Rationale for the Procedure
Exploratory laparotomies in trauma patients with suspected intra-abdominal injuries are associated with a high negative laparotomy rate and significant procedure-related morbidity. Diagnostic laparoscopy has been proposed for trauma patients to prevent unnecessary exploratory laparotomies with their associated higher morbidity and cost.
Technique
Many studies have documented the feasibility and safety of the procedure in trauma patients (level I-III) [1-25]. The procedure is usually performed under general anesthesia; however, local anesthesia with IV sedation has also been used successfully. The latter, in conjunction with a dedicated mobile cart, facilitates the procedure in the emergency department. A recent study demonstrated the safety and advantages of awake laparoscopy under local anesthesia in the emergency department over standard DL in the operating room (level III) [21]. Many authors have used low insufflation pressures (8-12 mm Hg); however, pressures up to 15 mm Hg have been described without untoward events. Special attention should be given to the possibility of a tension pneumothorax caused by the pneumoperitoneum due to an unsuspected diaphragmatic rupture. The pneumoperitoneum is created usually through a periumbilical incision using a Veress needle or open technique after insertion of a nasogastric tube and a Foley catheter.
In the case of penetrating wounds, air leaks can be controlled with sutures. A 30-degree laparoscope is advantageous, and additional trocars are used for organ manipulations. The peritoneal cavity can be examined systematically taking advantage of patient positioning manipulations. The colon can be mobilized and the lesser sac inspected. Suction/irrigation may be needed for optimal visualization, and methylene blue can be administered IV or via a nasogastric tube to help identify urologic or stomach injuries, respectively. In penetrating injuries, peritoneal violation can be determined.
Indications
� Suspected but unproven intra-abdominal injury after blunt or penetrating trauma
� More specific indications include:
� Suspected intra-abdominal injury despite negative initial workup after blunt trauma
� Abdominal stab wounds with proven or equivocal penetration of fascia
� Abdominal gunshot wounds with doubtful intraperitoneal trajectory
� Diagnosis of diaphragmatic injury from penetrating trauma to the thoracoabdominal area
� Creation of a transdiaphragmatic pericardial window to rule out cardiac injury
Contraindications (Absolute or Relative)
� Hemodynamic instability (defined by most studies as systolic pressure < 90 mm Hg)
� A clear indication for immediate celiotomy such as frank peritonitis, hemorrhagic shock, or evisceration
� Known or obvious intra-abdominal injury
� Posterior penetrating trauma with high likelihood of bowel injury
� Limited laparoscopic expertise
Risks
� Delay to definitive treatment
� Missed injuries with their associated morbidity
� Procedure- and anesthesia-related complications
Benefits
� Reduction in the rate of negative and nontherapeutic laparotomies (with a subsequent decrease in hospitalization, morbidity, and cost after negative laparoscopy)
� Accurate identification of diaphragmatic injury
� Ability to provide therapeutic intervention
Diagnostic Accuracy of the Procedure
The sensitivity, specificity, and diagnostic accuracy of the procedure when used to predict the need for laparotomy are high (75-100%) (level I-III) [1-25]; however, they depend on several factors (see Limitations of the Available Literature). When DL has been used as a screening tool (i.e., early conversion to open exploration with the first encounter of a positive finding like the identification of peritoneal penetration in penetrating trauma or active bleeding/peritoneal fluid in blunt trauma patients), the number of missed injuries is <1% (level II, III) [2-8]. Although early studies cautioned about the low sensitivity and high missed injury rates of the procedure when used to identify specific injuries (level II, III) [9-12], studies published recently consistently report a 0% missed injury rate even when DL is used for reasons other than screening (level I-III) [1-7,14,16-25]. This rate holds true for studies that have used laparoscopy to treat the majority of identified injuries (level II, III) [22,24,25].
Studies of DL for trauma report negative procedures in a median 57% (range, 17-89) of patients, sparing them an unnecessary exploratory laparotomy (level I-III) [1-7, 13-25]. On the other hand, the median percentage of negative exploratory laparotomies after a positive DL (false positive rate) is reported to be around 6% (range, 0-44) (level I-III) [1-7,14,16-25]. While most authors have converted to open exploration after a positive DL, some authors have successfully treated the majority of patients (up to 83%) laparoscopically (level II, III) [22,24,25]. The safety and accuracy of the procedure has also been demonstrated in pediatric trauma patients (level III) [22].
