6. 6. Specific area exsSpecific area exs. e.g. . e.g. breathing exsbreathing exs. & many . & many
circulatory exscirculatory exs..

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Other ClassificationOther Classification : :
1.1.Specific exs.:Specific exs.:
conducted as local or specific.conducted as local or specific.
2.2.General exs. :General exs. :
mov. for the whole body.mov. for the whole body.
for best results specific & general exs. should for best results specific & general exs. should
be combined.be combined.
3.3.Combined : Combined :
passive , occupational therapy & various passive , occupational therapy & various
recreational activities ( hydro gymnastics, recreational activities ( hydro gymnastics,
games, swimming, walking & cycling ).games, swimming, walking & cycling ).

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Basic Principles of Specific ExsBasic Principles of Specific Exs..
1. They must be performed in a 1. They must be performed in a smooth &smooth &
rhythmical mannerrhythmical manner, so that they don’t subject , so that they don’t subject
ms. & js. to sudden unexpected stress & strainms. & js. to sudden unexpected stress & strain
2. They must be based on 2. They must be based on sound starting positions.sound starting positions.
3. They must provide smooth 3. They must provide smooth progression progression from the from the
stage of extreme weakness to full use against stage of extreme weakness to full use against
the stress of normal working conditionsthe stress of normal working conditions

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4. The ex. must be done with 4. The ex. must be done with coordinated coordinated
muscle work.muscle work.
5. The exs. might provide 5. The exs. might provide progression of : progression of :
strength, mobility, coordination,…etc.strength, mobility, coordination,…etc.
6. All the exs. thay aim to strengthen weak ms. 6. All the exs. thay aim to strengthen weak ms.
should provide should provide a a wide ROMwide ROM as possible. as possible.

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Principle of RhythmPrinciple of Rhythm

–Muscular contraction must be followed by relaxation Muscular contraction must be followed by relaxation
& the relaxation period must be complete and long & the relaxation period must be complete and long
enough to allow normal circulatory conditions to be enough to allow normal circulatory conditions to be
restored. This principle applies particularly to exs. restored. This principle applies particularly to exs.
used to re-develop weak ms. after trauma or used to re-develop weak ms. after trauma or
disease.disease.
–It is based on the fact that m. efficiency depends It is based on the fact that m. efficiency depends
largely on the condition of it's local circulation:largely on the condition of it's local circulation:
If the circulation is good If the circulation is good  the breakdown products the breakdown products
of contractions are carried away quickly.of contractions are carried away quickly.
If the circulation is poor If the circulation is poor  the products tend to the products tend to
accumulate & produce early fatigue.accumulate & produce early fatigue.

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Principle Principle
of of
Sound Starting PositionSound Starting Position
The starting positions from which ex. is The starting positions from which ex. is
performed should facilitate the work of the m. &performed should facilitate the work of the m. &
be suitable for the particular phase of recovery be suitable for the particular phase of recovery
reached by the patient reached by the patient

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Principle of Strengthening & Principle of Strengthening &
MobilizingMobilizing
To strengthen weak ms. or to mobilize stiff joints, the To strengthen weak ms. or to mobilize stiff joints, the
starting positions of the exs. should be as steady as starting positions of the exs. should be as steady as
possible, so as to give the working muscles a firm possible, so as to give the working muscles a firm
origin from which to work.origin from which to work.
The larger the base of support, the steadier will be the The larger the base of support, the steadier will be the
position of the body.position of the body.
The nearer the center of gravity to the base of support, The nearer the center of gravity to the base of support,
the steadier the position.the steadier the position.
In some instances, additional stability is achieved by In some instances, additional stability is achieved by
arranging for the base to be enlarged in the direction arranging for the base to be enlarged in the direction
of the movement.of the movement.

