Osteoarthritis is the most common type of joint disease among elderly patients around the world. In response to the need for patient-centered care, patients’ and physicians’ preferences for knee osteoarthritis treatments have been studied in multiple countries, but not in Thailand. The objective of this study was to investigate Thai patients’ preferences and their willingness to pay (WTP) for knee osteoarthritis treatments by using a discrete choice experiment (DCE). Six knee osteoarthritis treatment attributes, including pain relief, delayed disease progression, gastrointestinal side effects, kidney side effects, cardiovascular side effects, and cost, were used to develop a paper-based, DCE questionnaire survey. Patients with knee osteoarthritis, who were at least 18 years old and who provided written informed consent, were recruited from the orthopedic department in a tertiary care hospital in Thailand via convenience sampling. The conditional logit model was used to determine patients’ preferences and WTP. The Institutional Review Board at Chulalongkorn University approved this study before it started. A total of 232 patients were collected and analyzed in this study. Patients preferred treatments with a higher efficacy (pain relief and delayed disease progression), a lower probability of side effects , and a lower cost. Regarding efficacy and side effects, the patients weighted the importance of a 1% change in cardiovascular side effects (− 0.08) more heavily than 1% changes in kidney (− 0.07) and gastrointestinal (− 0.02) side effects, delayed disease progression (0.02), and pain relief (0.01). Patients were willing to pay 29.56 Thai Baht (THB) and 41.84 THB per month for every 1% increase in pain relief and delayed disease progression, respectively. Conversely, patients were willing to pay 52.04 THB, 145.18 THB and 164.23 THB per month for every 1% decrease in gastrointestinal, kidney, and cardiovascular side effects, respectively. In conclusion, pain relief, delayed disease progression, gastrointestinal side effects, kidney side effects, cardiovascular side effects, and the cost of treatment were significant factors among patients undergoing knee osteoarthritis treatment. Additionally, patients had a higher WTP for delayed disease progression than pain relief and a higher WTP for a reduced probability of cardiovascular side effects than gastrointestinal and kidney side effects. These findings could be used to support treatment decisions for knee osteoarthritis patients in Thailand. Chronic Diseases and Health Promotion; it was found that 9.6% of men and 18.0% of women over 60 years old have asymptomatic OA1. The International League of Associations for Rheumatology (ILAR) and the Community Oriented Program for the Control of Rheumatic Diseases (COPCORD), which has studied the prevalence of various rheumatic diseases in Thailand and Asian countries, found that 3.7–39.2% of people in those countries had knee OA or chronic knee pain3. Another epidemiological study showed that the prevalence of knee OA in elderly Thai patients ranged from 34.5 to 45.6%, with more than half of these patients having pain in both knees4. Osteoarthritis (OA) is the most common type of joint disease in elderly individuals. Signs and symptoms of this disease include pain, stiffness, tenderness and swelling of the hand, wrist, or knee joint areas. The World Health Organization (WHO) reported the global prevalence of OA in the 5. NSAIDs, including diclofenac and etoricoxib, are the most commonly used treatments for knee OA because of their good efficacy. However, some side effects are frequently found, including gastrointestinal (GI), cardiovascular (CV) and renovascular systems6. Glucosamine sulfate is one of the treatment choices for mild to moderate knee OA with a good safety profile. For efficacy, glucosamine had been unclear in the past due to the mixed results from the various formulations and its impact on clinical outcomes7. In 2005, a Cochrane systematic review of 25 randomized controlled trials yielded inconclusive results regarding the benefits of glucosamine for pain relief8. Remarkably, subgroup analyses showed that only crystalline glucosamine sulfate was significantly more beneficial than placebo in terms of pain relief and functional improvement. Subsequent studies focused on the results from the different formulations of glucosamine. Recently, many studies have consistently demonstrated that crystalline glucosamine sulfate showed superior benefits over other formulations in terms of pain and functional improvement, delayed disease progression and reduced use of long-term NSAIDs14. With the results of cost-effectiveness, one study compared glucosamine to paracetamol and found that glucosamine was cost-effective and dominant compared with paracetamol and placebo15. Another study found that glucosamine presented a higher level of clinical effectiveness than current care for the treatment of knee OA but did not clearly demonstrate cost-effectiveness, which was