Medical Insider Blog

Shingles and How to Prevent It

  • Posted Jul 17, 2014
  • Audrey Liu, MD

Shingles is a painful blistering rash caused by the same virus that causes chickenpox (varicella-zoster virus). After chickenpox the virus stays in the body and quietly lives in the nerve endings in the spine, but at times it can reactivate to cause shingles. The virus comes out along the nerve, causing swelling and damage to the nerve. A painful, blistering rash appears along the path of the nerve. The acute pain lasts for a few weeks, but approximately 10-15% of people will have a prolonged pain syndrome called postherpetic neuralgia, which can last from months to years. While shingles is not considered a life-threatening infection, the nerve pain associated with shingles is very difficult to treat and can cause much suffering.  Shingles tends to occur as people age due to weakening immune systems. Approximately 50% of people after age 50 will develop shingles.

Can it be Prevented?

elderly woman getting vaccineThe Zostavax vaccine can prevent shingles. The vaccine has been available since 2006 and uses a live - but weakened - version of the varicella-zoster virus. This is the same vaccine that has been given to children to prevent chickenpox since 1995, but in a much stronger dose.

Zostavax is FDA-approved for use in adults after the age 50. The Centers for Disease Control and Prevention recommends that Zostavax be given to adults after age 60 as a one-time dose.  Side effects of the vaccine include pain and irritation at the injection site, a small rash at the injection site and headache.

Check back for my next posts, as I will be answering some frequently asked questions about the shingles vaccine.

Dr. Audrey Liu is an internal medicine / primary care physician who practices in Pompano Beach, FL at 2700 NE 14th St. Causeway, Suite 103.


Gain Control Over Back Pain

  • Posted Jul 08, 2014
  • Shannon Hastings, MSPT

Photo from Web MDChances are either you or someone close to you has experienced back pain.  Most people will tell you how debilitating it can be and have sought treatment to help reduce their pain.  Treatments can range from conventional medications, physical therapy, massage, acupuncture, chiropractic care, and can sometimes require surgery.  Most patients opt for the least invasive method to treat their condition.

Physical therapists are board certified medical professionals that utilize exercise and equipment to help patients regain or improve their physical abilities.  Physical therapy can help you improve your mobility and strength, while reducing your pain to enable you to return to your active lifestyle.  The key to successful therapy requires an extensive evaluation to identify each client’s specific problems.  Once indentified, it is imperative to customize a program specific to a patient’s needs to accurately treat their diagnosis. Our job is not only to help you regain your function, but also to educate you about the specific condition you may be dealing with to better serve you moving forward in your own treatment.

The McKenzie method is an indepth assessment of the spine to develop treatment and preventative strategies for patients with spinal pain.  By identifying certain motions that can reduce or eliminate pain, it enables patients to gain control over their specific issue.  This method focuses on self treatment through exercise and stretching, which empowers the patient by enabling them to be an active participant in recovery.  It can be effective in reducing the recurrence of future episodes of pain and ultimately decreasing the length of treatment time needed with physical therapy.

Physical therapists utilize a variety of treatment options to combat back and neck pain including exercise, manual therapy, joint mobilizations, ultrasound, electrical stimulation, and traction.

Physical therapy can be utilized for a variety of spinal conditions including, but not limited to: spinal stenosis, scoliosis, sciatica, cervical or lumbar radiculopathy, spondylolisthesis, degenerative disk disease, degenerative joint disease, and arthritis.  It is also commonly prescribed following whiplash injuries from motor vehicle accidents and after spinal surgery.

If you are looking to regain your active lifestyle and would like to try physical therapy to help understand and manage your back or neck pain, speak with your medical doctor to discuss if physical therapy is the right treatment for your condition.

Shannon Hastings, MSPT, is a staff physical therapist at Holy Cross Hospital's outpatient physical therapy clinic in the Rio Vista neighborhood of Fort Lauderdale, FL (1309 S. Federal Hwy.) and may be reached at 954-267-6819.

Are stem cell injections an effective treatment for knee osteoarthritis?