Procedure-related Complications and Patient Outcomes
Procedure-related complications occur in up to 11% of patients and are usually minor (level I-III) [1-25]. A 1999 review of 37 studies, which included more than 1,900 patients demonstrated a procedure-related complication rate of 1% [9]. Recent studies report a median of 0 (range, 0-10%) morbidity and 0% mortality (level I-III) [1-7,14,16-25]. Intraoperative complications can occur during creation of the pneumoperitoneum, trocar insertion, or during the diagnostic examination. These complications include tension pneumothorax caused by unrecognized injuries to the diaphragm, perforation of a hollow viscus, laceration of a solid organ, vascular injury (usually trocar injury of an epigastric artery or lacerated omental vessels), and subcutaneous or extraperitoneal dissection by the insufflation gas. Port site infections may occur during the postoperative course.
Negative DL is associated with shorter postoperative hospital stays compared with negative exploratory laparotomy (2-3 days vs. 4-5 days, respectively) (level II, III) [2,4-9,14,16-20,22-25]. Although a few studies have even demonstrated shorter stays after therapeutic laparoscopy compared with open (level III) [22,24,25], the only level I study available demonstrated a statistically significant shorter hospital stay after DL (5.1 vs. 5.7 days) [1]. In a very recent study, awake laparoscopy in the emergency department under local anesthesia resulted in discharge of patients from the hospital faster compared with DL in the operating room (7 vs. 18 hours, respectively; p<0.001) (level III) [21].
Comparative studies also suggest lower morbidity rates after negative DL compared with negative exploratory laparotomy (level II, III) [5,19,21], whereas other studies have shown similar outcomes (level I-III) [1,7].
Cost-effectiveness
A number of reports have demonstrated higher costs (up to two times higher) after negative exploratory laparotomy compared with negative DL (levels II, III) [6,14,17] as a direct consequence of shorter hospital stays. Nevertheless, a level I study did not demonstrate cost differences when an intention-to-treat analysis was used to compare a DL-treated group with that of an exploratory laparotomy-treated group [1]. Recently a level III study reported cost savings of $2,000 per patient when awake laparoscopy under local anesthesia was used in the emergency department compared with DL in the operating room [21].
Limitations of the Available Literature
The available literature has limited quality (only one small, level I study exists) and is very inhomogeneous, making generalizations and conclusions difficult. Study populations have been variable (blunt, penetrating, or mixed), and some studies have focused only on patients with suspected diaphragmatic injuries or blunt bowel injuries. Moreover, the indication for conversion to exploratory laparotomy has also been inconsistent. Most studies use peritoneal penetration or bleeding and free peritoneal fluid as an immediate reason for conversion, whereas others have converted only after specific injuries have been identified, and others have converted only when laparoscopic repair was impossible. The impact of laparoscopic expertise on the diagnostic accuracy of the procedure has not been assessed. Since the sensitivity, specificity, accuracy, and number of missed injuries can be substantially influenced by most of these factors, it is difficult to provide firm recommendations on the role of DL in trauma patients.
Recommendations
Diagnostic laparoscopy is technically feasible and can be applied safely in appropriately selected trauma patients (grade B). The procedure has been shown to effectively decrease the rate of negative laparotomies and minimize patient morbidity. It should be considered in hemodynamically stable blunt trauma patients with suspected intra-abdominal injury and equivocal findings on imaging studies or even in patients with negative studies but a high clinical likelihood for intra-abdominal injury (grade C). It may be particularly useful and should be considered in patients with penetrating trauma of the abdomen with documented or equivocal penetration of the anterior fascia (grade C). It should be used in patients with suspected diaphragmatic injury, as imaging occult injury rates are significant, and DL offers the best diagnostic accuracy (grade C). Patients should be followed cautiously postoperatively for the early identification of missed injuries. Therapeutic intervention can be provided safely when laparoscopic expertise is available (grade C). To optimize results, the procedure should be incorporated in institutional diagnostic and treatment algorithms for trauma patients.
