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Video Transcript: Rehabilitation Medicine

Part One:

Ellen Beth Levitt: Welcome to Maryland Health Today. I'm Ellen Beth Levitt. Physical rehabilitation plays an important role in helping people recover from spinal cord injuries, stroke and orthopedic injuries. And there are some new approaches that are helping people regain function and have a better quality of life. My guest is Dr. Peter Gorman, the chief of Rehabilitation Medicine at Kernan Hospital. And Dr. Gorman is also an associate professor of Neurology at the University of Maryland School of Medicine. Welcome to the show.

Peter H. Gorman, M.D.: Thank you very much.

Ellen Beth Levitt: What is rehabilitation medicine?

Peter H. Gorman, M.D.: Well, rehabilitation medicine is that field of medicine aimed at restoring function for parents that suffered functional decline because of injury or illness.

Ellen Beth Levitt: What role does it play for illness? People with certain types of injuries?

Peter H. Gorman, M.D.: Well, it's done as a team, the physician is the leader of the team and there are therapists, nurses and occupational therapists and psychologists and others working to help the patient.

Ellen Beth Levitt: Does rehabilitation also help with pain relief?

Peter H. Gorman, M.D.: Yes. For things like ultrasound, heat, massage can help.

Ellen Beth Levitt: What are the goals?

Peter H. Gorman, M.D.: Well, we want the focus on restoring function and that's the difference between what we do and the model. We want to keep people back in society to participate in their lives.

Ellen Beth Levitt: How can people benefit from it?

Peter H. Gorman, M.D.: Whether it's from a spinal cord injury or other illness or injuries, things are really topsy-turvy in patients? lives. Patients can benefit from a combined approach to help them restore their function as much as possible. Get them back on their feet, if you will.

Ellen Beth Levitt: You mention there's a team approach, why is that important?

Peter H. Gorman, M.D.: Well, each person from the team brings with them an expertise that can help the patient in their own way. A physical therapist helps with the patient able to transfer from one place to the other and an occupational therapist helps with activities in daily living and life that could lead to going back to school or to work.

Ellen Beth Levitt: You mentioned the psychologist as well. Why are they important?

Peter H. Gorman, M.D.: Well, in cases where there's cognitive difficulty, say in a person who has suffered a traumatic brain injury, a psychologist will help assess that injury. See where their deficits are and can intervene in helping the patient recover cognitive function.

Ellen Beth Levitt: You?re a neurologist. How does a neurologist fit into rehabilitation medicine?

Peter H. Gorman, M.D.: Well, a neurologist deals with illnesses and injuries of the spinal cord, 70% of the patients suffer from some kind of neurologic disease, whether that's stroke, spinal cord injury or multiple sclerosis or of the like.

Ellen Beth Levitt: It?s important for a neurologist to know what's going on and what a disease progression might be.

Peter H. Gorman, M.D.: Yes, I think so. There are other specialists who can help as well. But the neurologists play a strong role in the rehabilitation field.

Ellen Beth Levitt: There?s new thinking about rehabilitation, right?

Peter H. Gorman, M.D.: The paradigm shifted from what we do from 20, 30 years ago. a person suffering a stroke years ago may have went through months and weeks of rehabilitation and then resumes a sedentary life and that's not what we aim to do now days. It can affect the individual for months and if not years and help they regain function from their initial injuries.

Ellen Beth Levitt: Isn?t there thought that you can rewire the brain with certain types of rehabilitation after an injury and even months and years later?

Peter H. Gorman, M.D.: Yes, colleagues of mine have identified through the use of MRI technology the fact that the brain can rewire with practice. Patients with stroke, for instance who get on treadmills can regain motor control of their legs with that practice.

Ellen Beth Levitt: So, there are new pathways perhaps in the brain that develops to help the brain take over some of the damage?

Peter H. Gorman, M.D.: Well, that's what we're thinking now. We?re thinking this is something that can effect months and years out from an injury.

Ellen Beth Levitt: Well, that's amazing.

What kind of exercise would this require?

Peter H. Gorman, M.D.: Well, that's one motion. You can see on the video, we're using treadmills at the Baltimore VA Medical Center to look at retraining patients with stroke to walk better. the interesting thing is that helps with the walking and it improves general health, it's important to note that people with a stroke, for instance, the mayor cause of death is a heart attack.

Ellen Beth Levitt: Is that because they're not getting aerobic activity?

