Background: Patient-reported outcome measures (PROMs) are important in clinical practice and research. The growth of electronic health technologies provides unprecedented opportunities to systematically collect information via PROMs. Objective: The aim of this study was to provide an objective and comprehensive overview of the benefits, barriers, and disadvantages of the digital collection of qualitative electronic patient-reported outcome measures (ePROMs). Methods: We performed a systematic review of articles retrieved from PubMED and Web of Science. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed during all stages. The search strategy yielded a total of 2333 records, from which 32 met the predefined inclusion and exclusion criteria. The relevant ePROM-related information was extracted from each study. Results: Results were clustered as benefits and disadvantages. Reported benefits of ePROMs were greater patient preference and acceptability, lower costs, similar or faster completion time, higher data quality and response rates, and facilitated symptom management and patient-clinician communication. Tablets were the most used ePROM modality (14/32, 44%), and, as a platform, Web-based systems were used the most (26/32, 81%). Potential disadvantages of ePROMs include privacy protection, a possible large initial financial investment, and exclusion of certain populations or the “digital divide.” Conclusions: In conclusion, ePROMs offer many advantages over paper-based collection of patient-reported outcomes. Overall, ePROMs are preferred over paper-based methods, improve data quality, result in similar or faster completion time, decrease costs, and facilitate clinical decision making and symptom management. Disadvantages regarding ePROMs have been outlined, and suggestions are provided to overcome the barriers. We provide a path forward for researchers and clinicians interested in implementing ePROMs. Trial Registration: PROSPERO CRD42018094795; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=94795

Vacuum massage is a non-invasive mechanical massage technique performed with a mechanical device that lifts the skin by means of suction, creates a skin fold and mobilises that skin fold. In the late 1970s, this therapy was introduced to treat traumatic or burn scars.Although vacuum massage was invented to treat burns and scars, one can find very little literature on the effects of this intervention. Therefore, the aim of this review is to present an overview of the available literature on the physical and physiological effects of vacuum massage on epidermal and dermal skin structures in order to find the underlying working mechanisms that could benefit the healing of burns and scars. The discussion contains translational analysis of the results and provides recommendations for future research on the topic.An extended search for publications was performed using PubMed, Web of Science and Google Scholar. Two authors independently identified and checked each study against the inclusion criteria.Nineteen articles were included in the qualitative synthesis. The two most reported physical effects of vacuum massage were improvement of the tissue hardness and the elasticity of the skin. Besides physical effects, a variety of physiological effects are reported in literature, for example, an increased number of fibroblasts and collagen fibres accompanied by an alteration of fibroblast phenotype and collagen orientation. Little information was found on the decrease of pain and itch due to vacuum massage.Although vacuum massage initially had been developed for the treatment of burn scars, this literature review found little evidence for the efficacy of this treatment. Variations in duration, amplitude or frequency of the treatment have a substantial influence on collagen restructuring and reorientation, thus implying possible beneficial influences on the healing potential by mechanotransduction pathways. Vacuum massage may release the mechanical tension associated with scar retraction and thus induce apoptosis of myofibroblasts. Suggestions for future research include upscaling the study design, investigating the molecular pathways and dose dependency, comparing effects in different stages of repair, including evolutive parameters and the use of more objective assessment tools.

