Medical Insider Blog

Stretching: The Truth

  • Posted Nov 04, 2015
  • M. Alicia Edwards, MS, ATC

Stretching has been greatly studied in the past 15 years, and the results are in: static stretching is no longer a prerequisite to exercise and sport. Dynamic stretching has taken its place when preparing muscles and joints for physical activity. There are many questions that arise when it comes to exercise prep and optimizing performance:

               Are you still an avid pre-exercise static stretcher?         
         What is dynamic stretching? 
   Do you warm up?     Should you cool down?

Let's discuss each of these further.

Low Load Long Duration (Static) Stretching

Static stretching is defined as "to stretch muscles at rest." This seems counterproductive when we think about the times this type of stretching is most often performed – before exercise or sport. According to research, this type of stretching has been shown to actually decrease athletic performance. This fact is well known around the strength training community, and studies have only recently been testing the effect of this type of stretching with endurance athletes. Prolonged static stretching of a muscle and tendon decreases its 'stretch response,' which is a response where the muscle and tendon stores energy when it is stretched quickly.   When this reflex decreases, the muscles are weaker, subsequently decreasing performance.  So, you may be wondering, "Is static stretching even necessary?" The answer is YES, as long as it is done at the end of the exercise. Lengthening muscles and tendons is an important part of every physical activity routine and is appropriate for all ages.

Dynamic (Functional) Stretching

Dynamic and functional stretching help lubricate the joints and prepare the body for the bulk of the activity or workout. This is done by stimulating the same 'stretch response' we previously discussed. This type of stretching stores energy within the muscles and tendons and will translate to increased reflex response and athletic performance. For lower body, athletes' functional movements may include things like bodyweight squats, high knees, jumping jacks and lunges. For upper body athletes like overhead throwers or swimmers, these moments may include arm swings, arm circles and push-ups. 


For most people who currently participate in an active lifestyle or play a competitive sport, the concept of completing a warm-up prior to activity is a no-brainer. A proper warm-up is a proven way to help decrease the risk of injury, as well as increase athletic and physical activity function.  A warm-up is a mild to moderate physical activity that increases blood flow to the upper body and lower body musculature. It literally 'warms up' the muscles and joints, prepares the cardiovascular system for increased work and increases the body temperature. Hemoglobin in the blood releases oxygen easier at a higher temperature. Translation: more oxygen and blood to the muscles equals better performance. 

Cool Down

Cooling down after strenuous activity allows the body to gradually return to homeostasis. Homeostasis is 'your body's happy place.' It is when your body's internal functions are regulated at a normal, comfortable state. Letting the body cool down can be a safer way to complete exercise. How many people (including yourself) have you known to become faint or dizzy following exercise? Part of the reason this happens is because exercise is ended abruptly. This allows blood to pool in the large muscles groups of the legs. Slowly decreasing activity will let the body slowly readjust and redistribute the blood, decreasing the risk of becoming faint or lightheaded.

What does all this mean?

So, the take away is this: no matter what activity you are performing, a proper warm-up is always the first step, followed by dynamic stretching, cool down, and finally, static stretching.  The simple rearrangement of these components may very well be the key to better performance!

Stay tuned for next month's topic:  "Adhesions are the Reasons?" We'll discuss chronic tightness from myofascial restrictions and adhesions, how to find out if you have an adhesion and what you can do about it.

M. Alicia Edwards, MS, ATC, is a certified athletic trainer who practices with Holy Cross Orthopedic Institute Fort Lauderdale's Sports Medicine Program. For a sports medicine physician referral, call 954-900-6653.

Understanding Urinary Incontinence

  • Posted Oct 19, 2015
  • Anele R. Manfredini, MD

Urinary Incontinence (UI) is a condition involving an involuntary loss of urine that affects millions of women. The risk of public embarrassment may keep patients from enjoying many activities. When urine loss occurs during sexual activity, it can cause tremendous emotional distress.

Women experience UI twice as often as men. Pregnancy, childbirth, menopause and the structure of the female urinary tract account for this difference. However, both women and men can become incontinent from neurologic injury, birth defects, stroke, multiple sclerosis and physical problems associated with aging. Most cases of UI affect older women, but it can be seen at all ages.

