Traumatic disease

In recent decades, the problem of injuries and their consequences is regarded in the concept, the name of which is traumatic disease. The importance of this theory is in an interdisciplinary approach to consideration of the functioning of all the body systems from the moment of injury until recovery or death of the victim, when all the processes (fracture, injury, shock, etc.) are considered in the unity of the cause-effect relationships.

The value for the practice medicine is connected to the fact that this issue concerns the doctors of many specialties: experts in resuscitation, traumatologists, surgeons, therapeutists, family doctors, psychologists, immunologists, physiotherapists, as the patient who underwent trauma, sequentially receives treatment from these specialists both in the hospital and in the clinic.

The term "traumatic disease" appeared in the 50s of XX century.

Traumatic disease is a complex of symptom of compensatory-adaptive and pathological reactions of all the body systems in response to the trauma of various etiologies, characterized by staging and duration of course, which determines its outcome and prognosis for life and capacity for work.

Epidemiology of traumatic disease

Throughout the world, there is a tendency to annual increase of injuries. Today it is a priority health and social problem. More than 12.5 million people are injured per year, over 340 thousands are killed; another 75 thousands become disabled. In Russia, the rate of lost years of potential life caused by injuries is 4200 years, which is 39% more than due to diseases of the circulatory system, as most patients are young and are in most capable of working age. These data also pose specific objectives to traumatologists in implementation of the priority Russian national project in the health care.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10],

Symptoms of traumatic disease

Trauma is a strong emotional and painful stress, leading to the development of changes in all systems, organs and tissues (psycho-emotional state, the central and autonomic nervous system, heart, lungs, digestive system, metabolism processes, immune reactivity, hemostasis, endocrine reactions) in the victim; i .e. disorder of homeostasis occurs.

When speaking about the role of the nervous system in the formation of clinical variants of post-traumatic disorders, we should dwell on the specifics of the situation itself, when injury appears. At that, many urgent needs of the individual are blocked; this is reflected in the quality of life and leads to changes in the system of psychological adaptation. Primary psychological reaction to trauma can be of two types - anosognostic and anxious.

• In the case of anosognostic type, positive emotional background, minimum of vegetative manifestations and propensity for denying or belittling the symptoms of the illness are noted to 2 weeks after injury. Especially such a psychological reaction to trauma is characteristic mainly of young men, leading mobile lifestyle.
• Patients with anxiety type during the same terms tend to oppressed state, suspiciousness, depression, negatively colored emotional background, abundant vegetative symptoms, severe pain, fear, anxiety, lack of confidence in a good outcome, unwellness, sleep disturbance, decreased activity, which can exacerbate comorbidity and complicate the course of the underlying disease. Such a reaction is often typical for patients older than 50 years, predominantly female.

In the future dynamics by the end of the first month of the traumatic disease in most patients with anxiety type of reaction emotional state begins to stabilize, vegetative symptoms reduce, indicating a more adequate perception and a realistic assessment of their condition and the situation in general. While in patients with anosognostic type during 1-3 months from the trauma signs of anxiety, frustration and emotional discomfort begin to grow; they become aggressive, hot-tempered, there is concern about the present and the future ("a worrying assessment of the prospects"), which can partly be explained by the inability of patients to cope with the situation without assistance. Attempts to attract the attention of relatives and friends occur.

By the 3rd month of the disease only in a third part of patients harmonization of psychological state occurs; at this, good social adaptation, active participation in the treatment process and taking responsibility for their condition for themselves are noted. The majority of patients in this period the primary psychological reactions receive a maladaptive development in the form of prevalence of pathological types of attitude to the disease, increasing of anxiety with prevalence of mental component of anxiety over the vegetative one, increased aggressiveness and rigidity. This development gains psychoemotional state in a half of the patients with primary anosognostic and in 86% of patients with an initially anxiety type of reaction to trauma.

After six months from the date of injury in 70% of patients with traumatic disease maladaptive psychological condition, associated with frequent hospitalizations and prolonged forced isolation from the familiar environment, is preserved. In which connection, in half of them dysphoric type, characterized by an increase in conflict, aggression, selfishness with irritability, weakness, outbursts of anger and hostility toward others are formed, control of emotions and behavior is reduced. In another part of patients everything proceeds according to apathetic type, when self-doubt and feelings of helplessness dominate; at that, expressed vegetative component is noted, patients lose faith in the recovery, there is feeling of doom, the rejection of dialogue, vacancy, and indifference to everything, including their own health. All this has a significant impact on the process of rehabilitation of the patient, and therefore requires mandatory participation of clinical psychologist in the diagnostics and treatment of patients with traumatic disease.