  • Posted May 29, 2014
  • Francis McCormick, MD

SyringesOsteoarthritis (OA)
Osteoarthritis of the knee is a degenerative disease of articular cartilage resulting in pain and disability that can get in the way of your active lifestyle and simple daily activities. Knee osteoarthritis alone is a leading cause of disability in the U.S., with a recent increase of occurences in young athletes following a sports-related injury. The cartilage may erode completely over time, creating bone-on-bone friction exhibited by a cracking or popping sound, inflammation, and severe discomfort.
Current Non-Surgical Treatments for Knee OA
Current efforts to alleviate mild to moderate cases of osteoarthritis include physical therapy, weight loss and low-impact cardiovascular exercise, coupled with pharmacologic agents in order to reduce inflammation and discomfort. Pharmacological agents include the use of non-steroidal anti-inflammatory drugs (NSAIDs), viscosupplementation with hyaluronic acid, corticosteroid injections, and now stem cells and biologics. Cartilage cannot readily repair itself when damaged; the injection of stem cells and other biologics (i.e. Platelet Rich Plasma) from the body may solve this dilemma.

More on Biological Interventions for Knee OA
Historically, as the disease progresses, the efficacy of non-surgical treatments decrease, usually leaving a partial or total joint replacement as the only curative treatment for end-stage disease. In recent years, however, mesenchymal stem cells (MSCs) have been a topic of great interest as a biological intervention to regenerate damaged knee cartilage from OA. MSCs can differentiate into many types of connective tissues, including chondrocytes (the cartilage-building cells) as well as the capacity to self-renew, migrate toward injured tissues to repair them, an inhibit inflammation. Sources of MSCs include the bone marrow, fat tissue, umbilical-cord blood and amniotic fluid. Current debate exists in which source is the best to use in the regenerative scope of orthopedics and sports medicine. Many animal and early clinical studies show the effectiveness of MSCs in suppressing the pain and a possibility of regenerating cartilage, though further investigation is needed.

Is it Covered by Insurance?
For insurance to cover a medical intervention, the U.S. Food and Drug Administration (FDA) must first approve the treatment. Currently, there is no FDA approval for “Stem Cell” injections or treatments. This is an ongoing problem due to stem cells being considered a pharmacological treatment and currently lacks a consistent means of acquiring, culturing and administering to patients. Because of this, MSC therapy is very expensive with out of pocket expenses ranging from $450-$3,000. Therefore, current research aims to find the most feasible source of MSCs that creates the least amount of discomfort for the patient and increases cost-effectiveness, and also to further study the ability of the MSCs to efficiently differentiate and expand into a cartilaginous lineage. Our goal is to keep our active South Floridian out of the operating room and out in the sun.

Frank McCormick, MD is an orthopedic sports medicine surgeon who specializes in biological approaches to joint preservation. For more information on Dr. McCormick, visit his online physician profile: Francis McCormick, MD. To discuss your options in the treatment of osteoarthritis, Dr. McCormick may be reached for an appointment at 954-958-4800.

Co-Author: Emmanouil Kiriakopoulos, BS, research volunteer at the Holy Cross Orthopedic Institute.

Avoiding Weight Gain During Menopause

  • Posted May 14, 2014
  • Anele R. Manfredini, MD

Why am I gaining weight?
Despite all their efforts, most women gain weight during the menopause transition, especially around the abdomen, even while eating correctly and exercising. This weight gain is usually related to a variety of lifestyle and genetic factors, not just hormonal changes.

Menopausal women tend to be less physically active, which can lead to weight gain. Muscle mass naturally diminishes with age and decreased activity. If a woman continues to eat as she always has but reduces her activity level, she will gain weight. Furthermore, unlike body fat, lean body mass decreases with age.

Apple and Pear PhotoFor many women, genetic factors also play a role in this weight gain. If their parents or close relatives carry extra weight around the abdomen, they are likely to do the same.

Apples and Pears
Menopause plays a role in many women's midlife transitions from a pear-shaped body (wide hips and thighs, more weight below the waist) to an apple-shaped body (wide waist and belly, more weight above the waist). However, further study is needed on the exact role of menopause in body composition.