Reversible Causes of Urinary Incontinence

There are reversible causes of UI that should be excluded before extensive work-up:
D - Delirium
I - Infection
A - Atrophic vaginitis or urethritis
P - Pharmaceuticals
P - Psychological disorders
E - Endocrine disorders
R - Restricted mobility
S - Stool impaction

Types of Urinary Incontinence

Stress Incontinence: involuntary loss of urine during an increase of intra-abdominal pressure produced from activities such as coughing, laughing or exercising.

Overactive Bladder / Urge Incontinence: the involuntary loss of urine preceded by a strong urge to void, whether or not the bladder is full.

Overflow Incontinence: urine loss associated with overdistension of the bladder, typically caused by an underactive bladder (detrusor) muscle and/or outlet obstruction.

A diagnosis of UI can be made on the basis of a history, a good physical examination and laboratory tests.

Treatment Options for Urinary Incontinence

Stresss Incontinence: Treatment includes the rehabilitation of pelvic floor muscles through the use of pelvic muscle exercises (Kegel exercises), weighted vaginal cones and pelvic floor electrical stimulation. Other options include occlusive devices such as pessaries, alpha-adrenergic drugs and local estrogen replacement therapy (ERT).

Overactive Bladder: Treatments include behavioral therapy, pharmacologic agents, pelvic floor electrical stimulation, extracorporeal magnetic innervation, local ERT and neuromodulation.

Mixed: Treatment is based on the predominant symptom.

Overflow Incontinence: Treatments include medications, catheters to empty the bladder if necessary; and if no improvement, then surgery.

Physical Therapy / Rehabilitation

Physical therapists evaluate and treat joint dysfunction, muscle tightness, and weakness or imbalance in muscle groups. Women's health physical therapists, trained in the area of pelvic health, can identify possible reasons for pelvic floor dysfunction and develop a treatment plan, with your physician, specific to you. They may use hands-on techniques to address muscle tightness, or give you targeted exercises to improve muslce strength and correct problems. Other treatment strategies include biofeedback, postural training and strengthening of the core muscles.

Benefits of Physical Therapy

• Gives you control over your life and your bladder
•  Saves money and embarrassment by allowing less use of pads and undergarments
• Reduces use of medications for incontinence
•  Possibly prevents the need for surgery

Reference: Am Fam Physician. 2000 Dec 1;62(11):2433-2444

Dr. Anele Manfredini is a family medicine physician who specializes in women's health and practices at our Holy Cross Dorothy Mangurian Comprehensive Women's Center in Fort Lauderdale, FL. Our Women's Center also offers Women's Health Rehabilitation Services that offer treatments for pelvic floor dysfunctions and women's health issues. For referral information for Dr. Manfredini and/or Women's Health Rehabilitation Services, call 954-900-6653.

Innovations in Neurosurgery: Providing Quality Care in South Florida

  • Posted Jul 20, 2015
  • Ali Jourabchi Ghods, MD

In this video, Dr. Ali Jourabchi Ghods, Neurosurgeon in the Holy Cross Neuroscience Institute, discusses how neurosurgery and the technologies involved in treatments of brain cancer and brain tumors have evolved over the years. Dr. Ghods compares Whole Brain Radiation Therapy and compares it with current treatment – Stereotactic Radiosurgery, which uses focused radiation during surgery. He also explains the O-Arm technology and Stealth Navigation and their benefits, which include less radiation and offers 3-D imaging and navigation that improve precision, accuracy, efficiency, and safety during surgery.  Dr. Ghods expresses the importance of being able to offer innovative treatments to ensure that patients do not have to seek quality care outside of their own community: 

Dr. Ali Jourabchi Ghods is a neurosurgeon who practices at Holy Cross Neuroscience Institute (Holy Cross Hospital) in Fort Lauderdale, FL. For referral information, call 954-900-6653.