Mental status of patients with traumatic disease is often accompanied by autonomic symptoms.

In the response of the autonomic nervous system (ANS) to injury, four forms are distinguished:

• with a predominance of parasympathetic reactions in all terms of examination;
• with the presence of vagotonia in the early periods of traumatic disease and in remote periods – of sympathicotonia;
• with a short-term activation of the sympathetic section and stable eutonia in the future;
• with a stable dominance of sympathicotonia at all times.

Thus, in the case of pronounced predominance of parasympathetic symptoms in the early stages 7-14-th days are critical, when in patients in the clinical picture apathy, hypotension, orthostatic syncope, bradycardia, respiratory arrhythmia and other symptoms of vagotonia, which were absent before the injury, dominate. In the remote periods of traumatic disease 180-360-th day is considered the most dangerous in relation to the development of autonomic disorders in the case of this form of response. The vicious circle of autonomic imbalance, which is developing in the early stages, without corresponding correction in these patients may lead to the formation of the pathology until the diencephalic syndrome in remote periods. The latest is developed in the form of several variants: vegetative-visceral or neurotrophic syndrome, sleep and wakefulness disorder syndrome and vago-insular crises. This variant of the autonomic nervous system response to injury is called "decompensated form of parasympathetic type."

There also is another form of the autonomic nervous system response to injury, when two diametrically opposite periods are detected: from the first to the 30-th day the tone of the parasympathetic section dominates, and from 90-th to 360 -th day – sympathetic one. In the period from the 7-th to the 14-th day after the injury the following symptoms of prevalence of parasympathetic tone are recorded in these patients: bradycardia (heart rate is 49 per minute or less), hypotension, extra systole, persistent red dermographism and respiratory arrhythmia; 30-90-th day – the term of autonomic processes of adaptation compensation; from 90 to 360- th day in connection with the insufficiency of compensatory abilities of the system a large number of symptoms of the sympathetic section of the autonomic nervous system prevalence is detected: tachycardia (in the form of constant sinus or paroxysmal supraventricular and ventricular tachycardia), weight loss, hypertension and inclination to low-grade fever. This form of autonomic nervous system response to the conditions of traumatic disease should be referred to subcompensated.

The most common and physiologic form of autonomic nervous system response to injury in terms of uncomplicated traumatic disease is as follows: short-term (up to 7, maximum -14 days) sympathicotonia, with full restoration of vegetative balance for 3 months, the so-called "compensated form". With this character of vegetative processes the organism is capable of restoring the disturbed as a result of injuries regulatory relationship of sympathetic and parasympathetic sections without additional compensation.

There is another version of the autonomic response to trauma. It is observed in patients with episodes of high blood pressure (BP) related to psychoemotional overexertion or physical load in anamnesis. In these patients the tone of the sympathetic component prevails up to 1 year from the date of injury. In the early stages a critical peak of sympathicotonia increase is recorded by the 7-th day in the form of tachycardia (up to 120 per minute), arterial hypertension, palpitations, dryness of skin and mucous membranes; the poor tolerability of a stuffy room, a feeling of numbness in the morning, white dermographism are noted. In the absence of appropriate treatment such dynamics of the autonomic regulation of the heart and blood vessels work progressively leads to the development in half of them in remote stages of the diseases (90-360-th day) of pathological conditions, such as hypertension with frequent crisis course or paroxysmal tachycardia. Clinically, in these patients by the 90-th day more frequent bouts of sudden rise in blood pressure (160/90 mm Hg to 190/100 mm Hg), requiring an ambulance call, is observed. Therefore, the undergone trauma in patients, who have initially had a predisposition to increased blood pressure, becomes a factor in provoking the hypertension progression. It should be noted that the clinical course of the very hypertensive crises fits the concept of "Sympathoadrenal" or “type I crisis ", as blood pressure rises rapidly (from 30 minutes to an hour), while tremors of extremities, facial flushing, palpitations, anxiety, emotional coloration are observed, and there is often polyuria after pressure reduction. This form of the autonomic nervous system response to injury should also be attributed to decompensated, but of sympathetic type.