related to the magnitude and duration of quality of life gain16.Currently, several treatments are available for knee OA disease, including weight reduction, exercise, acupuncture, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), symptomatic slow-acting drugs for osteoarthritis (SYSADOA), intra-articular corticosteroid and surgery18. Two studies conducted an economic evaluation of glucosamine in Thailand. One study reported that glucosamine was not cost-effective for OA treatment at Thailand’s willingness to pay (WTP) threshold19. However, this study was performed under the Thai Ministry of Public Health perspective, which left outpatient as well as societal perspectives. Inconsistency results in another study, under a societal perspective, showed that the addition of crystalline glucosamine sulfate into standard treatment was cost-effective at the WTP threshold in Thailand20. Additionally, early adoption of crystalline glucosamine sulfate would be less costly and more effective than delayed treatment or the use of standard treatment alone.In Thailand, some knee OA treatments, including diclofenac, are listed in the National List of Essential Medicines (NLEM), which is used as a reimbursement list for all three major health insurance schemes, including the Civil Servant Medical Benefit Scheme (CSMBS), Universal Coverage Scheme (UCS), and Social Security Scheme (SSS). However, some treatments, including glucosamine sulfate, were restricted for reimbursement in the USS, SSS and CSMBS. The key reimbursement considerations for listing drugs on NLEM consist of safety and efficacy, the cost index, the cost-effectiveness analysis, and budget impact analysis results21. However, studies that rigorously examined patients’ preferences for knee OA treatments are available only in the United States, Australia and France. One study compared preferences for NSAIDs, opioids, glucosamine/chondroitin and capsaicin, considering only the risk of GI ulcers22. The results showed that patients were willing to receive the treatment with a lower risk of adverse effects. The second study compared preferences for oral prescription medication, steroid injection and viscosupplementation23. They concluded that patients preferred a longer-lasting pain relief treatment. However, neither study included CV and kidney side effects, even though these side effects are among the frequently found side effects of NSAIDs. Another study compared preferences for NSAIDs, glucosamine and acetaminophen which were roughly divided risk into three levels24. Both cardiovascular and kidney side effects were included in the analysis but combined into one attribute, resulting in separating out the impact of each side effect on patient preference. Additionally, little is known about the preference of knee OA patients in the Thai population.While the NLEM has a major impact on patient access to knee OA treatments, patients’ preferences for these treatments have not been included in these considerations. Without clinicians’ and policy-makers’ understanding of the patient’s perspectives on the treatments, patients may not adhere to the treatments and eventually experience poor health outcomes25. A DCE involves the generation of hypothetical choice sets incorporating multiple characteristics. Respondents are asked to choose among different choice sets. Currently, several published studies have used DCE as a tool to investigate patients’ preferences for OA treatment among other CA techniques since it could identify attributes significantly influencing preferences25. In addition to low cognitive complexity, it is easy to answer and use a small sample size to estimate WTP. With these benefits, the DCE method was the most appropriate tool to elicit the preferences of elderly patients in one tertiary care hospital included in the study. The objective of this study is therefore to investigate patients’ preferences and their WTP for knee OA treatments in Thailand by using DCE.The use of stated preference techniques in the form of conjoint analysis (CA) has grown for eliciting preferences. One of the commonly used CAs is the discrete choice experiment (DCE), which has increasingly been applied in the health care sector to measure preferences and quantify the relative importance of the benefits and risks of different health care products and programsThis study used a cross-sectional, DCE questionnaire survey design to determine patients’ preferences for knee OA treatments. A DCE has been used to examine stated preference by asking patients to consider various choice sets that include multiple alternatives described by study attributes and their alternatives. Based on random utility theory (RUT), a utility model is then developed to determine the relative importance of treatment attributes.26. From the literature, there were 35 attributes divided into three main groups of knee OA treatments including efficacy , side effects  and costs32. These attributes were then used as a guide for focus group discussion to