Peter H. Gorman, M.D.: Yes, and we can improve heart-lung fitness with exercise after the stroke and that's really, again, the paradigm shift.

Ellen Beth Levitt: Well, what does the research show now?

Peter H. Gorman, M.D.: We can intervene and improve the cardiovascular fitness and reduce the risk of diabetes and insulin requirements. For instance in patients who are already diabetic, we can improve the speed and symmetry of walking.

It fits into the realm of quality of life. I talked already about the using the walking paradigm, but we can also help with arm function and help with the quality of activities of daily living with arm exercises as well

Ellen Beth Levitt: What about people with a limited range of motion in their arm? Is this what we're seeing now, that kind of exercise that people can do?

Peter H. Gorman, M.D.: Well, we've, at the Baltimore VA Medical Center have been able to have collaboration with a group at MIT, who?s developed a robotic device.

Ellen Beth Levitt: Is that what we're seeing here?

Peter H. Gorman, M.D.: Well, that's what we're seeing now.

It?s a video game, if you will for the patients undergoing rehabilitation. They see a target and try to reach the target with their motions. If they can't do that, then the robotic arm brings the arm towards the goal and it completes the path. With repetition, we can improve the function over time.

Ellen Beth Levitt: Are these devices that we saw, the armed device and the treadmills; are they only available in a limited number of places so far?

Peter H. Gorman, M.D.: Yes, they're not available everywhere. Certainly, things like the treadmill training devices can be easily spread to other centers and it's our mission to do that to get the devices into nursing homes as well.

Ellen Beth Levitt: What we were seeing, those are located at -- Kernan Hospital and the Baltimore VA Medical Center?

Peter H. Gorman, M.D.: Yes, in downtown.

Ellen Beth Levitt: sometimes people will have a problem where their foot drops after an injuries it seem it is front part of the foot can't -- they can't raise it as they walk and that can make it difficult to walk after a stroke or other kind of injury. Is there a device that's tested with that type of problem?

Peter H. Gorman, M.D.: Sure, there are devices available now. They used the technology called functional electrical stimulation. You can see an individual with a weakness in their right leg walking with the device on right now on the monitor screen, through the walking cycles, through the electrical stimulation, it stimulates it in the appropriate time it helps with the speed of walking.

Ellen Beth Levitt: So this sends out like radio waves?

Well, electrical signals touching the muscles of the calf and can actually make the calf muscles contract and bring the foot up. It?s not really communicating with the ankle, but it's making the calf muscles work?

Peter H. Gorman, M.D.: Yeah, this is a sensor that senses when the ankles in the position, it only does it during part of the walking cycle.

Ellen Beth Levitt: Now, would someone have to keep a device like this and use it all the time or does this kind of training help their calf muscles start to get back to normal?

Peter H. Gorman, M.D.: Well, that's an interesting question, what we do tend to prescribe these for long time years. There?s also a training effect. If one takes it off, there may be improved function for patients that used it for many weeks and months.

There are two devices. Then, there's a therapeutic approach trying to improve the motor control they have as they walk.

Ellen Beth Levitt: Are these devices brand-new?

Peter H. Gorman, M.D.: The technology's been out for decade, but they've been user friendly recently.

Ellen Beth Levitt: What about people with limited use in their hands?

Peter H. Gorman, M.D.: Well, functional electrical stimulation can also be used to stimulate paralyzed muscles in the hand. That can be done in a functional approach, actually restore a hand graph, or a therapeutic approach to restore muscle strength. You can see this woman with a spinal cord injury here; she's getting an electrical stimulation of her form to improve the range of motion of her joints.

Ellen Beth Levitt: Without that, would she have been able to do that?

Peter H. Gorman, M.D.: No.

Ellen Beth Levitt: Okay, are these devices, then, they're used in a rehabilitation setting?

Peter H. Gorman, M.D.: Yes. This device would be used in a rehabilitation setting. It can be prescribed for home use too in some circumstances.

Ellen Beth Levitt: Would she then be able to actually use her hand to do more things? We were just seeing how the device allows her to move her wrists and her fingers; would she be able to start to use her hand?

Peter H. Gorman, M.D.: Well, we certainly hope we'll improve the function enough to allow her to do things with her hands like feeding herself, for instance. It takes a lot of things put together to get that actual task accomplished.

Ellen Beth Levitt: And I guess lot of practice and determination on the part of the patient as well.

Peter H. Gorman, M.D.: Yes, a lot of practice and determination.