Consequently, the more severe and prognostically unfavorable in relation to remote periods is considered the dominance in the early stages of traumatic disease (from the first to the 14-th day) the effect of the parasympathetic section of the ANS. Patients with an indication of the tendency to blood pressure increase or other risk factors of hypertension in the anamnesis require from the early terms after undergone injury increased sympathetic influence of the ANS prevention measures, systematic monitoring of blood pressure and electrocardiographic monitoring, the course assignment of individually selected doses of antihypertensive drugs (for example, “Enap”, “Prestarium” etc.), the use of an integrated approach to rehabilitation: electric, rational psychotherapy, autogenic training, and others.

Changes in the heart and blood vessels functioning take one of the first places among the visceral pathology in traumatic diseases: reduction in the functional activity as a whole of entire circulatory system in terms of a year or more from the date of injury. The1st-21st days are believed to be critical in relation to the development of heart insufficiency and post-traumatic myocardiodystrophy; this is manifested in the form of reducing of stroke index (SI) and ejection fraction (EF). One-time cardiac efficiency depends on several factors: the amount of affluent blood, the state of myocardial contractility and diastole time. In the case of severe mechanical trauma all these factors significantly affect the amount of SI; however, it is quite difficult to determine the unit weight of each of them. Most often, the low value of SI in victims in the early stages of traumatic disease (from the first to 2-st day) are due to hypovolemia, a decrease of diastole as a result of tachycardia, prolonged hypoxic episode, the influence on the heart cardio suppressive substances (kinins), released into the blood when large amounts of muscle tissue are damaged, hypodynamic syndrome and endotoxicosis that should certainly be considered for patients with mechanical injuries.

At the same time, extravascular (bleeding, exudation) and intravascular (blood pathological deposition, rapid destruction of donor red blood cells) should be considered as a factor in the development of post-traumatic deficit of blood volume.

In addition, severe mechanical trauma is accompanied by a significant increase in enzyme activity (2-4 times compared with the norm) of such cardiac enzymes as creatine phosphokinase (CPK), creatine kinase MB-form (MB-CK), lactate dehydrogenase (LDH), a-hydroxybutyrate (a-HBB), myoglobin (MGB), with the highest peak from the first to the 14-th day, indicating expressed hypoxic conditions of cardiomyocytes and inclination to dysfunction of the myocardium. This is especially to be considered in patients with an indication of coronary heart disease in the anamnesis, because their trauma can cause angina, acute coronary syndrome, and even myocardial infarction.

When there is traumatic disease, the respiratory system becomes extremely vulnerable and suffers one of the first. The ratio between pulmonary ventilation and blood perfusion is changed. Hypoxia is often revealed. Acute pulmonary insufficiency is characterized by the gradual development of arterial hypoxemia. In the case of shock hypoxia hematic component is present because of the decrease in the oxygen capacity of blood due to its dilution and erythrocyte aggregation. Further, respiratory distress, developing according to the type of parenchymatous respiratory insufficiency, occurs. The most severe complications of traumatic disease of the respiratory system are respiratory distress syndrome, acute pneumonia, pulmonary edema and fat embolism.

After severe injuries the transport function of the blood (the transport of oxygen and carbon dioxide) changes. This occurs due to the decrease in amount of red blood cells, hemoglobin, and non-heme iron by 35-80% with the reduction in the volume of tissue blood flow, limitation of the oxygen use by tissues in the case of traumatic disease; such changes are preserved in an average for 6 months to 1 year from the date of injury.

The imbalance of oxygen regime and blood circulation, especially in a state of shock, affects the metabolism and catabolism. Impaired carbohydrate metabolism is of particular importance in this case. After an injury hyperglycemia condition called "diabetes of injury" is developed in the organism. It is associated with the consumption of glucose by the damaged tissues and it’s coming out from the depot organs, blood loss, the addition of suppurative complications, as the result of what there is a reducing of the glycogenic myocardial reserve and carbohydrate metabolism of the liver changing. Energy metabolism suffers; the amount of ATP is reduced by 1.5-2 times. Simultaneously with these processes in the case of the traumatic disease a disorder of lipid metabolism, which is accompanied by acetonemiaand acetonuria during the torpid shock phase, decrease in the concentration of beta-lipoproteins, phospholipids and cholesterol, occurs. These reactions are restored in 1-3 months after the injury.

