Lateral Epicondylitis (Tennis Elbow)

English: Lifting backpack (Photo credit: Wikipedia)

I. Overview

The most common overuse syndrome characterized by inflammation or degeneration at the common extensor tendon that joins the forearm muscles to the lateral epicondyle of the elbow. The forearm muscles and tendons become damaged from overuse leading to pain and tenderness on the outside of the elbow. It is a strain injury from playing tennis or other racquet sports. However, you can still get tennis elbow even if you are not a tennis player and is actually more common in non-tennis players. Any repetitive gripping activities or several other sports can also put you at risk. The structures primarily involved are the wrist extensors, particularly the extensor carpi radialis brevis. It also affect the extensor digitorum, extensor carpi radialis longus, and extensor carpi ulnaris.

II. Functional Anatomy

A synovial hinge joint formed between the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm. The elbow joint complex made up of four articulation,  the humeroulnar, humeroradial, superior radioulnar, and inferior radioulnar joints. Muscles, ligaments, and tendons hold the elbow joint together to provide functional movements and dynamic stabilization to perform skilled and precise motions. The coordination of multiple muscles allows two degrees of freedom of movements,  the combinations of flexion-extension and pronation-supination. The two epicondyles are actually the bony protuberance at the distal end of the humerus, the medial and lateral epicondyle. The forearm muscle tendons attach the muscle to bone. In lateral epicondylitis, the injury is on the tendon attachment on the lateral epicondyle of the humerus. The tendon usually involved is the Extensor Carpi Radialis Brevis (ECRB). Experiences pain and localized tenderness in the lateral side of the elbow.

Elbow - coude (Photo credit: Wikipedia)

III. Contributing factors

1. Overuse
Any repetitive wrist action against resistance during extension and supination may produce damage to the forearm muscle, particularly the extensor carpi radialis brevis muscle which stabilizes the wrist when the elbow is in extension. An example is ground stroke (backhand) in tennis.

2. Work and Activities 
There is a risk to any work or leisure activities that has no proper training, techniques, and equipment.

• Tennis/Racquetball/Squash - Check equipment for proper fit
• Fencing
• Weight Lifting
• Painters/Painting
• Carpenters/Bricklayers/Plumbers 
• Seamstresses/Tailors
• Cooks /Butchers
• Politicians (excessive handshaking)
• Musicians (pianists, drummers)
• Raking
• Knitting
• A lot of typing
• A lot of mouse work

3. Age
It is more common to individuals in their late 30's and 50's secondary to the normal loss of extensibility of connective tissue with age

4. Symptoms 
The symptoms of tennis elbow include pain and localized tenderness along the lateral aspect of the elbow especially over the lateral epicondyle that sometimes radiates into the dorsum of the hand although the damage is in the elbow. Pain usually increases with activity like picking up an object, holding a glass/cup, opening a door, or making shake hands. The elbow ROM is usually normal and involved only one side.

IV. Diagnosis

1. History Taking

• Information from patient
• Age of the patient (usual age group affected 30 to 50 years of age)
• How your current symptoms developed and medications
• Any occupational risk factors
• Recreational sports activities
• Family and Past medical history like an elbow injury before, history of rheumatoid arthritis or nerve disease

2. Physical Examination

• Inspections for swelling or ecchymosis.
• Palpation of the extremity for pain and tenderness at the lateral epicondyle
• The severity, the occurrence, and location of pain in relation to movement/activity
• Always examine ROM of the shoulder, elbow, and wrist on the affected side to evaluate for radiohumeral bursitis, osteochondritis of the capitellum, or PIN entrapment.