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Principle Principle
of of
Developing CoordinationDeveloping Coordination
For developing neuromuscular co-For developing neuromuscular co-
ordination, the starting position should be ordination, the starting position should be
chosen gradually to increase the difficulty chosen gradually to increase the difficulty
in maintaining the balance in maintaining the balance

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Principle of ProgressionPrinciple of Progression
The methods of progression used depend on The methods of progression used depend on
whether an ex. is designed .whether an ex. is designed .
Indicated to re-develop strength, restore Indicated to re-develop strength, restore
mobility, or redevelop neuromuscular co-mobility, or redevelop neuromuscular co-
ordination.ordination.
One method of progression is the progression One method of progression is the progression
in time (performing the ex. for increasing in time (performing the ex. for increasing
periods of times).periods of times).

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Principle Principle
of of
Wide Range of MotionWide Range of Motion
Except in early phases of recovery, when Except in early phases of recovery, when
the ms. are very weak, all exs. which aim the ms. are very weak, all exs. which aim
at strengthening ms. should provide a at strengthening ms. should provide a
wide range of mov. as possible. In this wide range of mov. as possible. In this
way, all the fibers of the m. responsible way, all the fibers of the m. responsible
are exercised normally. Exercising a are exercised normally. Exercising a
muscle in part of it's range of mov. does muscle in part of it's range of mov. does
not mean that all it's fibers will be brought not mean that all it's fibers will be brought
into action.into action.

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Functional ExcursionFunctional Excursion
Functional excursion is defined as the distance that a m. is Functional excursion is defined as the distance that a m. is
capable of shortening after it has been elongated to it's capable of shortening after it has been elongated to it's
maximum.maximum.
Movement of the body segment occur either by the effect of m. Movement of the body segment occur either by the effect of m.
contraction (active) or by an external force (passive), forces contraction (active) or by an external force (passive), forces
which move the bones with respect to each other at the which move the bones with respect to each other at the
connecting joints.connecting joints.
The type of mov. depends on the structure of the joint, integrity The type of mov. depends on the structure of the joint, integrity
and flexibility of the soft tissues.and flexibility of the soft tissues.
The full motion possible is called range of motion.The full motion possible is called range of motion.
When moving a segment through it's range of motion When moving a segment through it's range of motion
( R.O.M.) all structures in the region are affected ( R.O.M.) all structures in the region are affected
( muscles, joints, surfaces, capsules, ligaments, fasciae, ( muscles, joints, surfaces, capsules, ligaments, fasciae,
vessels and nerves).vessels and nerves).

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–Functional excursion or range of a m. is limited by Functional excursion or range of a m. is limited by
the range available by the joint it crosses. This is the range available by the joint it crosses. This is
true for one joint m. ( brachialis m.) : ms. with their true for one joint m. ( brachialis m.) : ms. with their
proximal and distal attachments on the bones on proximal and distal attachments on the bones on
either side of one joint.either side of one joint.
–For two joint or multi-joint ms. ( crosses over two or For two joint or multi-joint ms. ( crosses over two or
more joints), their range goes beyond the limits of more joints), their range goes beyond the limits of
any one joint they cross ( biceps brachii).any one joint they cross ( biceps brachii).

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R.O.M. is described in terms of joint rangeR.O.M. is described in terms of joint range
( flexion, extension, abduction, ( flexion, extension, abduction,
adduction,& rotation) and muscle range adduction,& rotation) and muscle range
(related to functional excursion of ms.)(related to functional excursion of ms.)

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Definition Definition
of of
Active InsufficiencyActive Insufficiency
–Active insufficiencyActive insufficiency is is when the ms. can shorten when the ms. can shorten
no more. no more.
–If the ms. contracts and moves the elbow into If the ms. contracts and moves the elbow into
flexion and the forearm into supination, while flexion and the forearm into supination, while
simultaneously moving the shoulder into flexion, it simultaneously moving the shoulder into flexion, it
will shorten to a point known as active insufficiency.will shorten to a point known as active insufficiency.