Cause and Effect
Cause of weight gain include:
• Certain drugs
• Insulin resistance
• Emotional eating: depression and stress
• Estrogen loss
• Thyroid imbalance
• Cushing's syndrome
• Lack of exercise
• Excessive eating
• The natural course of aging

Most women in the U.S. and Canada are overweight at midlife. Additional weight gain increases risk of:
• Cardiovascular disease
• Type 2 diabetes
• High blood pressure
• Osteoarthritis
• Some types of cancer, including breast and colon

What You Can Do
Make physical activity a priority. Aerobic activity can help you lose weight or maintain a healthy weight. Strength training is also important: Gain muscle, and your body burns more calories. Women should exercise for a minimum of 2.5 hours per week of moderate exercise or 1.25 hours per week of vigorous exercise (or a combination of vigorous and moderate activity), as recommended by the American Heart Association in the April 2014 Update of the Guidelines for Cardiovascular Disease Prevention in Women. Thirty minutes per day, five days a week is an easy way to break up this exercise and manage your time.

Eat less, and eat right. Reduce calories without skimping on nutrition. Eat fruits, vegetables, whole grains and lean sources of protein. Don't skip meals, which may lead you to overeat later.

Seek support from friends and family.

Turn to your doctor for support in guiding you to a healthy diet, increasing physical activity and ruling out any disease that causes weight gain.

Anele R. Manfredini, MD, is a Family Medicine physician who specializes in Women's Health.

To Stretch or Not to Stretch?

  • Posted May 06, 2014
  • Rafael Gutierrez DPT COMT

People stretch because it feels good or because they think it will increase flexibility and maybe prevent injury. Static stretching has been shown to improve flexibility, but these effects are usually temporary and may only become permanent with a consistent stretching program. For most individuals, however, stretching before exercise does not have many benefits. Much research has demonstrated an increase in flexibility following a stretching regimen because our bodies, via the nervous system, have adapted to tolerating the stretch; however, stretching did not necessarily increase joint range of motion (ROM) or muscle elasticity.

People wonder if stretching prevents injury or if it decreases muscle soreness, strength or peak sports performance (specifically in sports where flexibility is not required, such as running).

What’s the verdict?
Whether or not to stretch is entirely up to the individual, but based on the literature, it is not necessary unless you are someone who requires consistent flexibility, like dancers or hockey goalies.

There is contradictory information on stretching recommendations, but if you decide to stretch, it should be done following a warm-up or after performing low to moderate activity. It also may be more beneficial to move the joints involved in an activity through the required ROM and movement pattern for that specific activity as opposed to any type of stretching.

Although there are few studies on the correlation of warm-up and injury prevention, some research show it is possible that warming up can assist in preventing injuries. Active individuals who participate in strength or dynamic performance activities should wait to stretch after their activity is finished because of the immediate decreases in strength and performance following stretching. If you do stretch, the American College of Sports Medicine recommends the following guidelines:

• Adults should do flexibility exercises at least two or three days each week to improve ROM.
• Hold each stretch for 10-30 seconds to the point of tightness or slight discomfort (should not be painful).
• Repeat each stretch two to four times, accumulating 60 seconds per stretch.
• Static, dynamic, ballistic and PNF (proprioceptive neuromuscular facilitation) stretches are all effective.
• Flexibility exercise is most effective when the muscle is warm. Try light aerobic activity or a hot bath to warm the muscles before stretching.

Rafael Gutierrez, DPT is a staff physical therapist at Holy Cross Hospital’s outpatient physical therapy facility in Boca Raton. He may be reached at 561-483-6924.

Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334-59. doi: 10.1249/MSS.0b013e318213fefb.

Herbert RD, Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ. 2002 Aug 31;325(7362):468.

Kamandulis S, Emeljanovas A, Skurvydas A. Stretching exercise volume for flexibility enhancement in secondary school children. J Sports Med Phys Fitness. 2013 Dec;53(6):687-92.

McHugh MP, Cosgrave CH. To stretch or not to stretch: the role of stretching in injury prevention and performance. Scand J Med Sci Sports. 2010 Apr;20(2):169-81. doi: 10.1111/j.1600-0838.2009.01058.x. Epub 2009 Dec 18.

McNeal JR, Sands WA. Stretching for performance enhancement. Curr Sports Med Rep. 2006 May;5(3):141-6.

Pope RP, Herbert RD, Kirwan JD, Graham BJ. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc. 2000 Feb;32(2):271-7.

Safran MR, Garrett WE Jr, Seaber AV, Glisson RR, Ribbeck BM. The role of warmup in muscular injury prevention. Am J Sports Med. 1988 Mar-Apr;16(2):123-9.