Disorders of protein metabolism are preserved for up to 1 year and occur during the early stages (up to 1 month) in the form of hypoproteinemia as a result of increased catabolic processes (reduced concentration of functional proteins: transferrin, enzymes, muscle proteins, immunoglobulins). When there are severe injuries, the daily protein loss reaches 25 g. In the future (up to 1 year) prolonged dysproteinemia related to disturbance of the ratio between albumin and globulin with the predominance of the latter, and increasing the number of acute-phase proteins and fibrinogen are recorded.

With the injury, electrolyte and mineral metabolism is disturbed. hyperkalemia and hyponatremia, the most pronounced during the shock state and quickly recovering (for 1 month of illness), are identified. While the reduction in the concentration of calcium and phosphorus is noted even 1 year after injury. This is an evidence of the fact that bone mineral metabolism suffers significantly and protractedly.

Traumatic disease leads to changes in water and osmotic homeostasis, acid-base status, pigment metabolism, vitamin resources exhaustion.

Particular attention should be paid to the functioning of such important systems as immune, endocrine and homeostasis system, as the clinical course of the disease and recovery of the damaged organism largely depends on their condition and response.

The immune system has an impact on the course of traumatic disease; at the same time, the mechanical trauma disturbs its normal functioning. Changes in the immune activity of the organism as the response to injury are considered as manifestations of the general adaptation syndrome.

In the early post-traumatic periods of time (up to 1 month from the date of injury) pronounced immunodeficiency of mixed origin (most of the indicators of immune status are reduced by an average 50-60%) is developed. Clinically, at this time the greatest number of infectious-inflammatory (half of the patients) and allergic (one third of patients) complications occur. From 1 to 6 months multidirectional shifts of adaptive nature are recorded. Despite the fact that after 6 months the formation of an adequate callus appears and the support function of an extremity is restored (which is confirmed by X-ray), immunological changes in these patients are prolonged and do not disappear even in 1, 5 years from the date of injury. During the remote periods (from 6 months to 1.5 years) immune deficiency syndrome, mainly according to T-deficient type (the number of T-lymphocytes, T-helpers / inducers, complement activity, the amount of phagocytes is reduced) is formed, which clinically manifests itself in a half, and the laboratory - in all patients, who underwent a serious injury.

Critical periods of possible immunopathological complications are the following:

• the first day, period from the 7-th to the 30-th day, and from 1 to 1.5 years - prognostically unfavorable for infectious-inflammatory complications;
• periods from the first to the 14-th day, and from 90-th to 360-th day - with respect to allergic reactions.

Such long-term immune shifts require an appropriate correction.

Severe mechanical trauma leads to serious changes in the hemostatic system.

In the status of hemostasis in patients within the first 7 days thrombocytopenia with intravascular thrombocytes aggregation and multidirectional shifts of coagulation tests is revealed:

• fluctuation of thrombin time;
• lengthening of activated partial thromboplastin time (aPTT)
• reducing of prothrombin index (PTI)
• reduction in the activity of antithrombin III;
• a significant increase in the amount of soluble fibrinmonomeric complexes in blood (SFMC);
• positive ethanol test.

All this indicates the presence of disseminated intravascular blood coagulation syndrome (DIC).

DIC-syndrome in examined patients is a reversible process, but giving long counterresponse. Most often this is due to a profound affection of the compensatory mechanisms of hemostasis system under the influence of severe mechanical trauma. In such patients long-flowing blood-dotting disorder (up to 6 months from the date of injury) is developed. From 6 months to 1.5 years thrombocytopenia, thrombophilia and fibrinolysis disorders reactions are recorded. As for laboratory indexes, during these terms a number of erythrocytes, the activity of antithrombin III, fibrinolytic activity can be reduced; amount of SFC in plasma can be increased. Clinically, in some patients the emergence of spontaneous gum and nasal bleeding, skin hemorrhages of petechial spotted type, and in some – thrombosis are observed. Consequently, in the pathogenesis of making and formation of traumatic disease course character disorders in the hemostatic system, which require to be diagnosed and corrected, are one of the leading factors.

The endocrine system in the functional state is one of the most dynamic systems; it regulates the activities of all morphological and functional systems of the body and is responsible for homeostasis and the organism's resistance.

In the case of mechanical injuries, functional activity staging of the hypophysis, thyroid, pancreatic and adrenal glands is determined. There are three periods of endocrine reactions in patients with traumatic disease: the first period – from the first on the 7-th day; second period - from the 30-th to 90-th day; third period - from 1 to 1.5 years.