3. Tests

• Laboratory and imaging studies rarely needed
• X-ray or MRI (magnetic resonance imaging) to diagnose tennis elbow or rule out other problems like osteophytes, degenerative joint disease, or stress fracture
• Electromyography if there is radial nerve involvement
• Special orthopedic tests

Mills test

• The examiner palpates the patient’s lateral epicondyle with a thumb while passively pronating the forearm, flexing the wrist and extending the elbow.
• Positive test is reproduction of pain near the lateral epicondyle
• This test is also to use to indicate radial nerve involvement

Cozen’s test  

• Patient actively make a fist, pronate the forearm as well as radially deviate and extend the wrist against a counterforce that is being applied by the examiner.
• The positive test is the reproduction of pain near the lateral epicondyle.

Tennis elbow test

• The examiner resists the extension of the 3rd digit of the hand while stabilizing more proximal
• The positive test is the reproduction pain or discomfort in the region of the lateral epicondyle because it stress the extensor muscles and tendon

V. Differential Diagnoses

• Medial Epicondylitis
• Cervical Radiculopathy
• Plica Syndrome
• Elbow and Forearm Overuse Injuries
• Little League Elbow Syndrome
• Radial Nerve Entrapment 

Medical Intervention:
There are many treatment options for tennis elbow geared toward the goals of decreasing inflammation and analgesia. 

Nonsurgical Treatment
1. The patient is advice to avoid activities or work that aggravates the injury and treats pain and inflammation with protection, rest, ice, compression, and elevation.
2. Pharmacological intervention 

• Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation such as ibuprofen, naproxen, or aspirin
• Monitor the effects on the gastrointestinal (GI) tract and renal function  with long-term use
• Topical NSAID such as diclofenac may offer some short-term relief.

3. Modalities

•  Ultrasound phonophoresis with hydrocortisone 
•  Electrical stimulation iontophoresis with NSAIDs and/or corticosteroid (dexamethasone) 

4. Counter-force bracing /Resting splints to relieve tension of the involved wrist extensor tendons
5. Physical therapy

•    Stretching to improve flexibility
•    Strengthening to increase functional activities
•    Progress from concentric to eccentric exercises and then resisted exercises as   tolerated
•   All exercise should be pain-free
•   Stretch and warm up before any sport or activity that will exercise your elbow or    arm.
•   Apply ice on your elbow after exercise

6. Steroid injections are very effective anti-inflammatory medicines to relieve symptoms.


Surgical Treatment
1. Recommended if the symptoms do not respond after 6 to 12 months of nonsurgical treatments
2. Surgical Option:
    a. Open surgery

• The most common approach to tennis elbow repair that involves making an incision over the elbow.

   b. Arthroscopic surgery

• This outpatient procedure involves using miniature instruments and small incisions. 

3. Rehabilitation

• Usually last 4 to 6 months postop
• Start the exercise with stretching and light, gradual strengthening exercise 2 months postop

4. Surgical risks

• Infection
• Nerve and blood vessel involvement
• Long-term rehabilitation process
• Loss of strength
• Loss of flexibility
• Possibility of another surgery

Home Care Program

• Give the same therapeutic program to the patient
• Patient education on modification of the activities that exacerbate the symptoms and use ice, elevation and rest as needed
• Advice patient about continued stretching and excercise to decrease the risk of recurrence
• Advice about the danger of rushing the recovery as it may worsen the damage

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Therapeutic Ultrasound

English: http://rheumatoidarthritis-symptoms.com - Rheumatoid Arthritis in the hands (Photo credit: Wikipedia)

Ultrasound in the medical community is used according to different purpose. It can be a diagnostic tool by imaging internal structures; the tumoricidal effects will help cancer patients in the destruction of tissue or as a valuable therapeutic agent in physical therapy. Ultrasound is one of the common deep heating therapeutic modality used by physical therapists today. Ultrasound consists of inaudible high‐frequency mechanical vibrations that produce thermal and nonthermal effects. The vibrations are created when an electrical energy is converted to acoustic energy through mechanical deformation of the piezoelectric crystal within the transducer/probe. The sound waves that pass through the skin causes a local deep heating and usually no sensation of heat will be felt by the patient. 