Ellen Beth Levitt: We have to take a break and when we come back, we'll talk about rehabilitation for spinal cord injuries. Stay with us.

Part Two:

Ellen Beth Levitt: Welcome back to Maryland Health Today. I?m Ellen Beth Levitt. My guest is Dr. Peter Gorman, the chief of Rehabilitation Medicine at Kernan Hospital. And he's also an associate professor of Neurology at the University of Maryland School of Medicine. How many people suffer from spinal cord injuries in the U.S. each year?

Peter H. Gorman, M.D.: There are about 12,000 spinal cord injuries in the U.S. every year. The number's been about the same over the last decade. Starting in the 70s, when records started to be kept.

Ellen Beth Levitt: I wondered if it was on the increase, but no?

Peter H. Gorman, M.D.: well, what's happened is there's better awareness by individuals, air bags in cars have helped, fortunately, some of the things that have counter balanced that, especially in a city like Baltimore, are the violent injuries, we've seen a lot of individuals hurt because of violent trauma and gunshot wounds.

Ellen Beth Levitt: And there are occupational injuries and falls and that sort of thing.

Peter H. Gorman, M.D.: Yes, and there are falls in the elderly population as well.

Ellen Beth Levitt: And also diving injuries?

Peter H. Gorman, M.D.: Sure.

And diving and other things like that. There?s a minority of the individual that is we see. They do occur in ocean city or other places like pools.

Ellen Beth Levitt: We saw as the trivia question, more men have spinal cord I think -- injuries compared to women? Why?

Peter H. Gorman, M.D.: Well, men tend to be the risk takers in our society. They drive faster and are more aggressive. That statistic has held true for year years.

Ellen Beth Levitt: And spinal cord injuries can vary in severity?

Peter H. Gorman, M.D.: Yes, in the level of injury, where along the spinal cord the injury occurs and the extent of injury, whether it's complete or incomplete.

Ellen Beth Levitt: Does the location determine the type of function somebody may have lost?

Peter H. Gorman, M.D.: Yeah, that's part of it. The person with an injury in the neck will likely have the impairment of arms and legs, as well as bowel and bladder functions and other problems. And a person with an injury in the back whether it's the mid-back or low back might just have problems with leg function and bowel and bladder difficulties.

Ellen Beth Levitt: What is a partial spinal cord injury?

Peter H. Gorman, M.D.: Well, often during trauma, the spinal cord is bruised, but not actually severed. One can have partial control of their legs and not full normal strength and function. About half of the patients we see have a partial injury.

Ellen Beth Levitt: Are there some way right after the injury occurs to take action so that the loss of function or the injury will be minimized?

Peter H. Gorman, M.D.: Well, there are. We don't have a lot of avenues to do that, but in trauma centers, we use a high dose steroid medication to reduce inflammation. And there are other approaches to reduce the inflammation such as the buffalo bills player, Mr. Everett, who had his spinal cord cooled.

Ellen Beth Levitt: Right now there isn?t anything --

Peter H. Gorman, M.D.: Well with, we don't have control, scientific trials of those techniques. We don?t have a lot of tools to reduce that inflammation. And we, and by we, I mean the scientific community's working on that.

Ellen Beth Levitt: Well, I?m sure a spinal cord injury can be devastating for someone's life and rehabilitation is important to get them back to as much function as possible and tries to learn things in a new way?

Peter H. Gorman, M.D.: Well, I think clearly, the rehabilitation is and will play a crucial role in the care of a person after an injury. Not only in restoring function and educational roles and making sure a person knows how to deal with the health issues as they come up. We want to recover as best we can and there are other components in this approach to dealing with this injury.

Ellen Beth Levitt: Does rehabilitation help regain function for some people?

Peter H. Gorman, M.D.: Yes, clearly it does. Especially in the patients that have the complete injury, we can, through exercise; training and repetitive motion and activities improve motor control and improve function. Even in the patients with a complete injury who may not recover function, we have to adjust and look at different approaches.

We have to teach people how to use a wheelchair if that's a requirement going forward for their lives. People can maintain and regain independence and that's one of the major goals of rehabilitation.

Ellen Beth Levitt: Are there devices, like I?ve seen a treadmill device called Lokomat that can help people? What is the Lokomat?

Peter H. Gorman, M.D.: Yes, we have one at Kernan Hospital. It?s a robotically assisted partial weight suspension treadmill training device. It?s a device that can bring a person through a normal walking cycle with an external robot. These patients are harnessing a parachute-type device that will partially unweigh them, so they don't have to put all of their weight on their legs.

