Laser treatment of specific scar characteristics in hypertrophic scars and keloid: A systematic review.

BACKGROUND: Hypertrophic scarring and keloid can cause significant emotional and physical discomfort. Cosmetic appearance, functional limitations, pain and pruritus form a degree of impairment. While the etiology is not fully known, there is a wide array of treatment options, which include excision, radiation, cryotherapy, silicone gel sheeting, and intralesional injections. A relatively new modality is laser therapy. While results are promising, the number of different laser systems is substantial. This review evaluates the available evidence regarding outcomes on specific objective characteristics (i.e., erythema, pigmentation, height, and pliability) of the different laser systems. METHODS: A systematic literature review was performed using MEDLINE, Cochrane Library, and EMBASE. Data on scar characteristics were extracted from scar scales Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS), and from objective measurement tools. RESULTS: Heterogeneity was seen in a lot of aspects: maturity of scar, origin of scar, follow-up, and number of treatments. The fractional ablative lasers CO2 10,600 nm and Er:YAG 2940 nm were found to produce the best results regarding erythema, height, and pliability, while the flash lamp-pumped pulsed dye laser (PDL) 585 nm scored slightly below that. CONCLUSIONS: Laser systems, and specifically the fractional ablative lasers CO2 and Er:YAG, improved various characteristics of excessive scarring. An overview of preferred laser modality per scar characteristic is presented. Accounting for the methodological quality and the level of evidence of the data, future research in the form of randomized trials with comparable standardized scar scales is needed to confirm these results.

Is Social Support Associated With Upper Extremity Disability?

BACKGROUND: Pain intensity and disability correlate with psychosocial factors such as depression and pain interference (the degree to which pain interferes with activities of daily living) as much or more than pathophysiology in upper extremity illness. However, other factors like emotional support (perception of being cared for and valued as a person), instrumental support (perception of availability of tangible assistance when needed), positive psychosocial impact (perception and focus on the positive side of a difficult situation, sometimes characterized as posttraumatic growth, benefit-finding, or meaning making), also might be associated with disability in patients with upper extremity orthopaedic illness. This is the first published study, to our knowledge, addressing the potential association of emotional support, instrumental support, and positive psychosocial illness impact with disability in patients with upper extremity illness. QUESTIONS/PURPOSES: We asked: (1) Is there a correlation between the QuickDASH and the Patient-reported Outcomes Measurement Information System (PROMIS(®)) emotional support Computer Adaptive Testing (CAT)? (2) Is there a correlation between the QuickDASH and PROMIS(®) instrumental support CAT? (3) Is there a correlation between the QuickDASH and PROMIS(®) positive psychosocial illness impact CAT? (4) Among the PROMIS(®) measures of depression, emotional support, instrumental support, positive illness impact, and pain interference, which accounts for the most variance in QuickDASH scores? METHODS: One hundred ninety-three patients with upper extremity illness (55% women; average age, 51 ± 18 years) of 213 approached (91% recruitment rate) completed the QuickDASH, and five different PROMIS(®) CATs: pain interference (the degree to which pain interferes with accomplishing one's goals), depression, emotional support, psychosocial illness impact, and instrumental support. We recruited patients from the practice of three surgeons in hand service of the department of orthopaedic surgery at a major urban university hospital. RESULTS: Pearson Product Moment Correlations showed that emotional support (r = -0.18; p = 0.014) and instrumental support (r = -0.19; p = 0.008) were weakly and inversely associated with the QuickDASH), while positive psychosocial illness impact was moderately and inversely associated with the QuickDASH (r = -0.36; p < 0.001). In multivariable analyses, pain interference, but not the social support measures, was the only psychosocial factor associated with the QuickDASH and alone explained 66% of variance. CONCLUSIONS: Emotional support, instrumental support and positive psychosocial illness impact are all individually associated with disability to a small degree, but pain interference (the degree to which pain interferes with accomplishing one's goals) has the strongest influence on magnitude of disability. LEVEL OF EVIDENCE: Level 1, prognostic study.

Finger Stiffness.

Background Finger stiffness varies substantially in patients with hand and upper extremity illness and can be notably more than expected for a given pathophysiology. In prior studies, pain intensity and magnitude of disability consistently correlate with coping strategies such as catastrophic thinking and kinesiophobia, which can be characterized as overprotectiveness. In this retrospective study we address the primary research question whether patients with finger stiffness are more often overprotective when the primary pathology is outside the hand (e.g. distal radius fracture) than when it is located within the hand. Methods In an orthopaedic hand surgery department 160 patients diagnosed with more finger stiffness than expected for a given pathophysiology or time point of recovery between December 2006 and September 2012 were analyzed to compare the proportion of patients characterized as overprotective for differences by site of pathology: (1) inside the hand, (2) outside the hand, and (3) psychiatric etiology (e.g. clenched fist). Results Among 160 subjects with more finger stiffness than expected, 132 (82 %) were characterized as overprotective including 88 of 108 (81 %) with pathology in the hand, 39 of 44 (89 %) with pathology outside the hand, and 5 of 8 (63 %) with psychiatric etiology. These differences were not significant. Conclusions Overprotectiveness is common in patients with more finger stiffness than expected regardless the site and type of primary pathology. It seems worthwhile to recognize and treat maladaptive coping strategies early during recovery to limit impairment, symptoms, and disability.

The correlation of cognitive flexibility with pain intensity and magnitude of disability in upper extremity illness.

Cognitive flexibility - the ability to restructure one's knowledge, incorporate new facts, widen perspective, and adapt to the demands of new and unexpected conditions - can help one adapt to illness. The aim of this study was to assess the relationship between cognitive flexibility and hand and upper extremity specific disability in patients presenting to a hand surgeon. Secondarily, we determined predictors of cognitive flexibility and pain. Eighty-nine consecutive outpatients completed the Cognitive flexibility questionnaire (CFS), Short Health Anxiety Inventory-5 (SHAI-5), Pain Self-Efficacy Questionnaire (PSEQ), Disabilities of Arm, Shoulder and Hand, short form (QuickDASH), and Patient Health Questionnaire for Depression-2 (PHQ-2) in a cross-sectional study. CFS did not correlate with disability or pain intensity. Disability correlated with PSEQ (r = -0.66, p < 0.01), PHQ-2 (r = 0.38, p = <0.01), and SHAI-5 (r = 0.33, p < 0.01). Pain intensity correlated with PSEQ (r = -0.51 p < 0.01) and PHQ-2 (r = 0.41 p < 0.01). There was a small correlation between the CFS and PSEQ (r = 0.25, p = 0.02). The best multivariable models for QuickDASH and pain intensity included PSEQ and PHQ and explained 35 % and 28 % of the variability respectively. Upper extremity specific disability and pain intensity are limited more by self-efficacy than cognitive flexibility. Interventions to improve self-efficacy might help patients with upper extremity illness.