Therapeutic Effects

• Scar tissue breakdown by gentle massage of muscles, tendons and/ or ligaments in the treated area 
• Decrease joint stiffness
• Pain relief from the reduction of swelling and edema
• Increase local blood flow reduces local swelling and chronic inflammation
• Decrease muscle spasm

Nonthermal Effects

• Stimulation of tissue regeneration
• Increase macrophage responsiveness
• Pain relief from tissue relaxation
• Speed up soft tissue repair from increased blood flow
• Increase blood flow according to some studies promotes fracture healing
• Increase skin and cell membrane permeability enhance the cell repair effects of the inflammatory response, especially in soft tissue injuries

Indications                                                                                                                                         

• Ligament Sprains
• Muscle Strains
• Tendonitis
• Joint Inflammation
• Plantar fasciitis
• Metatarsalgia
• Facet Irritation
• Impingement syndrome
• Bursitis
• Rheumatoid arthritis
• Osteoarthritis
• Scar tissue adhesion
• Bone fracture
• Contracture
• Trigger point
• Dermal ulcer
• Plantar wart
• Pain

          

Contraindications

• Vascular abnormalities - thrombophlebitis
• Impaired pain or temperature sensory deficits
• Directly on the abdomen of pregnant women
• Directly over active epiphyseal regions (growth plates) in children
• Metal implants below the area being treated
• Local acute infection 
• Over the eyes, skull, testes, or cervical ganglia
• Over local malignancy
• Over the spine after laminectomy
• Over cemented prosthetic joint

Treatment Parameters

The treatment will be based on the diagnosis and the desired effects. Define the duration, frequency, duty cycle and intensity of treatment. 

Therapeutic ultrasound is in the frequency range of about 75 and 3 MHz. A frequency setting of 1 MHz is used for heating deeper tissues (up to 5 cm). A setting of 3MHz produces a higher temperature with a depth of penetration of less than 2 cm. 

The ultrasound can be administered using a pulsed or a continuous transmission mode. The pulsed mode is used in situations where a heating effect is not desirable, such as a fresh injury with acute inflammation because it minimizes the thermal effects (nonthermal effect). A continuous mode is effective in elevating the tissue temperature to produce the thermal effects on the tissues (due to the absorption of the sound waves). Nonthermal effects are from cavitations, micro-streaming, and acoustic streaming.

Ultrasound is applied using a transducer in three different techniques. One is in direct contact with the skin, the other way is to slightly hold one half-inch above a body part for water immersion technique, and lastly the indirect contact using a fluid-filled bag (bladder technique). The direct contact technique can be either the stationary or moving techniques. In the moving technique, the transducer should continuously move in a small circular manner or in a longitudinal stroke over the treated area. Each motion should cover half of the previous circle or stroke. The water immersion technique is recommended if the area to be treated is smaller than the diameter of the available transducers or if the body area is irregular with bony prominences. The body part is immersed in a plastic or rubber basin (no metal) filled with tap or degassed water. Move the transducer in a longitudinal stroke while keeping a 1/2' to 1' distance from the skin. The bladder technique is also ideal for bony prominent areas. This technique uses a thin plastic bag (surgical gloves or balloon) filled with water and is placed on the area to be treated. A coupling media are applied and slowly move the transducer on top of the bag.

The application requires a coupling medium (gels) applied on the area to be treated to reduce surface friction and assist transmission of the ultrasonic waves by preventing reflection of the waves away at the soft tissue air interface. Besides gels as a coupling media, mineral oil is can also be used. Different media have also different acoustic impedance that affects the transmission and absorption of the ultrasound. A two media having the same impedance will produce maximal transmission of energy or else a greater the difference in impedance, the greater the reflection that will occur, and therefore, the smaller the amount of energy that will be transferred.

The ultrasound intensity of continuous US is normally set between 0.5 to 2 W/cm2 of thermal effects while pulsing US normally set between 0.5 to 0.75 W/cm2 with a 20% duty cycle. Maximum energy absorption in the soft tissue occurs from 2 to 5 cm. Intensity decreases as the US waves penetrate deeper. They are absorbed primarily by connective tissue: ligaments, tendons, and fascia.