The Fading Fad Diet

  • Posted Jun 29, 2015
  • David Zekser, MD

Many women feel forced to try to follow that strict, unyielding and frequently unhealthy short-term weightloss regimen that we lovingly know as THE DIET. The words bring regret and loathing to the minds of many women, like some disastrous relationship of the past. They might recall feeling jilted by all the fad diets they have loved and lost when the promise of miraculously stepping out of a pair of plus-size jeans into a bikini and high-heel shoes is replaced with the reality of modest weight loss, rapid regain and a sense of defeat.

The concept of the diet is outdated and redundant. A healthy weight is the byproduct of eating better, eating less of some foods and more of others, making better choices, consistency, and accepting the reality that a short-term solution will not solve a long-term problem. A few of the core concepts for weight loss that I find to be benefi cial and that I use in my own weight-loss program are:

Finding The Good MonsterSM

This relates to the concept of “damage control.” There will always be times when you are forced to eat the best option available, even if it is not a perfect one. If you are hungry and have 10 minutes to get to an appointment, you may have to choose between a slice of pizza, fast food places or not eating at all. Finding The Good MonsterSM means finding what works best for you in any situation and then moving forward while figuring out how to plan better meals and snacks.

Don’t expect a salad to fall out of the sky

Prepare in advance for busy times at work and leisure time at home by making good food choices more accessible and convenient than bad ones. It is just as easy to take the peel off a banana as a wrapper off a candy bar.

Cut back on the "bad" carbohydrates

This includes pasta, bread, rice and potatoes. Replace them with carbohydrates such as vegetables and fruit. Think about replacing food items instead of simply trying to eliminate them.

Think differently about dinner

Expectations of eating a big dinner or snacking before bedtime cause people to eat more at that time of the day simply out of habit, even when they are not hungry.

There are a lot of options for weight loss, but no matter what path you take to reach your goal, knowing how to stay there is the most crucial component to long-term success.

Dr. David Zekser is a primary care physician (Internal Medicine) practicing in the Rio Vista area of Fort Lauderdale. For referral information, please call 954-900-6653.

Contact Sports and Concussions (Part 2)

  • Posted Jun 22, 2015
  • Fernando Manalac, MD, MMM, CAQ...

If you missed “Part 1” of this post on how to prevent concussions, how they occur and symptoms  you may experience, you can read it here.

Concussion Management


Pre-Participation Evalutation (PPE): in my office, we conduct PPEs to establish a medical background from which medical decisions about physical activity may be made and medical clearance may be provided.

Baseline Testing: also available in my practice is a 20-minute computerized neurocognitive test (ImPACT testing) designed to measure the effects of concussion. After an athlete completes a baseline test, his or her data is stored on a secure, HIPAA compliant server. If a concussion is suspected in the future, a follow-up test is administered to see if the results have changed from the baseline. Traditional imaging procedures (CT or MRI) are helpful in identifying serious brain injuries, but they are not able to identify the functional effects of concussion. ImPACT can detect subtle changes in cognitive functioning that cannot be accurately measured by relying on athletes to report symptoms.

Other preseason testing include Maddox Questions (checks for memory), SAC (Standard Assessment of Concussion), BESS (Balance Error Scoring System); Sideline Concussion Assessment Tool (SCAT2); and NFL SCAT.


In addition to any necessary emergency response, the medical personnel on the field may perform various on-field and sideline assessments, such as a physical exam, neurocognitive and balance assessments, Neuropsychological (NP) Testing/Sideline Concussion Testing, and Return to Play evaluation.

At Home

• Dim/Quiet room

• Allow patient to sleep/rest!

• Very limited role of medications (OTC acetaminophen is most commonly prescribed)

• Seek medical attention if symptoms worsen acutely

Return to School/Play

Returning to school or play is a case by case management. Cognitive rest is needed – decreased concentration, reduced academic workloads, days off or shortened school days, extended test taking times and return to full academics when symptom-free. There should also be a progressive return to play: crawl -> walk -> run -> practice -> play. Talk to your doctor about treatments based on symptoms, age and medical history.

