二氧化碳点阵激光联合康复措施治疗烧伤后增生性瘢痕的临床观察

Clinical observation of carbon dioxide fractional laser combined with rehabilitation measures in the treatemnt of hypertrophic scar after burn

目的探讨在常规康复措施的基础上配合二氧化碳点阵激光治疗烧伤后增生性瘢痕的临床疗效。方法将2018年1月至12月昆山市康复医院收治的59例烧伤后增生性瘢痕患者按随机数字表法分为康复组(n=30)和激光组(n=29)。康复组和激光组的瘢痕常规治疗包括外用硅酮制剂、压力治疗、瘢痕按摩治疗、超声波治疗等;康复组和激光组均进行烧伤后的康复治疗,主要包括运动治疗(关节活动度训练、关节松动治疗、肌力训练、有氧训练等)、作业治疗(日常生活自理能力训练、手功能训练、文娱活动等)、物理因子治疗(气压治疗、创面的红蓝光治疗等)、心理康复、矫形器治疗、水疗等。激光组患者在给予瘢痕常规治疗及烧伤后康复治疗的基础上联合应用二氧化碳点阵激光治疗,每2个月1次。2组患者均持续治疗12个月。治疗前、治疗后(入组后第12个月时)使用温哥华瘢痕量表(VSS)对2组患者瘢痕情况进行评估;治疗前、首次激光治疗后即刻、首次激光治疗后1 d、首次激光治疗后14 d、治疗后(入组后第12个月时)采用视觉模拟评分法(VAS)对2组患者瘢痕紧缩感程度进行评分;治疗后(入组后第12个月时)使用VAS评分评价患者对瘢痕疗效的满意度分级,并计算满意率;记录患者12个月内不良反应发生的情况。对数据行t检验、Mann-Whitney U检验、Wilcoxon检验和χ^(2)检验。结果(1)治疗前,2组患者VSS评分比较,差异无统计学意义(Z=-0.777,P>0.05);治疗后(入组后第12个月时),激光组、康复组患者VSS评分[10.00(9.00,10.00)、12.00(10.75,13.00)分]均较治疗前显著下降,差异均有统计学意义(Z=-4.795、-4.852,P值均小于0.05),且激光组患者VSS评分显著低于康复组,差异有统计学意义(Z=-4.514,P<0.05)。(2)治疗前,2组患者瘢痕紧缩感程度VAS评分比较,差异无统计学意义(Z=-1.420,P>0.05);在首次激光治疗后即刻、首次激光治疗后1 d、首次激光治疗后14 d、治疗后(入组后第12个月时),激光组患者瘢痕紧缩感程度VAS评分[2(1,3)、3(3,4)、6(6,7)、7(6,7)分]均较治疗前VAS评分[10(10,10)分]显著下降,差异均有统计学意义(Z=-4.736、-4.788、-4.760、-4.767,P值均小于0.05),康复组患者首次激光治疗后即刻、首次激光治疗后1 d、首次激光治疗后14 d、治疗后(入组后第12个月时)瘢痕紧缩感程度VAS评分[8(8,10)、9(9,10)、8(8,9)、8(8,9)分]均较治疗前VAS评分[10(9,10)分]显著下降,差异均有统计学意义(Z=-5.035、-2.828、-2.449、-5.002,P值均小于0.05);在首次激光治疗后即刻、首次激光治疗后1 d、首次激光治疗后14 d、治疗后(入组后第12个月时),激光组患者紧缩感程度VAS评分均低于康复组,差异均有统计学意义(Z=-6.651、-6.732、-4.953、-6.029,P值均小于0.05)。(3)治疗后(入组后第12个月时)激光组患者满意度分级频数分布与康复组比较,差异有统计学意义(Z=-2.214,P=0.027);激光组患者满意率(58.62%)高于对照组(36.67%),激光组患者较满意例数/非满意例数(17/12)与康复组(11/19)比较,差异有统计学意义(χ^(2)=9.696,P=0.002)。(4)激光组患者不良反应发生率为10.34%(3/29),康复组患者不良反应发生率为6.67%(2/30),2组不良反应发生率比较,差异无统计学意义(χ^(2)=0.579,P=0.447)。结论二氧化碳点阵激光联合康复措施治疗增生性瘢痕效果优于单纯采用康复措施进行治疗,且患者的瘢痕紧缩感改善更显著、疗效满意度更高。