Ellen Beth Levitt: Is the man using his own legs there, or is the robot moving his legs for him?

Peter H. Gorman, M.D.: Well, a little bit of both, he has the ability to walk about 1/4 speed on the Lokomat, but the idea of getting him on the device is to train him to walk in a faster pattern and improve his motor control.

Ellen Beth Levitt: What?s the track record?

Peter H. Gorman, M.D.: Well, it was developed in Zurich and it's been around for five to ten years and we are just learning now about its effectiveness with stroke and spinal cord injuries. It seems to be very positive.

Ellen Beth Levitt: What kind of research are you doing and what are some of the hopeful approaches that could help people in the future with spinal cord injuries and perhaps other illnesses or injuries that affect their ability to get around and so forth?

Peter H. Gorman, M.D.: Well, as I hinted at it, the spinal cord is complex and a part of the nervous system. When you have an injury, there's a significant effect in the inflammation and we're looking at and hope to look at medications and approaches that will reduce the initial inflammation and there are other implants to possibly help recover and regenerate nerves and nerve tracks.

Ellen Beth Levitt: Well, I guess the injury, it means that the nerves are damaged going from that point down --

Peter H. Gorman, M.D.: So the signals from the brain to the lower nerves initially control the muscles no longer work and they're trying to restore the connectivity. That?s the ultimate goal. That?s a complicated medical problem. Some approaches, like the idea of using stem cells to help regeneration and other types of cells to do that as well, are in the early stages of animal studies and hopefully in a year or two the clinical trial as well. And in connection with that rehabilitation approaches, like the Lokomat and electrical stimulation, it all needs to be looked at more closely. They?re aimed at restoring function.

Ellen Beth Levitt: Is there more interest in the area now?

Peter H. Gorman, M.D.: I think so. The notoriety that Christopher reeve brought to the field has helped. There are funding sources that are available that weren't available before. A lot of things have helped to create an interest in the field. Ultimately, I think that a multifaceted approach to treatment of these cases with surgical approaches and implants of cells and rehabilitation will combine to hopefully make this recovery and improvement a reality.

Ellen Beth Levitt: What role do family members play when members of their family have an injury that's affecting their mobility?

Peter H. Gorman, M.D.: Clearly, in rehabilitation, we have to include the family, they're crucial in helping a family member recover emotionally and functionally. The family can help by learning about what's happened to their loved one and support them in a physical way and they can provide emotional support. All factors are important.

Ellen Beth Levitt: As a neurologist, what got you involved in rehabilitation medicine and the rehabilitation side of things?

Peter H. Gorman, M.D.: Well, I had a backbone in engineering and I was interested in the use of electrical stimulation and that was sort of a background before I went to medical school. As a neurologist, again, because there's so much rehabilitation needed in patients with the neurologic disease, that was a good fit for me and it was an opportunity to treat the patients long term. A group of patients, especially with spinal cord injury aren't often well known to other medical practitioners.

Ellen Beth Levitt: And these are people you might see after an initial recovery and stay with you for months or years, is that right?

Peter H. Gorman, M.D.: I follow these patients throughout their lives.

Ellen Beth Levitt: What do you think is the most hopeful thing on the horizon?

Peter H. Gorman, M.D.: Well, I guess the idea of a combined approach that we can try to intervene with new technologies in a multidisciplinary environment and help to intervene with the patients.

Ellen Beth Levitt: And the retraining of the brain, that's exciting as well.

Peter H. Gorman, M.D.: I think the paradigm we talked about is crucial. It doesn't end after a few weeks, it's a lifetime commitment.

Ellen Beth Levitt: Thank you so much for joining us. My guest has been Dr. Peter Gorman, chief of Rehabilitation Medicine at Kernan Hospital, which is part of the University of Maryland Medical System. And Dr. Gorman is also an associate professor of Neurology at the University of Maryland School of Medicine.

If you have any comments or questions about this program, please contact me by email at eblevitt@umm.edu.

And if you'd like to reach Dr. Gorman or any other University of Maryland physician, call 1-800-492-5538 or visit the Web site, there you'll find a great amount of health information and be able to see other "maryland health today" programs. That address is www.umm.edu. Take good care of yourself, and we'll see you next time for "Maryland Health Today."

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This page was last updated on: January 21, 2009.

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