Before returning to school or play, there must be a medical clearance, be symptom-free, not taking medications and there must be a return to baseline based on the neurocognitive / physical / balance exams.

Keep in mind that a premature return to play can lead to a more severe concussion/prolonged symptoms. “Second Impact” syndrome is a second episode of brain trauma before the brain heals from the first. Cerebral arteries lose their ability to autoregulate (vasoconstrict), resulting in diffuse brain swelling/increased intracranial pressure. Second Impact syndrome involves a high incidence of brain herniation, coma and/or death.

Chronic Traumatic Encephalopathy

This condition is known in boxing as Dementia Pugilistica or Punch-Drunk Syndrome. It’s a progressive degeneration of the brain secondary to multiple brain injuries (concussions). Symptoms involve a change in mood (depression/suicidal ideation), cognition (memory loss), movement (parkinsonianism/balance dysfunction) and behavior (aggression).

Protect Yourself

Before engaging in activities or sports in which head injuries are common (football, soccer, basketball, volleyball, baseball, hockey, etc.), consult with a sports medicine physician regarding how to prevent head injuries, your risks for concussion, a PPE, and baseline testing to be proactive in managing possible concussions.

Dr. Fernando Manalac is a board certified sports medicine physician who practices at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL. For referral information, call 954-900-6653.

Contact Sports and Concussions (Part 1)

  • Posted Jun 09, 2015
  • Fernando Manalac, MD, MMM, CAQ...

Dr. Manalac with nurse in helmet at concussion lectureContact sports like American football have long been known for brutal head injuries. As much education that our athletes still need today, we have come a long way since the sport’s origins in the 1860s - when the world lacked understanding of concussions and how to care for those with such head injuries. Over the years we have gained a much better understanding of the pathophysiology of concussions, symptoms, management, and more importantly, how to prevent the injury.


How Concussion Occurs

A concussion is caused when there is impact from which the brain shifts within the cerebrospinal fluid and strikes the skull, causing direct injury. The brain then whips back and strikes the opposite side of the skull. Commonly, there are rotational components to the force, which cause “twisting” of the brainstem and is associated with loss of consciousness. Microscopically there is shearing of the axons in the brain and excessive release of neurotransmitters - the brain’s attempt to start repairing itself or reach homeostasis. This is when you will experience a huge imbalance of energy supply and demand needed for recovery. It is also during this time that the brain is most vulnerable to a “Second Impact.”

Preventing Concussions

My patients and their family members may be surprised to know that protective equipment has not shown to reduce the number of concussions. Direct head trauma is not necessary to develop concussion; any impact that causes the brain to strike the skull or a rotation of the brain stem can cause a concussion. Neck strengthening programs may help in theory, but no studies have been done at this time. Limiting contact / cutting down on the number of contact practices has been shown to reduce concussions. Player behavior modification can help to prevent this head injury – educate players, coaches and trainers and adjust the rules to ensure proper technique and injury management.


If you do suffer from a concussion, the most commonly reported symptom is headache. Dizziness and nausea / vomiting may also occur, as well as visual disturbance. Cognitively, there may be memory loss, some have decreased concentration, confusion, and loss of consciousness. You may also experience emotional symptoms such as irritability, depression and anger. It is also common to feel drowsy or tired and have difficulty sleeping (insomnia). It is important to know, however, that with all possible symptoms, it only takes one symptom to constitute a concussion after a head injury.

Check back for Part 2 of this post for details on concussion management.

Dr. Fernando Manalac is a board certified sports medicine physician who practices at the Holy Cross Orthopedic Institute in Fort Lauderdale, FL. For physician referral information, call 954-900-6653.

Brain Aneurysm in Women

  • Posted Jun 02, 2015
  • Laszlo Miskolczi, MD

woman with headache
Brain aneurysm is a balloon-like structure that develops in a weak spot on the wall of a brain artery. Approximately two to five percent of the population has a brain aneurysm. Although only one to two percent of those aneurysms ever rupture, over half of the patients with ruptured aneurysms die within 30 days.