elicit the important treatment attributes. A total of seven knee OA patients participated in the focus group through consultation with the orthopedist. The focus group members consisted of six females and one male. Of these patients, the average age was 66 years and the average number of years after OA diagnosis was 5.71 years. The average pain rating score for their knee pain was 4 points out of 10. All of them previously used glucosamine sulfate and NSAIDs as knee OA medications. We initiated the focus group discussion with an overview of the topic, the objective of the study, the ground rules, and the duration of the discussion. A total of 35 attributes from the literature reviews were then introduced to the members for their opinions on the significance and relevance regarding the OA medication and the new attributes were also allowed for discussion to add to the list (if any). The group members were encouraged to communicate and exchange ideas on each other’s experiences. At the end of the discussion, the six most important attributes were summarized to ensure correct interpretation and allow the group members to elaborate their points further.To identify the key attributes of knee OA treatments, literature reviews were conducted to derive an initial list of attributes and the focus group was performed to prioritize and determine the key attributes as recommended by Helter and Boehler36. Glucosamine sulfate was used as the treatment that could reduce the risk of disease progression by 50% while other treatments were not reported37. The maximum level of probability of GI, kidney, and CV side effect attributes was derived from the side effects of NSAIDs41. The levels of the cost attribute were obtained from the Drug and Medical Supply Information Center (DMSIC), Ministry of Public Health42. This study assumed that patients received treatments with the maximum doses allowed for knee OA—acetaminophen (3000 mg/day), diclofenac (150 mg/day), etoricoxib (60 mg/day), glucosamine (1500 mg/day), and a triamcinolone acetonide injection (40 mg/every 3 months)44. The average price of all generic names of each treatment was used to calculate the cost per month. The attributes and their levels are shown in Table Based on the group consensus, the following six attributes were examined: pain relief, delayed disease progression, GI side effects, kidney side effects, CV side effects, and the cost of treatment per month. These attributes were varied across three plausible levels derived from the clinical literature. The range of levels for each attribute was designed to present the efficacy outcomes and side effects of knee OA treatments that could be seen in clinical trials or clinical practice. The highest and lowest levels of pain relief were extracted from the efficacy of steroid injection and acetaminophen respectivelyA paper-based, self-administered questionnaire survey was developed. The total number of possible combinations of the attributes and levels in this study was 729 (3 × 3 × 3 × 3 × 3 × 3 × 3). Since it was not possible to include all combinations in a questionnaire survey, an orthogonal design  was used to randomly draw a subset of all combinations by using Ngene software V.1.2.1). A total of 36 choice sets were generated and then divided into six blocks. Each questionnaire consisted of six choice sets from each block. Therefore, there were six questionnaire versions in this study. Each choice set contained two unlabeled, hypothetical OA treatment alternatives and one opt-out alternative, as illustrated in Fig. .2.1. A tPatients with knee OA who were 18 years old or above, treated and presented in the orthopedic department of a tertiary care hospital , were conveniently sampled by the researcher. Patients with mental disorders or a knee replacement planned within three months were excluded. The recruitment questions asked patients (i) had they been diagnosed with OA, (ii) what was the location of arthritis, (iii) did they plan knee replacement within three months, and (iv) were they willing to participate in the study. All patients who passed the recruitment questions and agreed to provide written informed consent were included in the study. Patients who participated in the focus group were excluded from participating in this main study.45. However, one of the following rules of thumb proposed by Johnson and Orme45 was increasingly used to estimate the minimum sample size requirement. The sample size was calculated from the Formula N > 500c/(t × a), where t is the number of choice tasks, a is the number of alternatives, and c is the number of analysis cells which was equal to the largest number of levels for any of the attributes. At least 125 patients were needed in the study.The sample size calculation differed substantially among the DCE studies with a range of smaller than 100 to larger than 1000 patientsEach patient who passed the recruitment questions was invited to respond to one random version of the paper-based questionnaire survey and received