Bibliography
1. Leppaniemi A, Haapiainen R Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma 2003; 55(4):636-45.
2. Ahmed, N., Whelan, J., Brownlee, J., Chari, V., and Chung, R. The Contribution of Laparoscopy in Evaluation of Penetrating Abdominal Wounds. Journal of the American College of Surgeons 2005;201(2):213-6.
3. Mitsuhide, K., Junichi, S., Atsushi, N., Masakazu, D., Shinobu, H., Tomohisa, E., and Hiroshi, Y. Computed Tomographic Scanning and Selective Laparoscopy in the Diagnosis of Blunt Bowel Injury: a Prospective Study. Journal of Trauma-Injury Infection & Critical Care 2005;58(4):696-701.
4. Cherry, R. A., Eachempati, S. R., Hydo, L. J., and Barie, P. S. The Role of Laparoscopy in Penetrating Abdominal Stab Wounds. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 2005;15(1):14-7.
5. Miles, E. J., Dunn, E., Howard, D., and Mangram, A. The Role of Laparoscopy in Penetrating Abdominal Trauma. Journal of the Society of Laparoendoscopic Surgeons 2004;8(4):304-9.
6. Taner, A. S., Topgul, K., Kucukel, F., Demir, A., and Sari, S. Diagnostic Laparoscopy Decreases the Rate of Unnecessary Laparotomies and Reduces Hospital Costs in Trauma Patients. Journal of Laparoendoscopic & Advanced Surgical Techniques 2001;Part A. 11(4):207-11.
7. Simon, R. J., Rabin, J., and Kuhls, D. Impact of Increased Use of Laparoscopy on Negative Laparotomy Rates After Penetrating Trauma. Journal of Trauma-Injury Infection & Critical Care 2002;53(2):297-302.
8. Murray, J. A., Demetriades, D., Asensio, J. A., Cornwell, E. E., III, Velmahos, G. C., Belzberg, H., and Berne, T. V. Occult Injuries to the Diaphragm: Prospective Evaluation of Laparoscopy in Penetrating Injuries to the Left Lower Chest. Journal of the American College of Surgeons 1998;187(6):626-30.
9. Villavicencio, R. T. and Aucar, J. A. Analysis of Laparoscopy in Trauma. [Review] [62 Refs]. Journal of the American College of Surgeons 1999;189(1):11-20
10. Rossi P, Mullins D, Thal E. Role of laparoscopy in the evaluation of abdominal trauma. Am J Surg 1993;166:707�711.
11. Ortega AE, Tang E, Froes ET, et al. Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries. Surg Endosc 1996;10:19�22.
12. Brandt CP, Priebe PP, Jacobs DG. Potential of laparoscopy to reduce nontherapeutic trauma laparotomies. Am Surg 1994;60: 416�420.
13. Mathonnet, M., Peyrou, P., Gainant, A., Bouvier, S., and Cubertafond, P. Role of Laparoscopy in Blunt Perforations of the Small Bowel. Surgical Endoscopy 2003;17(4):641-5.
14. DeMaria, E. J., Dalton, J. M., Gore, D. C., Kellum, J. M., and Sugerman, H. J. Complementary Roles of Laparoscopic Abdominal Exploration and Diagnostic Peritoneal Lavage for Evaluating Abdominal Stab Wounds: a Prospective Study. Journal of Laparoendoscopic & Advanced Surgical Techniques 2000;Part A. 10(3):131-6.
15. Elliott, D. C., Rodriguez, A., Moncure, M., Myers, R. A., Shillinglaw, W., Davis, F., Goldberg, A., Mitchell, K., and McRitchie, D. The Accuracy of Diagnostic Laparoscopy in Trauma Patients: a Prospective, Controlled Study. International Surgery 1998;83(4):294-8.
16. Zantut, L. F., Ivatury, R. R., Smith, R. S., Kawahara, N. T., Porter, J. M., Fry, W. R., Poggetti, R., Birolini, D., and Organ, C. H., Jr. Diagnostic and Therapeutic Laparoscopy for Penetrating Abdominal Trauma: a Multicenter Experience. Journal of Trauma-Injury Infection & Critical Care 1997;42(5):825-9.
17. Marks, J. M., Youngelman, D. F., and Berk, T. Cost Analysis of Diagnostic Laparoscopy Vs Laparotomy in the Evaluation of Penetrating Abdominal Trauma. Surgical Endoscopy 1997;11(3):272-6.
18. Smith, R. S., Fry, W. R., Morabito, D. J., Koehler, R. H., and Organ, C. H., Jr. Therapeutic Laparoscopy in Trauma. American Journal of Surgery 1995;170(6):632-6.
19. Sosa, J. L., Arrillaga, A., Puente, I., Sleeman, D., Ginzburg, E., and Martin, L. Laparoscopy in 121 Consecutive Patients With Abdominal Gunshot Wounds. Journal of Trauma-Injury Infection & Critical Care 1995;39(3):501-4.
20. Hallfeldt, K. K., Trupka, A. W., Erhard, J., Waldner, H., and Schweiberer, L. Emergency Laparoscopy for Abdominal Stab Wounds. Surgical Endoscopy 1998;12(7):907-10..
21. Weinberg JA, Magnotti LJ, Edwards NM, Claridge JA, Minard G, Fabian TC, Croce MA. "Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds. Injury. 2007;38(1):60-4.
22. Feliz A, Shultz B, McKenna C, Gaines BA. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg. 2006;41(1):72-7.
23. McQuay N, Britt LD. Laparoscopy in the evaluation of penetrating thoracoabdominal trauma. Am Surg. 2003;69(9):788-91.
24. Fabiani P, Iannelli A, Mazza D, Bartels AM, Venissac N, Baqu� P, Gugenheim J. Diagnostic and therapeutic laparoscopy for stab wounds of the anterior abdomen. J Laparoendosc Adv Surg Tech A. 2003 Oct;13(5):309-12.
25. Chol YB, Lim KS.Therapeutic laparoscopy for abdominal trauma. Surg Endosc 2003;17(3):421-7