Safran MR, Seaber AV, Garrett Jr WE. Warm-Up and Muscular Injury Prevention An Update. Am J Sports Med Oct 1989, Volume 8, Issue 4, pp 239-249.

Sainz de Baranda P, Ayala F. Chronic flexibility improvement after 12 week of stretching program utilizing the ACSM recommendations: hamstring flexibility. Int J Sports Med. 2010 Jun;31(6):389-96. doi: 10.1055/s-0030-1249082. Epub 2010 Mar 22.

Shrier I. Does stretching improve performance? A systematic and critical review of the literature. Clin J Sport Med. 2004 Sep;14(5):267-73.

Wallmann HW, Christensen SD, Perry C, Hoover DL. The acute effects of various types of stretching static, dynamic, ballistic, and no stretch of the iliopsoas on 40-yard sprint times in recreational runners. Int J Sports Phys Ther. 2012 Oct;7(5):540-7.

Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or modifying sensation? Phys Ther. 2010 Mar;90(3):438-49. doi: 10.2522/ptj.20090012. Epub 2010 Jan 14.

Joint Preservation: Avoiding Total Knee Replacement

  • Posted Apr 15, 2014
  • Francis McCormick, MD

Knee replacements typically last 10-15 years, which means in younger patients, they could face several more surgeries. There are new alternatives available for young active patients with which we are seeing great results.

Cartilage TransplantationCartilage and meniscal transplantation
Athletes in their 20s and 30s who suffer knee injuries (torn ACL or meniscus) can be treated with great success. However, problems may occur five to ten years down the road that are a result of those injuries, and they are at increased risk for early osteoarthritis. These problems get in the way of the patient's active lifestyle. Cartilage or meniscal transplantations may be done to return these patients to their active lifestyles quicker and with less risk of complications, compared to total knee replacements using metal or plastic components. The procedure is done through tiny incisions, which facilitate recovery and involve less pain.

A piece of the patient's tissue - the size of a tic tac - is taken from his or her knee and that tissue is sent to a lab in Massachusetts where the cells are grown and expanded. A few weeks later once the cells have grown, we transplant the expanded patient's cells back in the knee. After a few months, the cells grow within the patient's knee with properties similar to those of the original cartilage, repairing the injury and avoiding total knee replacement. The body is really great at healing itself, we just need to help guide it along.

Donated Cartilage
Some patients donate their cartilage when they pass away. This is a source of natural tissue with which young, active damaged knees may be replaced.

Platelet Rich Plasma
Platelet Rich Plasma (PRPs) and stem cells are also potential sources for cartilage transplantation, to reduce inflammation, enhance tissue regeneration and curb tissue degeneration.

Partial Knee Replacement
When there is significant wear on one aspect of the knee, an overnight procedure may be done called a Partial (Uni-compartmental) Knee Replacement, which involves limited pain and rapid recovery compared to a total knee replacement.

From the Patient's Perspective

One of my patients came to me because he felt he was too young for major knee surgery. Here's his story:

Click to watch WSVN 7 segment with our patient Blake McCormack

Learn more about Dr. McCormick from his physician profile: Francis McCormick, MD.
For information on Holy Cross's Sports Medicine program, visit

Thyroid Problems – Are They Serious?

  • Posted Mar 28, 2014
  • Matthew Shlapack, MD

Different types of thyroid problems
Thyroidal illness is a broad medical category that includes both structural problems such as thyroid nodules and hormonal illnesses such as hypothyroidism and hyperthyroidism.

Is it serious?
Thyroid nodules, commonly called “goiters,” are very common but can contain thyroid cancer and should be worked up. Thyroid nodules can be seen as a generalized enlargement of the lower front of the neck or as a mass in this area, but nodules are not always visible to the eye. Thyroid cancer is not usually aggressive but if present and untreated it can be progressive, placing an individual at serious risk. Fortunately, the workup and treatment is straightforward, and in the hands of a good care team, it can be dealt with and usually cured.

How do I know if I have a disorder of thyroid function?
Abnormalities of thyroid function can cause a wide range of symptoms ranging from fatigue and weight gain in the case of hypothyroidism, to heat intolerance, anxiety, and palpitations with hyperthyroidism.