• In the first period, a significant decrease in the activity of the hypothalamic-pituitary-thyroid system, combined with a sharp increase in the activity of the pituitary-adrenal system, reduction of endogenous function of pancreatic gland and increasing of somatotropic hormone activity is noted.
• In the second period there is increased activity of the thyroid gland, the pituitary gland activity is reduced during normal operation of the adrenal glands, the synthesis of somatotropic hormone (SH) and insulin is decreased.
• In the third period, the following changes are recorded: increased activity of the thyroid gland and the pituitary gland at a low functional capacity of the adrenal glands, increase in the content of C-peptide, the number of somatotropic hormones comes to the rate.

The most significant prognostic factors in traumatic disease are cortisol, thyroxine (T4), insulin and somatotropic hormone. Differences in the functioning of certain parts of the endocrine system during the early and remote periods of traumatic disease are noted. At that, from 6 months to 1.5 years after the trauma hyperthyroidism due to T4, hypofunction of the pancreas due to insulin, reducing of the pituitary gland activity due to adrenocorticotropic (ACTH) and thyroid-stimulating hormone (TSH), increased activity of the adrenal cortex due to cortisol are revealed in patients.

It is important for the practitioner, that endocrine changes in the response to trauma are ambiguous: some are adaptable, transient in nature and do not require correction. Other changes, referred to as pathological, need specific treatment, and such patients need long-term monitoring by an endocrinologist.

In patients with traumatic disease metabolic and destructive changes in the digestive organs, depending on the location and severity of the injury, occur. The development of gastroenteric bleedings, erosive gastroenteritis, stress ulcers of the stomach and duodenum, cholecystopancreatitis is possible; sometimes acidity of the gastrointestinal tract and absorption of food in the intestines are disturbed for a long time. In the case of severe traumatic disease course the development of hypoxia of the intestinal mucosa, the possible result of which can be a hemorrhagic necrosis, is observed.

Classification of traumatic disease

Classification of traumatic disease is proposed by I. Deryabin and O. Nasonkin in 1987. The forms of the disease course.

According to severity:

• mild;
• medium;
• severe.

By nature:

• uncomplicated;
• complicated.

By outcomes:

• favorable (complete or incomplete recovery, with anatomical and physiological defects);
• unfavorable (fatal or becomes chronic).

Periods of disease:

• •acute;
• •of clinical recovery;
• of rehabilitation.

Clinical forms:

• head injury;
• spinal injury;
• isolated chest injuries;
• multiple stomach injuries;
• combined pelvic injuries;
• combined injuries of extremities.

Classification of forms of traumatic disease according to the degree of compensation of functions of organs and systems is as follows:

• compensated;
• subcompensated;
• decompensated.

It is necessary for practitioner, dealing with trauma and post-traumatic pathology, to take into account the following principles:

• syndromic approach to the diagnostics;
• access to the level of pre-diseases diagnostics and their prompt correction;
• individual approach to rehabilitation;
• not disease, but the patient’s treatment.

[11], [12], [13], [14], [15], [16]

Treatment of traumatic disease

Treatment of traumatic disease depends on the severity and stage of the illness; but in spite of the general principles, the most important thing is an individual approach, taking into account the complex of syndromes in a particular patient.

The first stage (pre-hospital) begins at the scene of the accident and continues with the participation of specialized ambulance service. It includes an emergency arrest of haemorrhage, restoration of airway patency, mechanical ventilation (ALV), chest compressions, adequate anesthesia, and infusion therapy, imposition of aseptic dressings on wounds and transport immobilization and delivery to the hospital.

The second phase (stationary) goes on in a specialized patient care institution. It consists of traumatic shock elimination. All patients with trauma may experience severe pain reaction, so they need adequate analgesia, including modern non-narcotic drugs (“Lornoxicam”, “Ketanov”, “Tramadol” + “Acetaminophen”), narcotic analgesics and psychotherapy aimed at pain relief. Blood loss in the case of thigh fracture is up to 2.5 liters, thus the volume of circulating blood needs to be supplied. For this purpose there are modern medications: hydroxyethyl starch, gelatin, antioxidants and detoxicants (Meglumine sodium succinate, “L-Tryptophan”). During the period of shock and early post-shock reaction start of catabolic processes occurs. In the case of severe injuries, the daily loss of protein is up to 25 g, moreover there is a so-called "eating" of own skeletal muscle; and if during this time the patient does not get help, the muscle mass is independently restored only by one year (and not in all patients). We cannot forget about the parenteral and enteral nutrition in patients of traumatic profile; balanced mixture “Nutricomp” for enteral nutrition and preparations "three in one" - for parenteral nutrition (“Kabiven”, “Oliclinomel”) suit this purpose best. In the case of successful solution of the mentioned problems, normalization of blood volume occurs, hemodynamic instability restores, providing delivery of oxygen, plastic nutrients and energy to tissues, and thus stabilizes the homeostasis in general. Besides the loss of muscle mass, protein metabolism disorders support available posttraumatic immunodeficiency, which leads to inflammatory complications and even sepsis development. Therefore, along with adequate nutrition it is necessary to carry out the correction of immune disorders (for example, polyoxidonium).