1. What is Minimally Invasive Surgery?
Minimally Invasive Surgery, some people refer to this simply as MIS, is a broad term for any procedure performed with small incisions (or sometimes no incisions at all).
Laparoscopic Surgery refers to MIS in the abdominal cavity. A telescope and long, fine caliber instruments are inserted into the abdomen to see and perform the surgery. The incisions used are 5 to 10 mm in size. These incisions heal quickly after surgery, resulting in small "keyhole" scars. Sometimes, even finer instruments are used (2 to 3 mm) in what we call Needloscopic Surgery. This results in "pinhole" scars that are hardly discernable.
The same technique is called Thoracoscopic Surgery when used in the thoracic cavity (to approach the esophagus, for example) or Endoscopic Surgery when used elsewhere (for example in the neck for Endoscopic Thyroid Surgery).
2. Can my operation be done using Laparoscopic Surgery?
Almost any conventional operation can be done laparoscopically. This can something simple, like the removal or a gallbladder or appendix, to something very complex, like the resection of the stomach for cancer. Some of the complicated operations can be technically demanding, and a good outcome depends on the skill and experience of the surgeon. In general, we believe that, under our hands, the laparoscopic options gives a better result. Occasionally however, laparoscopic surgery is contraindicated in certain patients, and some operations may be too difficult to offer any substantial benefit over conventional open surgery.
3. What are the contraindications to Laparoscopic Surgery?
The only absolute contraindications are an unstable patient (for example, someone who is bleeding actively from trauma) or a patient who is unfit for general anaesthesia (since GS is always required for laparoscopy). In certain patients, the contraindications are relative and have to be evaluated individually. These patients include those who have severe heart or lung disease, have previous abdominal surgery, bowel obstruction or bleeding problems.
4. What about pregnant patients?
In general, we try to not to do elective surgery during pregnancy. In those cases where we must, we try to delay the operation until the second trimester, or until fetal viability, or till after delivery. If surgery is absolutely essential, laparoscopic surgery is as safe as open surgery, and even offers certain advantages. However, great care has to be taken with surgery and anaesthesia as the dangers are real: about 12% risk of miscarriage in the first trimester, 5 to 8% risk or preterm labour in the second trimester and 30% risk of preterm labour in the third trimester.
5. What are the benefits of Laparoscopic Surgery?
Since only "keyhole" incisions are used, the post operative functional recovery is rapid. Most patients are discharged from hospital faster and return to work earlier. There is less wound pain and the cosmetic outcome is excellent. In the long term, there are fewer problems with post-surgery bowel adhesions. There is also recent evidence to suggest that the reduced disturbance to the immune system during laparoscopy results in better survival after cancer resection when compared to open surgery. This is because the minimal insults allow the body to fight off circulating cancer cells more effectively.
6. Are there any disadvantages of Laparoscopic Surgery?
Laparoscopic surgery is technically more difficult than conventional open surgery. Moreover, as some of these procedures have only evolved in the last few years, not all surgeons are trained to perform them. Surgeon related errors can occur. Finally, laparoscopic surgery often takes longer to perform and may cost more in terms of equipment used - although this is not always so!