How it affects women

Brain aneurysms occur much more frequently in women. According to a study published in Stroke, the highly regarded journal of the American Heart Association, more than two thirds of all patients with ruptured aneurysms were women. Half of them were between ages 30 and 60.

Aneurysms grow slowly, over decades. Women with aneurysms that ruptured during their retirement already had a well-defined aneurysm before they even reached 60.

The statistics are shocking

Between ages 60 and 69, women are three times more likely to have an aneurysm than men. Between 70 and 79, it is close to five times more likely for women.

Signs and symptoms

Brain aneurysms grow silently from a weak spot of the artery. The most important signs are sudden onset double vision, a hanging eyelid, or a sudden onset severe headache with nausea that may or may not go away. People with any of these symptoms should seek immediate help.

Who is at risk?

Compared with the 230,000 yearly cases of breast cancer, only about 30,000 aneurysm ruptures occur in the United States each year. Therefore, a screening test for the general population would not make sense. However, testing may be important for people with family members who have had brain aneurysms, especially if one relative had more than one brain aneurysm. Patients who smoke or have high blood pressure are also at higher risk of developing and rupturing brain aneurysms.


According to an article published in the American Journal of Neuroradiology, among 65,000 patients reviewed, treatment risk is much lower today than 10 to 20 years ago. Patients who underwent minimally invasive coil embolization had three times less risk for a bad outcome than patients undergoing surgical clipping. It is important, however, that an individual approach based on patient-specific anatomy be followed in every case.

The technological requirements and expertise of diagnosing and treating brain aneurysms are available only at select institutions. Holy Cross Hospital is a comprehensive stroke center that has received the Gold and Gold Plus awards from the American Stroke Association every year since 2009. These are the highest levels of the American Stroke Association’s acknowledgement of excellence in stroke and aneurysm care.

Laszlo Miskolczi, MD, is a world-renowned neurointerventional radiologist who practices at Holy Cross Hospital's Comprehensive Stroke Center. For physician referral information, call 954-900-6653.

I'm Not Sitting this One Out

  • Posted May 14, 2015
  • Fernando Manalac, MD, MMM, CAQ...

How many of you Road Runners have ever experienced pain or soreness in the back of your thigh (hamstrings), in the back of your ankle (Achilles) or the side of your thigh (iliotibial band)?  If so, there’s an excellent chance that it’s caused by a tendinopathy:

Tendon = the white stretchy tissue that attaches muscle to bone 

opathy = condition or disease process.  

There are three main types of tendinopathy: tendon strain (tear), tendinitis and tendinosis. Runners who run long enough will probably experience every type of tendinopathy.

Traditional treatment for tendinopathy

RICE (rest, ice, compression, elevation) and NSAIDS are the mainstay of Mom’s management for the strains and inflammation (the “itis”). However, the degeneration of the tendon, otherwise known as tendinosis, doesn’t always respond to these traditional treatments.

When tendon is not healing

Your race is in three or four weeks, the last thing you want to do is sit this one out. Platelet rich plasma (a.k.a. PrP or blood-spinning) may be an option. PrP is a procedure done in my office where I draw your blood; place that blood into a centrifuge to spin down and separate the platelets from the rest of the blood; and inject only the platelets (which house growth factors) with some plasma with a few white blood cells into an injury site to help heal tissue.

Factors that affect PrP

This procedure has helped some of the biggest professional athletes, as well as non-athletes alike. Research has shown mixed results, and most experts believe this is because not all PrP is created equal. Varying levels of platelets exist in everyone. At your next blood test, compare your platelet level to your family member’s level, or even to your own last blood test results…much different, right? Also, some PrP kits can control the amount of platelets, red blood cells, and white blood cells, which have an affect on success of treatment. 

Taking Advil or Aleve could also render your platelets dysfunctional; stop all NSAIDS before and after the procedure. Not eccentrically loading tendons within the first couple weeks after the procedure has also provided suboptimal results. PrP is very promising - as evidenced by the abundance of available literature and by studies in the pipeline - and may be the right therapy to successfully treat your tendinopathy.