A typical ultrasound treatment will take from 3-5 minutes, depending on the size of the area being treated. Larger areas require duration of 5 minutes.

Duty cycles are the portion of treatment time that ultrasound is generated during the entire treatment or a Pulse ratio, which determines the proportion of time that the machine is ON compared with the OFF time. Some machines use ratios, and some percentage.

• In continuous US, the machine continuously generates ultrasound, giving 100% duty cycle and produces thermal effects.
• In pulsed US, a 50% duty cycle if the machine US generation (ON) have equal duration with machine in not generating US (OFF). This is a pulse ratio of 1:1.This is the nonthermal effects. 
• If the duty cycle is 20%, the US generated (ON) is 20% of the treatment, while the other percentage the machine is not generating US (OFF). This is the machine pulsed at a ratio of 1:4

Mode              Pulse Ratio                            Duty Cycle

Continuous                                                          100%

Pulsed                  1:1                                           50%

                             1:2                                           33%

                             1:3                                           25%

                             1:4                                           20%

                             1:9                                           10%

Phonophoresis

This is a non-invasive way of administering medications to tissues below the skin. This transdermal delivery of medication is recommended for patients who are uncomfortable with injections. Medications regularly used include anti-inflammatory agents or analgesics (cortisone). It is effective with both continuous and pulsed techniques.

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• Ultrasound can accelerate wound healing

Hot Moist Packs

These are the commercially available superficial heating modality used by many PT clinics and hospitals to provide moist heat. This consists of a silicate gel enclosed in a cotton canvas fabric. Silicate gel is the main property because it absorbs more water and when it is immersed in  hot water it provides a considerable store of heat energy that last 30 to 40 minutes. Heating is through conduction and has little to or no effect on the temperature of  deeper tissues. Hot packs are available in different size and shape to fit different body areas.

Physiologic Responses:

• Increases circulation - promotes soft-tissue healing
• Increases muscle temperature - decreases pain and stiffness
• Relaxes spasm 

Treatment Parameters:

• Hot packs are stored in a tank filled with hot water between 70 to 75 degrees Celcius.
• Application of the packs requires six to eight layers of towels around the hot pack to provide thermal insulation thus lessening the danger of burn
• Ideally, it should be applied on top of the patient. If the patient lies on top of the hot pack additional toweling is required
• Check skin after five minutes for excess or sign of a burn.
• Call the attention of the PT for discomfort
• Applied at least 20 to 30 minutes to achieve the desired effects

Method of Application:

One-towel method

• Fold four towels in half, width-wise.
• Place each towel on top of the other, forming eight layers of toweling.
• Place towels on the treatment area.
• Place pack on towels and cover pack with folded towel to retard heat loss.

Two-towel method

• Fold two towels lengthwise and
• Place one perpendicular over the other, forming a cross.
• Place pack in the center of the towels.
• Fold the ends of the towels over the pack, forming eight layers of toweling on top of the pack. Invert pack placing the eight layers of toweling on the patient.

Contraindications and Precautions:

• Impaired skin sensation
• Circulatory dysfunction - varicose veins, DVT, and arterial diseases
• Taking analgesic drugs
• Infections and open wounds - danger of cross-contamination
• Cancer and tuberculosis - may enhance the progression of the disease
• Gross edema
• Impaired cognitive - lack of comprehension
• Deep x-ray therapy
• Liniments
• Pregnancy - should not be applied directly over the uterus
• Fever
• Acute inflammation
• Presence of metal implants 
• Advanced age
• Menses - increases menstrual flow if applied to the lower back or over the pelvis

Advantages:

• Easy to apply
• Saves time for personnel
• Efficient in heat conduction
• Available in different sizes and shape to fit clinical needs
• Has more sedative effects than dry heat
• Low cost
• Long life
• Patient acceptance

Disadvantages:

• Not easily applied around shoulders and hips
• Somewhat heavy
• Cannot be used on extremely sensitive patients
• May cause skin rash

Alternatives:

Hot Compress 

• Ideal for home use; an alternative to hot moist pack
• Greater heat loss and need constant change.
• Place the towel in hot water and wrung out t properly if you use this method of application.