Public Hospitals
in India

Dr.
Shriniwas
Kashalikar


Since the public services and especially public health services, affect most of us, it is essential to find out the root causes of their deficiency and try to deal with them. This is one of the intellectual measures of stress management and benefits every individual concerned.

The causes of degeneration of quality of public health services in public hospitals in India; is the prevalence of the two concepts on which these institutions work. These concepts are, free medical care and economic dependence of these institutions on the government revenue and donations.

FREE MEDICAL CARE
The free medical care gives rise to parasitism, beggarly tendency, meekness and irresponsibility towards personal and public health amongst the patients.

The free medical care creates a special and extremely favorable situation and golden opportunity for the powerful, rich and famous individuals to exploit the government revenue and tax payers� money.

The free medical care leads to zero returns and subsequent deterioration in the facilities given to patients and employees.

The free medical care associated with perpetual absence of returns leads to unjustifiably low salaries, delay in filling the vacancies, excessive working hours and duties, and delay in promotions.

This state of affairs demoralizes the sincere and dedicated employees and promotes irresponsibility, lethargy, absenteeism, corruption etc.


ECONOMIC DEPENDENCE OF THESE INSTITUTIONS ON THE GOVERNMENT REVENUE AND DONATIONS
The public hospitals are not self-sufficient and do not have any productive/commercial projects to support them. Naturally since there are no returns either from patients or from any other source, for what is spent, the public hospitals are always in loss.

This has lead to inadequate progress in terms of inadequate facilities, inadequate salaries, inadequate employment in terms of number of employees in almost every category, protracted duty hours, worsening working conditions, worsening of staying conditions for the employees and crowding of patients due to huge patients/employee ratio.

All these factors have lead to deterioration of the quality of medical care. In fact because of this a large number of lower middle class and even poor patients turn to private practitioners, consultants and hospitals.

This deterioration can be overcome by trying to make the public hospitals self-sufficient. For this, the concept of free medical care has to be replaced by more just system of payment. This would bring adequate revenue to ensure progress in terms of adequate facilities, adequate salaries, appropriate employment which could ensure normal duty hours, improvement in working conditions, improvement in staying conditions for the employees and preventing excessive and many times [because the services are free] unnecessary crowding of patients.

One may raise the objection that this is difficult to implement in case of very poor, helpless, unsupported patients.

It is very true that no sensitive and sensible individual would think of doing it as well. These patients who are in agonies, in emergencies, or helpless etc. should be made exception and a separate arrangement can be made for them. But in most other cases the problem can be overcome by making provision for payment through �services� or soft loans.

Another way to make the public hospitals self-sufficient is by buttressing them with productive / commercial projects. One can think of more innovative plans as well.

This is important because:
A] it would inculcate a sense of responsibility towards one�s own health, towards public funds, towards public services, amongst everyone including the patients.
B] it would generate the sense of accountability, satisfaction and fulfillment amongst the employees
C] It would ensure optimal progress in medical care especially in terms of holistic approach
D] It would improve the lives of patients as well as employees
E] It would make the revenue hitherto squandered on free medical care available for other developmental work thereby facilitating national progress.
F] it would reduce the corruption born of out of injustice
G] it would reduce the crowding and degeneration of private medical care.

DR. SHRINIWAS KASHALIKAR

In the year 1992 the first report on the Incisional Hernia Repair by Laparoscopic method was published. Number of case reports appeared in the literature since than.
Aims
Indications: Any ventral or scar hernia with 3cm or more fascial defect can be repaired with laparoscopy easily.
Swiss-Cheese Hernias (Multiple small defects) is a good indication for the laparoscopic approach, allowing a clear delineation of all defects.
Relative contraindications: Obstructed/incarcerated hernia, multiple operations
Methods
Operative techniques
Method 1: Intraabdominal intraperitoneal using mesh prosthesis to close and cover the defect.
Method 2 The mesh is placed in the preperitoneal space in order to prevent the adhesions. This method mimics the conventional approach and avoids formation of adhesions.

Results The postoperative pain was significantly less. There was no ileus, no wound infection. The patients were discharge within 3 days.

Discussion: The laparoscopic ventral or scar hernia repair is still a debatable topic. It can be used in selected patients with less postoperative morbidity.
Method 1 is using intraperitoneal mesh hence there is tendency for adhesions.
Method 2 uses preperitoneal mesh having very few indications. It very difficult as the plane in preperitoneum can be achieved easily in small and moderate size hernial sacs

Conclusion
Laparoscopic ventral and scar hernia repair still need a controlled trial. At present only selected ventral hernias are suitable for laparoscopic repair.