a brief description of the study objective and an explanation of the attributes and levels. The questionnaire comprised three sections and was self-reported. Patient characteristics, including age, gender, weight, height, marital status, education level, health insurance, total monthly personal income, total monthly household income for all family members, and disease history, were requested to be answered in the first section of the questionnaire. In the second section, patients were asked to indicate knee OA-related experiences, including the number of years of OA experience, the severity of OA symptoms, and medication history. In this section, a visual analog scale was designed to document the disease-related symptom severity in OA patients. For the final section, six choice sets were presented to evaluate knee OA treatment preferences. For each choice set, patients were assessed using the following question: “What medicine option do you prefer when receiving treatment for their OA?” Patients could choose among three alternatives: two medications with different efficacy, side-effect and cost profiles, or opt-out alternative. To check and determine the understanding, one choice set, which contained the superiority on all attribute levels to the comparator scenario, was added to every version of the questionnaires. This dominant scenario should rationally be the chosen option. If they did not answer the dominant scenario in this validity check, their data were removed from the analysis. A token of appreciation was given to the patients after they finished.We assessed patient preference based on the utilities extracted from the DCE questionnaire using the conditional logit model. The patient values were evaluated from the following treatment characteristics: pain relief, delayed disease progression, GI side effects, kidney side effects, CV side effects, and the cost of treatment per month.46:0 is a constant, β1 to β6 are the coefficients of pain relief, delayed disease progression, GI side effects, kidney side effects, CV side effects, and cost, respectively, and ℇ is the error term. The statistical significance level was set at 0.05. The conditional logit model was developed to estimate the utility model. The value of each coefficient reflected the relative importance of each attribute. The sign represents whether the attribute had a positive effect or a negative effect on utility, as compared with the base level.Only responses from the patients who answered all questions completely were included in the data analyses. All data analyses were conducted by using StataIC 16. The patient characteristics and OA-related experiences were descriptively analyzed. Based on the RUT, the utility (U) for each patient (i) selecting an alternative (j) was developed47. This parameter indicated how much patients were willing to pay for a one-unit change in each attribute. The Delta method was used to determine 95% confidence intervals of WTPs48.WTPs for each attribute was calculated as the ratio between the coefficient of each attribute and the coefficient of the cost attributeThe Institutional Review Board at Chulalongkorn University approved this study before it started (IRB No. 468/62). This study was conducted in accordance with the Declaration of Helsinki and the Principles in the Belmont Report. Informed consent was obtained from all patients.2. The majority of the patients were females (85.78%), married (62.07%), and unemployed (80.17%). Most of them reported that they had a bachelor’s degree or higher (63.36%). Approximately 58% of them used the CSMBS as their health insurance. The average individual monthly income was 28,631.25 Thai Baht (THB), and the average household monthly income was 72,732.11 THB. For the clinical characteristics of OA, the average number of years after OA diagnosis was 6.32 years. The average pain rating score for their knee pain was 4.30 points out of 10. The majority of them previously used glucosamine (86.64%) and NSAIDS (73.28%) as OA medications.A total of 237 patients with knee OA provided complete responses to the entire questionnaire. However, five of them (2.11%) were removed because they did not choose a dominant scenario in the validity choice set. The remaining 232 (97.89%) were included in the analyses. Table p < 0.001). The positive signs of pain relief and delayed disease progression indicated that the patients in this study preferred knee OA treatments with higher efficacy for pain reduction and a delayed rate of joint degeneration. The negative signs of GI side effects, kidney side effects, CV side effects, and cost attributes indicated that the patients preferred a lower chance of having side effects from the treatments and lower treatment costs. Among the efficacy and side effect attributes of the OA treatments, the patients gave a higher weight to the importance of a 1% change in CV side effects (− 0.08) than a 1% change in kidney (− 0.07) and GI (− 0.02) side effects, delayed disease progression (0.02), and pain