Hot Water Bottle

• A rubber hot water bottle applied in the same way as hot moist packs
• Ideal for home use

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Body Mass Index (BMI)

English: This is a person with a Body Mass Index of 19 (Photo credit: Wikipedia)

It is a recognized and generally accepted measure utilized by physicians and health experts to determine weight status (underweight, overweight, and obesity). It measures body fat based on height and weight. An elevated or higher BMI are increased risk for the following diseases:       

• Hypertension - high blood pressure
• Cardiovascular Disease - Stroke
• Coronary Heart Disease
• Gallbladder Disease
• Dyslipidemia/Hyperlipidemias - 
• Osteoarthritis
• Type 2 Diabetes Mellitus
• Some cancers - endometrial, breast, and colon cancer
• Sleep Apnea
• Epidural Lipomatosis

International Classification of Adult Underweight, Overweight, and Obesity according to BMI

Classification	BMI(kg/m2)
	Principal cut-off points	Additional cut-off points
Underweight	<18.50	<18.50
Severe thinness	<16.00	<16.00
Moderate thinness	16.00 - 16.99	16.00 - 16.99
Mild thinness	17.00 - 18.49	17.00 - 18.49
Normal range	18.50 - 24.99	18.50 - 22.99
		23.00 - 24.99
Overweight	≥25.00	≥25.00
Pre-obese	25.00 - 29.99	25.00 - 27.49
		27.50 - 29.99
Obese	≥30.00	≥30.00
Obese class I	30.00 - 34.99	30.00 - 32.49
		32.50 - 34.99
Obese class II	35.00 - 39.99	35.00 - 37.49
		37.50 - 39.99
Obese class III	≥40.00	≥40.00

Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.

The BMI is calculated by the weight in kilograms divided by the square of the height in meters (kg/m²).

                                                       

Visit these links to determine your BMI:

BMI3D
Center for Disease Control and Prevention

(kg/m²)
(kg/m²
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Dataflow SCFHS (Saudi Arabia)

English: Saudi Arabia (Photo credit: Wikipedia)

Working in a healthcare industry in Saudi Arabia is quite tempting especially in the government-run facilities. The main thing is the tax-free salary. Besides, you will be provided with free accommodation and transportation.  Some are generous enough to give you food allowance. To sum up everything, there is a big chance for you to save if you spend your hard-earned money wisely. 

To realized everything I've mentioned above, you must fulfill the requirements mandated by law. Every individual, regardless of nationality, who wishes to practice their profession in Saudi Arabia are required to undergo registration process at the government regulatory body. Just like any other country, you are required to come in for an examination to check your competency and be able to practice your profession legally. I'll focus this topic to my fellow professionals in the healthcare industry,  particularly the physiotherapist. 






If you are living outside Saudi Arabia:

• Start the verification process with Dataflow.
• Click this website link>>> Dataflow SCFHS
• Click on the 'To initiate a new case' to register and to log in. Provide your email and password.
• Fill in all the required information (applicant) in the online application form.
• It should be written in English.
• Prepare all the documents in a scanned copy to be uploaded on the page where they are needed. Not a single upload.
• Documents to be submitted depend on the country where you from. Anyway, you will ask to what are these documents as you go along with your application.
• Applicants from the Philippines, prepare your College Credentials (TOR, Diploma), Government-issued IDs (Passport), Certificate of Employment(COE), and PRC Records. There is a note there mentioning nurses who doesn't have PRC will fall in the category of Nurse . I guess it applies to anyone who doesn't have PRC.
• Print, sign, scan, and upload the Letter of Authorization.
• Go over the pages and patiently review the information you provided before you proceed to the payment section.
• You cannot edit or make changes in your application once your payment is done.
• Anyway, they will inform you if there are changes to be made for clarification.
• Payment is SR500 thru credit card.
• If you don't  have the credit card, try to borrow from your friends or family and just pay them in cash.
• Once payment is done, you will receive an email from them to confirm your payment.
• Your will again receive an email if started working in your application as well as the anticipated date to finish.
• Keep all the email from them for future references.
• Check your SCFHS account to monitor the progress of your application.