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Definition of Passive InsufficiencyDefinition of Passive Insufficiency
–The position known as The position known as passive insufficiencypassive insufficiency is is
when the ms. is fully elongated.when the ms. is fully elongated.
–The m. is lengthened full range by extending the The m. is lengthened full range by extending the
elbow, pronating the forearm & simultaneously elbow, pronating the forearm & simultaneously
extending the shoulder.extending the shoulder.
–N.B.: N.B.: To maintain normal R.O.M., the segments To maintain normal R.O.M., the segments
must be moved through their available ranges must be moved through their available ranges
periodically (whether it is a joint range or muscle periodically (whether it is a joint range or muscle
range).range).

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Factors lead to decreased ROMFactors lead to decreased ROM
Systemic, joint, neurologic or muscular Systemic, joint, neurologic or muscular
diseases.diseases.
Surgical or traumatic causesSurgical or traumatic causes..
Inactivity or immobilizationInactivity or immobilization for any reason. for any reason.
Therapeutically, range of motion activities are Therapeutically, range of motion activities are
administered to maintain existing joint or soft administered to maintain existing joint or soft
tissue mobility. This will minimize the effects of tissue mobility. This will minimize the effects of
the formation of soft tissue adhesions, m. the formation of soft tissue adhesions, m.
weakness, joint range limitations & finally m. weakness, joint range limitations & finally m.
contractures.contractures.

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Indications and Goals of Range Indications and Goals of Range
of Motionof Motion
When a patient is unable to or unsupposed to actively When a patient is unable to or unsupposed to actively
move a segment or segments of the body e.g. when move a segment or segments of the body e.g. when
comatosed, paralyzed or on complete bed rest, or when comatosed, paralyzed or on complete bed rest, or when
there is an inflammatory reaction + active ROM is there is an inflammatory reaction + active ROM is
painful, controlled passive ROM is used to decrease the painful, controlled passive ROM is used to decrease the
complications of immobilization in order to:complications of immobilization in order to:
–Maintain Maintain joint & soft tissue integrityjoint & soft tissue integrity( avoid adhesions).( avoid adhesions).
–MinimizeMinimize the effect of formation of the effect of formation of contracturescontractures..
–Maintain Maintain mechanical elasticity of m.mechanical elasticity of m.
–Assist in circulationAssist in circulation and and vascular dynamics.vascular dynamics.
–Enhance Enhance synovial movsynovial mov. for cartilage nutrition & diffusion of . for cartilage nutrition & diffusion of
materials in the joint.materials in the joint.
–Decrease painDecrease pain
–Assist the Assist the healing processhealing process following injury or surgery following injury or surgery
–Help Help maintain the pt.'s awareness of movement.maintain the pt.'s awareness of movement.

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When a When a therapist is teaching an active extherapist is teaching an active ex. .
program, passive ROM is used to program, passive ROM is used to
demonstrate the desired motion to the pt.demonstrate the desired motion to the pt.
When a When a therapist is preparing the pt. for therapist is preparing the pt. for
stretchingstretching, passive ROM is often used before , passive ROM is often used before
passive stretching techniques (techniques to passive stretching techniques (techniques to
increase the ROM, when ROM is restricted).increase the ROM, when ROM is restricted).
When a When a therapist is evaluating inert structures,therapist is evaluating inert structures,
passive ROM is used to determine limitations passive ROM is used to determine limitations
of motion, to determine joint stability, and to of motion, to determine joint stability, and to
determine m. & other tissue elasticity.determine m. & other tissue elasticity.

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Indications of Active and Active Indications of Active and Active
Assistive ROMAssistive ROM
When a pt. is able to actively contract the ms. and When a pt. is able to actively contract the ms. and
move a segment either without assistance and there move a segment either without assistance and there
are no contra-indications, active ROM is used to:are no contra-indications, active ROM is used to:
–Accomplish the Accomplish the same goals of passive ROM with the same goals of passive ROM with the
added benefits that results from the m. contraction.added benefits that results from the m. contraction.
–Maintain physiologic elasticity & contractility of the Maintain physiologic elasticity & contractility of the
participating m.participating m.
–Provide sensory feedback from the contracting m.Provide sensory feedback from the contracting m.
–Provide a stimulus for bone and joint tissue integrityProvide a stimulus for bone and joint tissue integrity..
–Increase circulation and prevent thrombus formationIncrease circulation and prevent thrombus formation..
- - Develop co-ordination & motor skills for functional Develop co-ordination & motor skills for functional
activities.activities.