Exercise prescription for fitness
In this mechanised world the only muscles we are using are our fingers for various controls.
The only weight we are carrying is our own body weight.
In all, a sedentary lifestyle accounts for some 250,000 premature deaths annually

At any age of life exercise makes an integral part of physical as well as emotional and psychological fitness.But exercise has to be integrated into our daily life as much as we are brushing our teeth daily.
THE BENEFITS OF EXERCISE IN A NUTSHELL
� Even in the elderly woman, exercise can attenuate certain effects of aging and sedentary
lifestyles.
� Regular exercise may decrease the incidence and severity of hot flashes, which occur in
75% of menopausal women. Menopausal women typically benefit most from exercise in
combination with estrogen replacement therapy.
� Weight-bearing exercise, resistance training and high-intensity fitness regimens can reduce a
woman's risk of fractures and help retard sarcopenia.
� Cardiovascular effects of exercise are also dramatic, as studies have shown that perimenopausal
women who are more physically active and gain less weight have lower elevations of LDL,
total cholesterol and triglycerides than their heavier, less active counterparts.
Components of fitness are
&#61607; Cardiorespiratory fitness
&#61607; Weight control and fat distribution and body composition
&#61607; Muscular strength
&#61607; Endurance,
&#61607; Flexibility


Various types of exercises are:
&#61656; Stretching exercises
&#61656; Toning exercises
&#61656; range of movement exercises
&#61656; strength building exercises and resistance exercises to increase BMD and decrease sarcopenia
&#61656; meditation or relaxing exercises
some precautions while doing exercises are
1. Warm up is must
2. Take plenty of water
3. Room temp should not be very hot
4. Switch on the music to enjoy your exercise
5. Vary your exercises so that you are not bored
6. Make a group and enjoy your exercise and be cheerful.
7. First learn proper way of doing exercise and then slowly you can add weights
8. DON�T GIVE UP ! RESULT WOULD COME SLOWLY BUT WOULD COME DEFINITELY.
9. Intensity of exercise can be measured by various means:
� Talk test
� 2. Heart rate test
� 3. Borg rating of perceived exertion (RPE) scale
� 4. MET Test.
Heart rate test is easy to use and is calculated form MHR
.MHR (maximum heart rate is 220-age in years and targeted heart rate for moderate exercise should be 60 -80 % of your MHR and for severe intensity of exercise it can be 85-90% of MHR
10.When ever you start exercising first thing is to do warm up and this can be done either by cycling or treadmill walking or just by stretching the group of muscles you are going to exercise.
11.Take lots of water inbetween,
12.learn proper technique of doing these exercises and exercise whole body , but in one day you can do one or two group of exercises.
In this session we would tell about leg execises which can be done at home.

Warm up
If you are doing with tread mill see to it that the surface is not inclined.Warm up can be by simple walking even.or by sationary cycling for 5- 10min.
If you have to lose weight then these execises can be for longer period like 15-20 min.but for toning up and strength building warm up 5-10 min. is ok.
Walking as an exercise



Walking to be effective has to be at a brisk pace. Slow walking does not give any benefits of weight losing or even for cardioprotection.you should do at a pace that you are barely able to talk.
Foot wear should be proper and ideally it should not be on hard surface.




Stretching is a vital component of any exercise program. A brief stretch after any workout is a nice way to relax-and it helps prevent injury and maintain flexibility. Furthermore,stretching helps reduce back pain from osteoporosis, as well as other aches and pains.
Leg exercises
Leg exercises should be done to strengthen your all leg muscles and give them full range of motion and some of these exercises are following which can be done at home.



HAMSTRING STRETCH

Sitting on the ground, with one leg straight and the other one comfortably bent in front of your body, bend at the waist and lean forward, keeping your back as straight as possible and don�t arch it. Reach with your arms towards the foot until a stretch is felt under your thigh. Hold each stretch for a minimum of 30 seconds, any less than 15 seconds and the muscle will not conform to the new increase in length. Do 3 reps, 3-6 times a day. Any pain you feel with this exercise should only be a local stretching sensation to the back of your thigh area, without aggravating your condition.