In the presence of DIC-syndrome it is necessary to add to the mentioned therapy the following means: fresh frozen plasma containing all the necessary components of the anti-clotting system (antithrombin III, protein C, etc.) in combination with heparin; antiaggregant agents (“Trental”, “Dipyridamole”); therapeutic plasmapheresis for unblocking the mononuclear phagocyte system and the organism detoxication; polyvalent protease inhibitors (aprotinin); and peripheral adrenergic receptor blocking agents (“Phentolamine”, “Droperidol”).

Elimination of post-traumatic acute respiratory failure (ARF) should be pathogenic. For emergency patency of airways restoration inspection of the upper respiratory tract is performed, eliminating the tongue impaction and lower jaw. Then with the use of electric pumps mucus, blood and other liquid ingredients are aspirated from the tracheobronchial tree. If the patient is conscious and adequate breathing is restored, an inhalation oxygen therapy is prescribed and control of the lungs ventilation is performed. Intubation of trachea (rarely tracheotomy), followed by mechanical ventilation (ALV) is indicated for the bad case patients with failure of external respiration function or in the case of its excessive tension. It is also used for the prevention and treatment of respiratory distress syndrome of adults. The next and most difficult section of the struggle with ARF is restoration of chest framing at chest trauma and the pneumothorax elimination. At all stages of the struggle with ARF adequate tissue oxygenation using mechanical ventilation, and as soon as possible - in a pressure chamber, is necessary.

Victims with psychogenias (aggressive behavior, expressed excitement, etc.) require the administration of one of the following medications: “Chlorpromazine”, “Haloperidol”, “Levomepromazine”, bromdigidrochlorfenilbenzodiazepin. The alternative is the introduction of a mixture, consisting of “Chlorpromazine”, “Diphenhydramine”, and magnesium sulfate. In the case of suporose state, 10% solution of calcium chloride (10-30 mL) is introduced intravenously; sometimes rausch-narcosis is used. When there are anxiety- depressive states, “Amitriptyline”, “Propranolol” and “Apo-clonidine” are prescribed.

After taking out of the victim from the acute state and conducting of emergency surgical intervention, complete examination of the patient, carrying out deferred operations or other manipulations, aimed at eliminating defects (imposition of skeletal extension, plaster bandages, etc.) is necessary. After identifying the leading clinical syndromes, it is necessary in addition to the treatment of main process (injury of a particular area) to carry out the correction of common organism reactions to trauma. Timely prescription of medications, facilitating the restoration of homeostasis, such as antihomotoxic drugs and systemic enzyme therapy agents (“Phlogenzym”, “Wobenzym”) helps improve the course of traumatic disease, reduce the risk of infectious and allergic complications, restore neuroendocrine responses, tissue respiration, adjust the microcirculation and, consequently, optimize reparative and regenerative processes in the presence of fractures, prevent the development during the distant periods of the disease acquired immune deficiency and syndromes of pathology of hemostasis system. The complex rehabilitation measures should include adequate physical therapy (massage, UHF, electrophoresis of calcium and phosphorus, laser therapy of bioactive points, physical therapy), hyperbaric oxygenation (up to 5 sessions), acupuncture and gravitational therapy. The use of preparations containing mineral-vitamin complexes gives a good effect.

Taking into account the psychogenic actions of injuries, it is necessary to involve psychologists and use a range of different psychotherapeutic techniques, medications and social rehabilitation programs. The most commonly combination of situational defense, emotional support and cognitive therapy methods, preferably in group conditions, is applied. It is necessary to avoid procrastinating of psychosocial interventions course in order to avoid the effect of the formation of secondary gain from illness.

Thus, traumatic disease is of great interest to a wide range of doctors of practice medicine, as the rehabilitation process is long and requires the involvement of experts of various profiles, and also needs a development of fundamentally new therapeutic and preventive measures.