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When a pt. has weak musculature, and scores When a pt. has weak musculature, and scores
poor to fair minus m. testpoor to fair minus m. test ( (grade 2, grade 3 -grade 2, grade 3 - ), ),
active Assistive ROM is used, to provide active Assistive ROM is used, to provide
enough assistance to the ms. in a controlled enough assistance to the ms. in a controlled
manner, so that the m. can function at its manner, so that the m. can function at its
maximum level & progressively be maximum level & progressively be
strengthened.strengthened.
Active and Active Assistive ROM can be used Active and Active Assistive ROM can be used
to to improve cardiovascular and respiratory improve cardiovascular and respiratory
responses, when done with multiple responses, when done with multiple
repetitions.repetitions.

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Special ConsiderationsSpecial Considerations
1. When a segment of the body is immobilized for a 1. When a segment of the body is immobilized for a
period of time, period of time, ROM is used on the regions above and ROM is used on the regions above and
below the immobilized segment to: below the immobilized segment to:
a) Maintain the areas in as normal condition as possible. a) Maintain the areas in as normal condition as possible.
b) Prepare for new activities as walking with crutches.b) Prepare for new activities as walking with crutches.
2. When a patient is on bed rest, ROM is used to 2. When a patient is on bed rest, ROM is used to
avoid the complications of decreased circulation, bone avoid the complications of decreased circulation, bone
demineralization, decreased cardiac & respiratory demineralization, decreased cardiac & respiratory
function.function.

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Limitations of ROMLimitations of ROM
–Limitations for Passive MotionLimitations for Passive Motion::
True passive relaxed range of motion may be True passive relaxed range of motion may be
difficult to obtain, difficult to obtain, when the m. Is innervated & the when the m. Is innervated & the
pt. is conscious.pt. is conscious.
Passive motion Passive motion will not:will not:
1 . 1 . Prevent m. atrophyPrevent m. atrophy..
2 . 2 . Increase strength and enduranceIncrease strength and endurance..
3 . 3 . Assist circulation to the extent that active, Assist circulation to the extent that active,
voluntary m. contraction doesvoluntary m. contraction does..

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Limitations for Active ROM:Limitations for Active ROM:
For strong ms., it For strong ms., it will not maintain or will not maintain or
increase strength.increase strength.
Active ROM Active ROM will not develop skill or co-will not develop skill or co-
ordination except in the mov. pattern ordination except in the mov. pattern
used.used.

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Precautions & Contra-indications to Precautions & Contra-indications to
ROM:ROM:
A. Both passive and active ROM are contra-indicated A. Both passive and active ROM are contra-indicated
under any circumstance when the under any circumstance when the motion to a part is motion to a part is
disruptive to the healing process.disruptive to the healing process. But also, complete But also, complete
immobility leads to adhesion & contracture formation, immobility leads to adhesion & contracture formation,
sluggish circulation & prolonged recovery time.sluggish circulation & prolonged recovery time.
–Historically, ROM has been contra-indicated Historically, ROM has been contra-indicated
immediately immediately following acute tearsfollowing acute tears, , fracturesfractures and and
surgerysurgery, but because the benefits of controlled motion , but because the benefits of controlled motion
have demonstrated decreased pain and increased rate have demonstrated decreased pain and increased rate
of recovery, early controlled motion is used as long as of recovery, early controlled motion is used as long as
the pt.'s tolerance is monitored.the pt.'s tolerance is monitored.
–Additional traumaAdditional trauma to the part is contra-indicated. to the part is contra-indicated.

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–Signs of too much or wrong motion Signs of too much or wrong motion
includeinclude::
Increased painIncreased pain
Increased inflammationIncreased inflammation ( great swelling, heat ( great swelling, heat
and tenderness).and tenderness).
B. Usually active ROM of the upper extremities B. Usually active ROM of the upper extremities
and limited walking near the bed are tolerated and limited walking near the bed are tolerated
as early exs. as early exs. after myocardial infarctionafter myocardial infarction..
Careful Careful monitoring of symptomsmonitoring of symptoms, , bl. pressurebl. pressure, ,
perceived exertionperceived exertion are necessary. are necessary.