Gluteus Stretch
Lying down on your back, bend your right knee, and place your left leg over the right leg, resting the outside of the left ankle slightly above the right knee. Place your right hand around the outside of your right thigh and place the left hand around the inside of your right thigh. Lock the two hands together. Now pull forward towards your chest to achieve a stretch in the left gluteus portion of your buttocks. Do the exact opposite to achieve a stretch of the right gluteus portion of the buttocks. Hold each stretch for a minimum of 30 seconds, any less than 15 seconds and the muscle will not conform to the new increase in length. Do 3 reps, 3-6 times a day. Any pain you feel with this exercise should only be a local stretching sensation to the back of your thigh and buttocks area, without aggravating your condition.



Calf Stretch
Start with stretching the right Gastrocnemius portion of the right calf area. While standing, place your right leg in front of you and your left foot directly behind you. Place the toes of your right forefoot up against a door or other flat wall surface, keeping your heel down to the floor. Lean against a wall or other stationary object, both palms against the object. The leg you want to stretch is back, several feet from the wall, your heel firmly positioned on the floor. Your other leg is flexed about halfway between your back leg and the wall. Start with your back straight and gradually lunge forward until you feel the stretch in your calf. "It is important to keep your back foot straight and angled 90 degrees from the wall," . Hold each stretch for a minimum of 30 seconds. Any less than 15 seconds and the muscle will not conform to the new increase in length. Do 3 reps, 3-6 times a day. Any pain you feel with this exercise should only be a local stretching sensation to the calf area of the leg, without aggravating your condition.

Quadriceps Stretch
Start with stretching the left Quadriceps muscle. While standing hold a solid surface for support and bend back your left leg. Grab your left ankle and pull that foot to your left buttocks while simultaneously pulling your left thigh backwards while keeping your back straight. Pulling your thigh backwards is a very important part of this stretch, as it will place the stretch in the mid-thigh instead of overloading the pressure on the knee. Do the exact opposite to achieve a stretch of the right Psoas portion of your front upper thigh area. Hold each stretch for a minimum of 30 seconds. Any less than 15 seconds and the muscle will not conform to the new increase in length. Do 3 reps, 3-6 times a day. Any pain you feel with this exercise should only be a local stretching sensation to the Quadriceps muscle area of the upper thigh, without aggravating your condition.






Inner side of thigh muscles stretch or adductor stretch

Our muscles do not work alone when we perform certain exercises. Our adductor muscles are working simultaneously with others while doing squats, leg presses, or lunges. Make sure that your adductor muscles are in their good condition everytime you perform stretching activities.
To stretch the groin simply place the feet together pull in toward yourself grab onto your ankles and apply force with your elbows down on your legs. If your doing this stretch correctly you'll feel a pulling on your upper inner thigh.






Front Lunge
The lunge is a dynamic exercise that targets the muscles of the thighs, back, and buttocks,
strengthening the bones in the hip and spine. The wide leg squat addresses the same muscles,
but the lunge includes balance and coordination as well.
Starting position: Stand next to table or counter with your feet hip-width apart, knees
slightly bent. Lightly hold on to the counter with one hand.
1-2-3-Forward: Take a large step forward with your right leg. Land on the heel of your right foot, and then roll your foot forward until it is fl at on the fl oor. Keeping your body erect, bent both knees so that your hips drop straight down. Your front thigh should be almost parallel to the floor, and the knee of your back leg should approach the floor. The knee of your forward leg should be over your ankle, not past your toes. The heel of your back leg will come off the floor. Your weight will be equally distributed between your front foot and the ball of your back
foot.
This exercise can be done with holding free weights in your hands, and as your strength goes on increasing you can increase weights or you can do with weights attached to a barbell and barbell is held at the upper part of your back.



Pause for a Breath
Return: Push back forcefully with the front leg to return to the starting position.
Pause for a breath, and then repeat the move.
Reps and Sets: Alternate legs as you step forward until you have done 8 reps with each leg � this
is 1 set. Rest for a minute or two and do a second set.
This exercise can be done without weights or slowly you can add weights.

Wide Leg Squat
It strengthens the muscles of your front, back, and inner thigh as well as your buttocks and the hip-bones, i.e.hamstrings, quadriceps and gluteus muscles.
Stand about 6 inches in front of the chair with your feet a little wider than shoulder-width apart. Take a deep breath and flex your knees and then aim your buttocks back and slowly lower yourself into the chair. Your knees should remain above your ankles;your knees should never go beyond your toes.
Pause, and slowly stand. Then repeat the move 8�10 times and three sets of same repetitions.