Note:

Eligibility Number is provided to you after the verification (Dataflow). Use that Eligibility Number to register and schedule a Prometric Examination in the Philippines.

Useful Site:
http://www.dataflowgroup.com/applicant-gateway

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Obstetrics (Pregnancy and Exercise)

Muscles of the trunk (Photo credit: Wikipedia)

Exercise and Pregnancy

Regular exercise at the right intensity is an essential way of helping your body cope with the increased physical demands on your joints, muscles, heart and lungs during pregnancy. A recommended exercise, adequate diet, proper hydration, appropriate clothing, and optimal environment during exercise must be considered to obtain the best result.

I. Physiologic Changes during Pregnancy:

• Pregnancy weight gain
• Abdominal muscles are stretched and weakened
• Increased deep of respiration; hyperventilation and dyspnea during late pregnancy
• Increased tidal volume and increased minute ventilation
• Increased oxygen consumption per minute (15-20%)
• Ligamentous laxity secondary to hormonal changes  - hypermobile joints
• Frequent urination due to pressure in bladder
• Stress incontinence due to pelvic floor dysfunction
• Increased blood volume (40-50%); increased heart rate and cardiac output; decrease BP due to venous distensibility
• Increased basal metabolic rate and increased heat production
• Anemia may occur
• May develop hypotension in supine position during late pregnancy from pressure on the inferior vena cava.

II. Postural Changes during Pregnancy:

• Kyphosis with scapular protraction
• Increased cervical lordosis
• Forward head posture

III. Balance Changes during Pregnancy:

• Changes in center of gravity -shift forward and upward
• Wider base of support in standing

IV. Pathologies:

A. Diastasis Recti (Abdominal Separation)
A separation of the rectus abdominis muscles along the linea alba very common among pregnant women. Also common to newborn babies secondary to incomplete development and usually resolved without intervention. Men can possibly get it from weight cycling, doing wrong sit-ups or weightlifting, or from other causes.

Causes: 
Exact cause in unknown. Pregnant women may have the condition because of increased tension on the abdominal wall. Multiple births or many pregnancies have higher risk.

Symptoms:
It looks like a ridge running down the midline of the abdomen, anywhere from the xiphoid process to the umbilicus and more prominent with muscle  straining. Most easily seen when the baby tries to sit up. The top of the pregnant uterus is often seen bulging out of the abdominal wall in the late pregnancy. A trace of the unborn baby may be seen in some severe cases.






Testing:

• Patient in hook lying position.
• Place your fingers (palm facing you) just above your belly button.
• Lift your head and neck very slightly off the floor and press down with your fingertips.
• A gap felt greater than the width of two fingers indicates diastasis.
• A diastasis recti gap is measured in the width of fingers. 

Avoid :

• Be careful with crunches, sit-ups, oblique (twists) combined with crunches that will strain your abdominal muscles.
• Constipation and lifting heavy things.

Treatment: 

• No treatment is necessary for women while they are still pregnant.
• Education in the causes of diastasis recti and on the inappropriate abdominal exercises to avoid.
• Postpartum abdominal binding may be helpful in some cases because can help with awareness of the abs and for lower back support.
• Perform deep abdominal exercises  targeted to help narrow the separation between the muscles.
• Observe body mechanics
• Postural Awareness
• Maternity Belly Band

B. Pelvic Floor Weakness

Pelvic floor muscles are muscular bottom part of the abdomen which are attached and span to the bottom of the pelvis. These muscles function to support pelvic floor organs, aid in sexual performance (orgasm), gives us control over the bladder and bowel, stabilize connecting joints, and act as a venous and lymphatic pump for the pelvis.They come under great strain in pregnancy and childbirth. Being pregnant and giving birth, these muscles of your pelvic can become overstretched and weak as early as 12 weeks into your pregnancy.