Normalization of thyroid hormone levels with treatment is important for preservation of good health, avoidance of complications and resolution of these symptoms. Talk to your doctor if you are concerned about your thyroid.

Dr. Matthew Shlapack is an endocrinologist (a physician specialist who treats diseases and illnesses involving the endocrine system – thyroid, hormones, metabolism, diabetes, etc.).

Proposed Changes to the Nutrition Facts Label

  • Posted Mar 17, 2014
  • Jessica Weissman, MS, RD, LDN

Since 1993, the only major change to the Nutrition Facts label has been the requirement to declare trans fat, effective in 2006. Since the Nutrition Facts label is such an important tool to help people make better food choices, the United States Food and Drug Administration (FDA) is proposing to update the label in order to more closely reflect how much American’s actually eat. These changes are intended to have a major impact on food choices and American public health, especially in individuals with chronic diseases such as cardiovascular disease and diabetes. The proposal includes changes to the label’s design to highlight key parts such as total calories and serving sizes.

On average, Americans get 16 percent of their total calories from added sugars in products such as soda, energy drinks, and dairy-based desserts and candy, and health experts recommend that Americans should reduce their intake of calories from added sugar. The new label would require more information about “added sugars” so that consumers who want to limit their added sugar intake can compare brands carrying similar products.

Nutrition Facts Labels Serving Size Changes

Additionally, because the amount of consumption of foods has changed over the past 20 years, the new labels would include serving sizes which reflect the amounts people actually eat (see image). In fact, by law, the serving size information must be based on what people actually eat, not on what they “should” be eating. For example, a 20-ounce bottle of soda would be labeled as one serving rather than as more than one serving. Other proposed changes to the Nutrition Facts label include requiring the declaration of potassium and vitamin D, changing the layout to emphasize certain parts such as percent daily value, and increasing the daily value for sodium intake. The proposed changes would affect all packaged foods except those regulated by the U.S. Department of Agriculture’s Food Safety and Inspection Service, including certain meat, poultry, and processed egg products. The proposed rules are available for public comment for 90 days. For more information, please visit the FDA website.

Rehab, Relax and Restore

  • Posted Feb 17, 2014
  • Rafael Gutierrez DPT COMT

Orthopedic manual physical therapy is a hands-on approach to treating musculoskeletal and neuromuscular dysfunction. Physical therapists trained in manual therapy use specific techniques, such as joint mobilizations, manipulations, soft tissue techniques and therapeutic exercises for improving mobility and function throughout the body.

Conditions Treated

Manual therapy is effective for a wide range of ages and can be used to treat many conditions, including:

• Orthopedic and sports injuries
• Cervicogenic headaches
• Neck and back pain
• Radiculopathy
• Sacroiliac dysfunction
• Postural dysfunction
• Postsurgical issues
• Osteoarthritis
• Ligament sprains
• Muscle strains
• Tendinopathies

How it Works

Manual therapy is effective because it helps restore normal mobility to affected joints and muscles. Joint mobilizations and manipulations help reduce stiffness, increase circulation, decrease pain, and restore mobility in joints to improve biomechanical motion. Soft tissue techniques also increase circulation and relax muscles so they can move through the normal range of motion without restrictions.

Therapeutic Exercise

Therapists who have undergone advanced training in orthopedic manual therapy have also received training in therapeutic exercise geared specifically toward rehabilitation. These exercises may differ from your typical exercise routine because they are dosed and targeted specifically toward the problem areas. Therapists will also address other areas in the body that may be adding to the problematic site during the therapy sessions. Through manual therapy and therapeutic exercise, physical therapists can help patients reduce pain and restore normal function to help patients return to their daily activities.

Rafael Gutierrez, DPT, COMT, is a staff Physical Therapist at Holy Cross Hospital’s outpatient physical therapy clinic in Boca Raton. He may be reached at 561-483-6924. Meet our other therapists and learn how we can help you get moving again at


About Holy Cross Hospital

Holy Cross Hospital is a nonprofit, Catholic hospital in Fort Lauderdale, Florida, dedicated to innovative, high quality and compassionate care. For nearly six decades, Holy Cross has continuously expanded its services to provide leading-edge care for their patients in Florida and for those from elsewhere in the United States. Holy Cross also offers an International Services program to ensure that patients from outside the U.S. receive the care they need.

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