Objective To explore the clinical effect of carbon dioxide fractional laser combined with conventional rehabilitation methods on hypertrophic scar after burned.Methods From January to December 2018,59 patients with hyperplastic scars after burns admitted to Kunshan Rehabilitation Hospital were divided into rehabilitation group(n=30)and laser group(n=29)by the random number table method.Conventional scar treatments in the rehabilitation group and laser group include:topical silicone preparations,pressure therapy,scar massage,ultrasound therapy,etc.;both the rehabilitation group and laser group were received burn rehabilitation treatment[exercise therapy(joint mobility training,joint loosening therapy,muscle strength training,aerobic training,etc.),occupational therapy(daily self-care ability training,hand function training,recreational activities,etc.),physical factor therapy(air pressure therapy,red and blue light therapy on wounds,etc.),psychological rehabilitation,orthopedic therapy,hydrotherapy,etc.].Patients in the laser group were treated with carbon dioxide fractional laser treatment on the basis of conventional scar treatment and burn rehabilitation treatment,once every 2 months.Both groups of patients were treated continuously for 12 months.Before and after treatment(at the 12th month after enrollment),the Vancouver scar scale(VSS)was used to assess the scar;before treatment,immediately after the first laser treatment,1 d after the first laser treatment,14 d after the first laser treatment,and after treatment(at the 12th month after enrollment),the degree of scar tightening of patients were scored by the visual analogue scale(VAS);after treatment(at the 12th month after enrollment),the VAS was used to evaluate the patient′s satisfaction with the scar curative effect and the satisfaction rate was calculated;the occurrence of adverse reactions in patients within 12 months were recorded.The data were analyzed by t test,Mann-Whitney U test,Wilcoxon test and chi-square test.Results(1)Before treatment,there was no significant difference in VSS score between the two groups(Z=-0.777,P>0.05);after treatment(at the 12th month after enrollment),the VSS scores of patients in the laser group and rehabilitation group were[10.00(9.00,10.00)points and 12.00(10.75,13.00)points],which were significantly lower than those before treatment,the differences were statistically significant(Z=-4.795,-4.852;with P values below 0.05),and the VSS score of the laser group was significantly lower than that of the rehabilitation group,the difference was no statistically significant(Z=-4.514,P<0.05).(2)Before treatment,there was no significant difference in the VAS score of the degree of scar tightening between the two groups(Z=-1.420,P>0.05);immediately after the first laser treatment,1 d after the first laser treatment,14 d after the first laser treatment,and after treatment(at the 12th month after enrollment),the VAS score of the degree of scar tightening in the laser group[2(1,3),3(3,4),6(6,7),7(6,7)points]were significantly lower than before treatment[10(10,10)points],and the differences were statistically significant(Z=-4.736,-4.788,-4.760,-4.767;with P values below 0.05);patients in the rehabilitation group immediately after the first laser treatment,1 d after the first laser treatment,14 d after the first laser treatment,and after treatment(at the 12th month after enrollment),the VAS score of the degree of scar tightness[8(8,10),9(9,10),8(8,9),8(8,9)points]were significantly lower than the before treatment[10(9,10)points],the differences were statistically significant(Z=-5.035,-2.828,-2.449,-5.002;with P values below 0.05);and immediately after the first laser treatment,1 d after the first laser treatment,14 d after the first laser treatment,and after treatment(at the 12th month after enrollment),the VAS scores of the patients in the laser group were significantly lower than those in the rehabilitation group,the differences were statisctically significant(Z=-6.651,-6.732,-4.953,-6.029,with P values below 0.05).(3)After treatment(at the 12th month after enrollment),the frequency distribution of satisfaction grading in the laser group was statistically different than that in the rehabilitation group(Z=-2.214,P=0.027);the satisfaction rate of patients in the laser group(58.62%)was high than that in the control group(36.67%);the difference in the number of satisfied cases/dissatisfied cases in the laser group(17/12)and the rehabilitation group(11/19)was statistically significant(χ^(2)=9.696,P=0.002).(4)The incidence of adverse reactions in the laser group was 10.34%(3/29),and the incidence of adverse reactions in the rehabilitation group was 6.67%(2/30),there was no statistically significant difference in the incidence of adverse reactions between the two groups(χ^(2)=0.579,P=0.447).Conclusion Carbon dioxide fractional laser combined with rehabilitation measures are more effective in treating hypertrophic scar than using rehabilitation measures alone,and the patient′s scar tightening feeling is improved more significantly,and the curative effect satisfaction is higher.