A wide variety of non-invasive treatments has been proposed for the management of hypertrophic burn scars. Unfortunately, the reported efficacy has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a new non-invasive type of mechanotherapy to treat wounds and scars. The aim of the present study was to examine the objective and subjective scar-related effects of ESWT on burn scars in the early remodelling phase. Evaluations included the Patient and Observer Scar Assessment Scale (POSAS) for scar quality, tri-stimulus colorimetry for redness, tewametry for trans-epidermal water loss (TEWL) and cutometry for elasticity. Patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group, and were tested at baseline, after one, three and six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks. Results for 20 patients in each group after six months are presented. The objective assessments showed a statistically significant effect of ESWT compared with placebo on elasticity (P = 0.011, η2P=0.107) but revealed no significant effects on redness and TEWL. Results of the clinical assessments showed no significant interactions between intervention and time for the POSAS Patient and Observer scores. ESWT can give added value to the non-invasive treatment of hypertrophic scars, more specifically to improve elasticity when the treatment was already started in the first three months after wound closure. Pathological scarring is a common problem after a burn injury. A wide variety of non-invasive treatments has been proposed for the management of these scars. Unfortunately, the reported efficacy of these interventions has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a relatively new non-invasive therapy to treat both wounds and scars. The aim of the present study was to examine the scar-related effects of ESWT on burn scars in the early phase of healing. The scars were subjectively assessed for scar quality by the patient and an observer using the Patient and Observer Scar Assessment Scale (POSAS). Objective assessments included measurements to assess redness, water loss and elasticity. Forty patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group (the device simulated the sound of an ESWT treatment but no real shocks were applied), and were tested at four timepoints up to six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks. The objective assessments showed a significant improvement of elasticity in the intervention group when compared with placebo but revealed no significant effects on redness and water loss. Results of the clinical assessments showed no differences between the groups for the POSAS Patient and Observer scores. ESWT can give added value to the non-invasive treatment of pathological scars more specifically to improve elasticity in the early phase of healing.

Background: Vacuum massage is a non-invasive mechanical massage technique invented to treat burns and scars. To date, no effects of vacuum massage on thickness and density of human scar tissue have been reported. The process in which external stimuli are converted into biochemical responses in the cell is known as mechanotransduction. In the skin endothelial cells, fibroblasts and myofibroblasts embedded in the extracellular matrix (ECM) sense mechanical stimuli (created by vacuum massage) and may promote intracellular processes leading to matrix remodelling. Since mechanotransduction could be a plausible working mechanism for vacuum massage as an anti-scarring therapy, this study aims to investigate the short-term effects of vacuum massage on thickness and density of epidermis and dermis in burn scars in order to find proof of ECM remodelling. Methods: A one group experimental study was performed. Patients with burn scars on upper extremities, lower extremities, and trunk were recruited for participation in this study. The DUB®cutis 22 MHz ultrasound scanner was used to assess thickness and density of the epidermal and dermal skin layers. After baseline measurements, vacuum massage was performed according to a pre-defined protocol. Measurements were carried out at 5 min, 30 min, 1 h, and 2 h post-intervention. Results: Thirteen scar sites from 9 different patients were investigated. In 8 out of the 13 scar sites, a disruption of the epidermis was noticed after the vacuum massage. Five minutes after the intervention, epidermal density decreased statistically significantly (p = .022) and dermal thickness increased (p = .018). Both changes lasted for more than 1 h, but after 2 h, the changes were no longer statistically significant. Dermal density decreased significantly (p = .048) immediately after the intervention, and this decrease was still present after 2 h (p = .011). Conclusions: Preliminary results show that the disruption of the epidermis may indicate that vacuum massage could be able to actually breach the skin barrier. The statistically significant changes in the dermal layers could suggest an increased ECM production after vacuum massage.

Fibrosis is characterized by scarring and hardening of tissues and organs. It can affect every organ system, and so could result in organ failure due to the accumulation of extracellular matrix proteins. Previous studies suggest that mechanical forces (such as shockwave therapy, SWT) initiate a process of mechanotransduction and thus could regulate fibrosis. Nevertheless, it is largely unexamined which pathways are exactly involved in the application of SWT and can regulate fibrosis. The present article seeks to elucidate the underlying effect of SWT on fibrosis. Evidence shows that SWT activates macrophage activity, fibroblast activity, collagen amount and orientation and apoptosis, which ultimately lead to an adaptation of inflammation, proliferation, angiogenesis and apoptosis. The included articles reveal that other proteins and pathways can be activated depending on the energy levels and frequency of SWT. These findings demonstrate that SWT has beneficial effects on fibrosis by influencing the proteins and pathways. Based on these data, which highlights the underlying mechanisms, we can make preliminary conclusions about the treatment modalities of SWT in scar formation, such as the energy levels and frequencies that are necessary to prevent or treat fibrotic tissue.