relief (0.01). In summary, these results showed that the patients preferred treatments with higher efficacy, fewer side effects, and lower cost. In addition, the patients were more concerned about the risks of having side effects than the efficacy of the medicine, as indicated by the relative size of the coefficient attached to this attribute.Table Table Our results showed that pain relief, delayed disease progression, GI side effects, kidney side effects, CV side effects, and cost were significantly important attributes when the patients chose knee OA treatments. Intuitively, the patients preferred treatments with higher efficacy, fewer side effects, and lower cost. While the patients focused on the pain relief and delayed disease progression efficacies of the OA treatments, they had concerns about the GI, kidney, and CV side effects of the treatments. In other words, they traded off between the benefits and risks when they chose the treatments. In addition, they also considered the amount of money that they needed to pay per month for knee OA treatments.49, which concluded that patients with knee OA placed more importance on the lower risk of adverse effects than on the efficacy, such as reduced pain. Hauber et al.49 found that patients attached greater importance to eliminating the risks of adverse events than to reducing pain. Fraenkel et al.22 concluded that the risk of common adverse effects, e.g., GI ulcers, had the largest impact on patients’ preferences for knee OA treatments. It is noteworthy that CV side effects were not included in this study. Laba et al.24 found that delayed disease progression, side effects, out-of-pocket costs, and the schedule of treatment had impacts on the patient’s continuation of OA treatments. These side effects included high blood pressure and heart, kidney, and/or liver problems. In contrast, the other two studies’ findings were different50. Postnett et al.23 concluded that the amount of copayment and the duration of pain relief had the largest impacts on patients’ preferences for knee OA treatments, while Ratcliffe et al. found that the level of joint aches, the level of physical mobility, and the risk of serious side effects were significant attributes for OA patients50. One of the reasons was that these studies included different treatment attributes. Another reason would be that the patients in these studies were different in terms of demographic characteristics and preferences. For instance, our study tended to include older patients with knee OA. Therefore, their concerns about the side effects of OA treatments might be different.However, the importance of pain relief, delayed disease progression, GI side effects, kidney side effects, CV side effects, and cost for the patients varied. Our findings were consistent with three previous studiesThe findings showed that the delay in disease progression was more important to the patients than the pain relief. The reason might be that the patients would like to delay the time when they needed knee surgery which could incur higher costs and risks. Among the side effects, it was intuitive that the patients weighed the CV and kidney side effects higher than the GI side effect since the GI side effects tended to be milder and easily managed.53 to calculate the WTP. We found that patients were willing to pay for glucosamine sulfate 2226 THB per month, while both diclofenac and etoricoxib were less preferred than the baseline. Interestingly, the WTP for glucosamine sulfate from this study was seven times higher than its generic current price (approximately 320 THB for one month) and one times higher than its original current price (approximately 1100 THB for one month) in Thailand. Conversely, diclofenac and etoricoxib were extremely low compared to their current price . These costs were obtained from the Drug and Medical Supply Information Center, Ministry of Public Health. The interpretation was that patients perceived the benefits of glucosamine sulfate more than its cost, while they perceived the benefits of diclofenac and etoricoxib less than their cost. The reason should be that glucosamine sulfate retarded the progression of the disease and had a good safety profile. Diclofenac and etoricoxib, NSAIDs, had good efficacy for the relief of pain, but they might have a problem with gastrointestinal, cardiovascular and renovascular systems. Although patients preferred the benefit of glucosamine sulfate, they were still restricted from accessing it because they had to meet all reimbursement criteria before starting treatment. The results of this study could emphasize the inclusion of the patient perspective in the development of reimbursement criteria.We obtained the attribute levels of knee OA treatments including diclofenac, etoricoxib and glucosamine sulfate from published literatureOur study had some limitations. First, the study did not have a sufficient sample size to examine preference heterogeneity. It is possible that patients with different characteristics and