Patients with spinal cord damage due to uncertain/unknown etiology: the CP phenomenon (confusion and perplexity). Case reports.

Usually, most of the clients who are referred to departments of rehabilitation medicine, bear firm and sound diagnoses. We describe herewith 10 patients who developed spinal cord pathologies due to unknown or uncertain etiologies. We would like to share our thoughts with the readers.

Civilian spinal cord injuries due to terror explosions.

STUDY DESIGN: Retrospective analysis of civilians with spinal cord injuries (SCIs) due to terror explosions. OBJECTIVES: To analyze and describe the clinical characteristics and rehabilitation outcomes of civilians with SCI due to explosions admitted for in-patient rehabilitation from 2000-2004. SETTING: SCI rehabilitation service, Tel Hashomer, Israel. METHODS: Retrospective chart review. Civilians with SCI due to terror-related gunshot wounds (GSWs) served as a control group. RESULTS: Eleven civilians with SCI caused by penetrating atypical foreign objects (PAFOs) and eight with GSWs were identified. The male-to-female ratio was approximately 2:1. Foreign objects were present within the spinal canal in seven patients, causing bone injury without canal penetration in three, and one patient had both bone injury and canal penetration. The most common level of injury was thoracic. Seven had complete motor SCI. Three individuals improved in American Spinal Injury Association status: one individual improved from B to C (cervical); one from C to D (thoracic); and the third from D to E (lumbar). Despite the similar acute hospital length of stay and functional independence measure (FIM) scores on admission, the PAFO group had a shorter rehabilitation length of stay with higher FIM scores and higher FIM efficiency at discharge. CONCLUSIONS: Although the pathophysiology of PAFO blast injuries is similar to the high-velocity GSWs or the high-energy military munition injuries, better rehabilitation outcomes were seen, with slightly higher FIM efficiency and efficacy at discharge. This result is likely to be caused by less neurological tissue damage at impact.

[From the "teeth-drawer", the "quick-pistol drawer" to the "stent"--the contribution of dentists to history].

In this short review, some facts on the historical background of dentistry are given along with descriptions of dentists who contributed to history in various fields. The history of general anesthesia is also tightly connected with a few dentists.

[The rehabilitation of patients with intellectual disability who sustained traumatic injury].

Mentally retarded people usually receive care in special social, vocational, behavioral or educational facilities. Only recently, we gained some experience in the rehabilitation after trauma of those with mental retardation. We presume that with the increasing awareness of the benefits of comprehensive and early rehabilitation after trauma, orthopedic surgeons, neurosurgeons, and physicians who work in intensive care units, refer more patients who had never before gained from this specialty. We would like to share our experience of the unique rehabilitation process of this population.

[Medical rehabilitation of patients with osteogenesis imperfecta (OI) and additional newly acquired disabilities].

Adults with Osteogenesis Imperfecta (OI) are rarely referred to facilities of general rehabilitation medicine. Recently, two OI patients were admitted to our department because of additional neurological disabilities: stroke and spinal cord injury. In these circumstances, the hospitalization course has different characteristics.

[Our experience with the medical rehabilitation of homeless-disabled people].

During the last two years, 11 homeless-disabled people were treated at our rehabilitation ward. All of the patients were Jewish, six were new immigrants from Russia, their age ranged between 34 to 60 years, most of these patients had completed at least high school education, and all had managed to have a "normal" social-working life until the crisis which led them to the street. Six became alcoholics and one was a narcotic-drug user. None of these patients suffered from malnutrition or mental disorder, and after the rehabilitation process was over, they became independent, performing the activities of daily living. Most of them decided to return to their previous street--living place, despite their disabilities. This new combination of relatively young disabled-homeless people at our rehabilitation facility demands novel and different rehabilitation approaches.

Professor Heinrich Sebastian Frenkel: a forgotten founder of rehabilitation medicine.

Frenkel was born and later on practiced medicine in Heiden, Swizerland. This small town became, by his vigilant and innovative work, a place of pilgrimage for neurologists. He was the first to introduce the concept of exercise to restore dexterity and to improve ambulation and so pioneered the specialty of physical medicine and rehabilitation. Frenkel's method and philosophy became the foundation of treatment for many chronic neurological disabling diseases. His personality and work influenced many famous neurologists, worldwide.

Transverse myelitis in patients with antiphospholipid antibodies--the importance of early diagnosis and treatment.

Transverse myelitis (TM) is a rare manifestation of systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). No uniform therapeutic protocol exists for its treatment, and the prognosis is usually poor. Here we describe four patients having TM associated with antiphospholipid antibodies. Treatment measures and delay in diagnosis between symptom onset and the initiation of treatment varied between patients, but the earlier the diagnosis and the more aggressive the treatment the better was the patient's outcome. Based on these cases and on a literature review we suggest that early aggressive treatment (usually with pulses of methylprednisolone and cyclophosphamide) might improve the prognosis of patients with TM associated with antiphospholipid antibodies.