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Procedures for Applying ROM Procedures for Applying ROM
TechniquesTechniques
On the basis of evaluation of the pt.'s impairments & On the basis of evaluation of the pt.'s impairments &
level of function, level of function, determinedetermine whether passive, active whether passive, active
assistive or active ROM will meet the goals.assistive or active ROM will meet the goals.
Place the pt. in a Place the pt. in a good alignedgood aligned, comfortable, , comfortable, relaxedrelaxed
position.position.
Free the regionFree the region from restrictive clothing, splints & dressing. from restrictive clothing, splints & dressing.
The therapist (th.) must be positioned so that the The therapist (th.) must be positioned so that the proper body proper body
mechanics are used.mechanics are used.
To control mov., To control mov., grasp the extremity around jointsgrasp the extremity around joints. If . If
the joints are painful, modify the grip to provide the joints are painful, modify the grip to provide
support necessary for control support necessary for control

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Full support is given to the areas of poor Full support is given to the areas of poor
structural integrity, as structural integrity, as hyper mobile jointshyper mobile joints, ,
recent fracturesrecent fractures or or paralyzed limb segmentparalyzed limb segment..
Move the segment through its Move the segment through its pain free pain free
rangerange. . Do not forceDo not force beyond the available beyond the available
range. If you force motion range. If you force motion  stretching stretching
technique.technique.
Perform the motion Perform the motion smoothly and smoothly and
rhythmicallyrhythmically, , 5 to 10 repetitions5 to 10 repetitions. The no. of . The no. of
repetitions depends on the objectives of the repetitions depends on the objectives of the
of the program & the pt.'s condition.of the program & the pt.'s condition.

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If the plan includes the use of passive ROM:If the plan includes the use of passive ROM:
a)a)The force for The force for mov. is externalmov. is external 
provided by the P.Tprovided by the P.T
or normal body part or mechanical.or normal body part or mechanical.
b) b) No active assistanceNo active assistance or resistanceor resistance is given by is given by
the pt's ms. crossing the pt. If so, it becomes the pt's ms. crossing the pt. If so, it becomes
an active exercise.an active exercise.
The motion is carried out within the freeThe motion is carried out within the free
ROM ROM
((available range, without force or pain).available range, without force or pain).

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If the plan is to use active assistance or If the plan is to use active assistance or
active ROM;active ROM;
DemonstrateDemonstrate to the patient the desired to the patient the desired
motion, using passive ROM, then ask the motion, using passive ROM, then ask the
patient to perform the motion.patient to perform the motion.
Assistance is givenAssistance is given only when needed for only when needed for
smooth motionsmooth motion. When there is weakness, . When there is weakness,
assistance is given only at the beginning or assistance is given only at the beginning or
at the end of ROM.at the end of ROM.
The The motionmotion is performed is performed within the available within the available
RORO MM

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ROM techniques may be performed in :ROM techniques may be performed in :
a) a) Anatomic planes of ROMAnatomic planes of ROM ( frontal, ( frontal, sagittal &sagittal &
transverse).transverse).
b) b) M. range of elongationM. range of elongation (antagonistic to the (antagonistic to the
line of m. pull). line of m. pull).
c) c) Combined patternsCombined patterns ( in several planes of ( in several planes of
motion). motion).
d) The motion is performed in d) The motion is performed in functional functional
patterns, used in ADL ( Activities of Daily patterns, used in ADL ( Activities of Daily
Living). Living).
The pt.'s The pt.'s general conditions should be monitoredgeneral conditions should be monitored
during and after the procedureduring and after the procedure..
Record observable and measurable reactions to Record observable and measurable reactions to
the treatment.the treatment.
Modify or progress the treatment (ttt) as Modify or progress the treatment (ttt) as necessary. necessary.