Effects of Weak Muscles:

As a result of weak pelvic floor muscles, the internal organs are not fully supported leading to difficulty controlling the release of urine, feces, or flatus (wind). It is quite common that you may accidentally leak a little urine when you coughing, sneeze, or exercise (stress incontinence) and it can continue after pregnancy. Constipation is common in pregnancy and adds more strain on your pelvic floor. Another thing, weak vaginal muscles may put your uterus, bowel or bladder to slip forward or down against the walls of your vagina (prolapse) making sex less satisfying, and feel less sensitivity in your vagina.

Pelvic Floor Exercise:

Strengthen the muscles of the pelvic floor helps to reduce or avoid stress incontinence even if you’re young and not experiencing from stress incontinence.A few daily pelvic floor exercises will help to treat bladder weakness or prolapse symptoms. Encourage strengthening of the muscle after each baby as muscles tend to weaken with age and will help to prevent problems later on.  Keep your pelvic floor strong for the rest of your life since hormonal changes after the menopause worsen incontinence.

Kegels Exercise

• Start with an empty bladder before you begin.
• The way to check if you are doing it right is by inserting a clean finger into your vagina and try to squeeze the muscles surrounding it. If you feel pressure around your finger, then that's it.
• Begin by contracting these muscles for 5-10 seconds, then relax, repeating 10-20 times. Do this at least three times a day.
• It is perform without pulling in your tummy, squeezing your legs together, tightening your buttocks, or holding your breath.

V. Benefits of Exercise during Pregnancy

• Support the extra weight of pregnancy.
• Promote healing in incision area due to increase blood circulation 
• A more satisfying sex life
• It can help reduce back pain, improve or maintain muscle tone, reduce leg cramps, swelling and constipation, and improve sleep patterns 
• often feel better about themselves and their changing body during pregnancy.
• less likely to experience fatigue due to improved sleep pattern, are less anxious and experience reduced pain perception and neuromuscular tension.

VI. Postural Education during Pregnancy

• Stand tall, with your abdominal muscles gently drawn in and your shoulders back, and gently drop your chin. 
• Watch and maintain a correct posture regularly during the day.

VII. Ideal exercises or activities during pregnancy (No complications)

• Light stretching
• Walking
• Golfing
• Low impact aerobics
• Water aerobics
• Pregnancy exercise classes
• Stationary cycling
• Swimming (freestyle not breaststroke)
• Light weight training 

VIII. Exercises activities to avoid during pregnancy

• Skiing/Water skiing
• Lifting heavy weights
• High impact or jerky movements
• Contact sports
• Scuba diving
• Excessive twisting and turning activities - Skating
• Prolonged bouncing activities - Horseback riding
• Any activities or exercises that cause pain or numbness, stop it immediately or advise the instructor if you are in a class.
• Exercises that require you to hold your breath or shortness of breath.
• Prolonged standing static exercises.
• Exercises that involving sudden changes in direction.
• Activities or exercise involving sudden changes in intensity.
• Exercises that increase the curve in your lower back.
• Avoid exercise in the supine position after the first trimester.
• Stop exercising when fatigued and not exercise to exhaustion.

IX. Contraindications:

• Pregnancy induced hypertension
• Preterm rupture of membrane/leaking of amniotic fluid
• Preterm labor during the prior or current pregnancy
• Incompetent cervix
• Persistent second to third trimester bleeding
• Intrauterine growth retardation
• Reduced movements of your baby
• Dizziness, faintness, headaches, blurred vision, nausea or vomiting

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