Conversion motor paralysis disorder: overview and rehabilitation model.

It is important to consider a differential diagnosis between paralysis on an organic basis and paralysis and disability due to psychological mechanisms in people with physical impairment secondary to trauma, without evidence of organic etiology. We review the most dramatic type of conversion disorder (CD)-'Conversion Motor Paralysis'. Recent important medical literature concerning the accepted treatment and rehabilitation management will be reviewed and discussed. The inter-disciplinary in-patient team management approach in a rehabilitation setting offers the benefits of a comprehensive assessment and treatment. The diagnosis is temporary and conditional, since there may be a long delay until the appearance of organic findings. A complete medical assessment is essential in order to rule out any possibility of an organic etiology. In as many as 25% to 50% of patients diagnosed as conversion, an organic medical diagnosis was found.

Conversion motor paralysis disorder: analysis of 34 consecutive referrals.

STUDY DESIGN: We present our cumulative experience with patients sustaining the most dramatic type of Conversion Disorder (CD) - Conversion Motor Paralysis. SETTING: Rehabilitation departments, Reuth Medical Center, Tel-Aviv and Sheba Medical Center, Tel-Hashomer, Israel. METHODS: During the period 1973-2000, 34 patients with neurological symptoms without any anatomical or physiological basis were admitted to both rehabilitation departments. This number consists of less than 1% of the total acute traumatic and non-traumatic spinal cord disorders admitted annually to these centers. RESULTS: Twenty-five of the subjects were men (mean age of 30 years) and nine were women (mean age of 31.4 years). Neurological symptoms included: paraplegia (complete or incomplete) (18), hemiplegia or hemi paresis (11), tetraplegia (complete or incomplete) (three), monoplegia (one), triplegia (one). The final diagnosis on discharge was CD in 30 of the 34 cases, the remaining four being diagnosed as malingering. Functionally, nine patients had a complete recovery, 10 a partial recovery and 15 remained unchanged. CONCLUSION: Disabled people who experienced traumatic events resulting in various disabilities are admitted usually to a rehabilitation center. However, some of them are later diagnosed as having Conversion Disorder or malingering. We believe that their participation in active regular and integrative rehabilitation process is beneficial to most of them. Most of these patients gain functional independence and return to the main stream of life.

Treatment of male infertility due to spinal cord injury using rectal probe electroejaculation: the Israeli experience.

STUDY DESIGN: Male infertility caused by anejaculation is common among patients with spinal cord injury (SCIP). The fertility options for SCIP have improved impressively over the past 10 years. We present the Israeli experience in the treatment of infertility in a large series of SCIP. The issues which are addressed include the treatment of ejaculatory dysfunction, seminal quality and fertility management in SCIP. SETTING: Sexual rehabilitation clinic, Neuro-Rehabilitation department, Sheba Medical Center, Israel. METHODS: Between June 1992 and May 1998, a total of 84 consecutive SCIP were treated in our clinic with electro-ejaculation (EEJ), representing a sample of the SCIP population, composed mostly of young men traumatically injured. The patients have sustained different levels and completeness of spinal injury. Among the patients 33 were interested in achieving pregnancy (39.3%), while the rest were interested in determining fertility potential for family. With EEJ, a low-current stimulation of the ejaculatory organs via a rectal probe is done. The collected semen is used for fertility determination or for fertilization. RESULTS: Eighty-four patients were treated by EEJ. Mean age was 31.3 and mean age at injury was 21.7. There were 29 cervical, 50 thoracic and five lumbar lesions. Sixty-three had complete injury (ASIA A) and 21 incomplete (ASIA B -15, ASIC C -5, ASIA D -1). Fifty-nine had upper motor neuron lesions, and 25 had lower motor neuron. A total of 355 stimulations were performed. Ejaculate was obtained in all patients in 350 stimulations (98.6%), and sperm was present in 74 patients (88.1%) in 296 of the stimulations (83.4%). Fairly good numbers of spermatozoa were obtained, whereas sperm motility and morphology of spermatozoa were low in most cases. A significant difference in sperm count, motility and morphology was noted between antegrade and retrograde samples. No significant improvement in sperm quality after four repeated consecutive stimulations was noted in 38 SCIP. Side effects were minor and encountered in 16 patients (19.1%). Out of 33 couples who wished to achieve pregnancy, 26 reached the stage of insemination. Four pregnancies were achieved after 33 cycles of In-Uterine-Insemination (pregnancy rate 28.6% per couple), and 15 after 68 cycles of In-Vitro-Fertilization (micromanipulation) (pregnancy rate of 68.75% per couple). In all, of 101 conception attempts 23 were successful, resulting in pregnancies in 18 couples, and accounting for an overall pregnancy rate of 70% per couple. CONCLUSION: The high percentage of pregnancies imply that, despite the typically poor sperm motility noted in EEJ, rectal probe EEJ combined with assisted reproductive techniques, and performed by a team approach, is an efficient and safe technique for treating infertility among SCIP.