Fernando J. Manalac, M.D., MMM, CAQSM, CMQ, is a fellowship trained non-surgical sports medicine physician at Holy Cross Orthopedic Institute in Fort Lauderdale, FL. Board certified in Internal Medicine, Sports Medicine and Medical Quality, Dr. Manalac specializes in non-operative management of musculoskeletal issues at any age. Learn about the Sports Medicine program at Holy Cross Orthopedic Institute by visiting HolyCrossOrthopedics.com. For physician referral information, call 954-900-6653.

What is a Faith Community Nurse?

  • Posted Apr 20, 2015
  • hchadmin

Nurses are a compassionate and transforming healing presence within our communities.

By building alliances between two healing communities – the medical facilities and faith communities – faith community nurses focus on the intentional care of the spirit as part of the process of promoting holistic health and preventing or minimizing illness; they promote the fullness of life that God intends for each individual.

Guided by the Scope and Standards of Faith Community Nursing, faith community nurses serve in communities that are diverse in denomination, size, race and ethnicity. They assist each community to develop their vision for promoting health as wholeness in the context of the values, beliefs and practices of their faith tradition and to provide support for implementing and sustaining their vision.

Specific services of faith community nurses may include:
• Integrator of faith and health
• Health educator and counselor
• Referral advisor
• Provider of screening tests/risk assessments
• Community liaison and patient advocate
• Coordinator of volunteers
• Facilitator of support groups

Upcoming Continuing Education Opportunity from Holy Cross Hospital's Faith Community Nursing Program:

Advance Directives and End of Life Care
April 27, 2015 | 7:30am – 8:30am  or  5:30pm – 6:30pm
Jim Moran Heart and Vascular Building, 2nd Floor Multi-Purpose Room
Holy Cross Hospital

This activity has been approved by the Florida Board of Nursing for one (1) contact hour. (FBN# 50-951)

RSVP:  Valerie Fox, Faith Community Nursing Coordinator | 954-267-9551

FREE to Holy Cross Associates, community members and students

Treatments for Tendon Pain

  • Posted Mar 05, 2015
  • Fernando Manalac, MD, MMM, CAQ...

What are Tendons?
Tendons are the stretchy, white bands of connective tissue that are at the ends of muscle and connect the muscle to the bone.

How a Tendon Causes Pain
When a tendon is stretched or eccentrically overloaded, the fibers can tear. This is called strain. Other types of tendinopathy (disease of a tendon) include tendinitis and tendinosis. Tendinitis is acute inflammation of a tendon. Tendinosis is degeneration of the tendon fibers from repetitive microtrauma resulting in the development of abnormal tendon tissue. The commonality amongst these tendon problems is that they can all cause significant pain and dysfunction, keeping people from doing the recreational activities they need or the work that needs them.

Treating Tendon Pain
In the not-so-long-ago past, treatment plans for these tendon problems were very limited: rest, ice, compression and elevation were, and still are, the best initial therapeutics. NSAIDS and other medications and modalities are also used to reduce inflammation and can be very beneficial. Prescription medications and cortisone injections may have a limited role in persistent tendon pain or inflammation. However, nothing has been shown to be more effective than eccentric exercise in physical therapy at repairing damaged tendon. 

What if Treatments Have Not Worked?
What do you do if none of these therapeutics have worked? From the 1970s-2000s, advanced treatment for tendinopathy was limited to surgery. Surgery is still the only clear fix for complete ruptures of tendons; meaning, if a tendon is torn in half, the only way to get perfect function is to reattach those two ends. However, performing surgery on strains (partial tears) that won’t heal, or refractory tendinoses, may actually be excessive.

Orthobiologic injections, such as Platelet Rich Plasma and Mesenchymal Stem Cells and minimally invasive techniques, such as percutaneous tenotomy, are revolutionizing the advanced treatment of tendinopathy.

Schedule an appointment with Dr. Manalac to discuss if one of these therapeutics might be appropriate for you and can get rid of your tendon pain once and for all.
Dr. Manalac is a non-surgical sports medicine physician who practices in Fort Lauderdale. For referral information, call 954-900-6653.



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.

Blog Categories

Blog Archive