OA-related experiences might prefer different knee OA treatments. However, the study findings would guide or encourage discussion among patients with knee OA treatments, their health care providers, and policy-makers when they make treatment decisions. Subsequently, the treatment decisions would be tailored for each individual patient. Second, this study collected data from only one tertiary care hospital. The majority of patients were well educated and had middle to high incomes. Therefore, the findings might not be generalized to other patient populations. Last, the limited number of attributes in this study might not completely explain patients’ preferences for knee OA treatments. It is possible that other treatment attributes might be significantly important to the patients. They should be examined further. Nevertheless, this study conducted a literature review and confirmed with patients and clinical experts to carefully select the attributes. They should include the majority of the important attributes.In conclusion, this study found that Thai patients focused on pain relief, delayed disease progression, GI side effects, kidney side effects, CV side effects, and cost when they chose knee OA treatments. For efficacy, the patients’ preferences weighed delayed disease progression higher than pain relief. Among all study side effects, CV side effects affected most of their preferences. Additionally, they valued net benefits for glucosamine sulfate but not for diclofenac and etoricoxib. The findings suggest that they are willing to pay more for glucosamine sulfate than diclofenac and etoricoxib. Our observations are intended to provide empirical evidence for physicians and regulators during the assessment of medication prescriptions, the development of practical guidelines, and the consideration of OA treatment selection into the National List of Essential Medicines.Supplementary Information.


The objective of the study was to evaluate the effectiveness of interferential current treatment on a range of motion of joint and shoulder pain, functional status, and quality of life in patients with subacromial impingement syndrome and to compare interferential current with transcutaneous electrical nerve stimulation and sham interferential current.Patients complaining of shoulder discomfort participated in the present study. Diagnosis of subacromial impingement syndrome is based on anamnesis, clinical examinations, and shoulder magnetic resonance imaging. A total of 52 patients divided into 3 groups: Group 1  received interferential current, group 2  received transcutaneous electrical nerve stimulation, and group 3  received sham interferential current. Hot pack and exercise treatments were added to all groups. All groups were treated for 3 weeks, 5 times a week, for 15 sessions and 20 minutes for each session. Evaluations were made before treatment (T0), in the middle of treatment , and at the end of treatment  using active range of motion and visual analog scale for pain, the Arm, Shoulder, and Hand Problems Questionnaire for functional status, and Short Form-36 for quality of life.P < .05). However, there was no statistically significant difference at T2 between the groups (P > .05).There were significant improvement effects on all of the range of motion, visual analog scale, and the Arm, Shoulder, and Hand Problems Questionnaire scores at T2 and on the scores in some subparameters of Short Form-36 in all groups ( Interferential current and transcutaneous electrical nerve stimulation exhibited equivalent results regarding range of motion, pain, function, and quality of life of patients with subacromial impingement syndrome, with no significant difference between interferential current and transcutaneous electrical nerve stimulation. Adding interferential current or transcutaneous electrical nerve stimulation treatments to hot pack +exercise therapy did not result in any extra benefits to the patients. Only 1 study investigated the therapeutic efficacy of IFA treatment on subacromial impingement syndrome (SIS).IFA, transcutaneous electrical nerve stimulation, and S-İFA treatment protocols were effective in patients with SIS. However, we found no superiority of 1 protocol compared to other(s).Only hot pack and exercise therapy would be sufficient.2 To stop the inflammatory process, alleviate pain, preserve joint mobility, and prevent progressive pathological changes, SIS uses a variety of physical therapy applications, including prevention, rest, medical treatment, exercises, and electrotherapy modalities.2The term “subacromial impingement syndrome” (SIS) refers to a collection of shoulder symptoms and physical and radiographic results that may be attributed to the compression of tissues surrounding the glenohumeral joint. This might be done by raising the afflicted shoulder. This disorder, which includes subacromial space pathologies such as rotator cuff partial tears, rotator cuff tendinitis, calcific tendinitis, and subacromial bursitis, is the most prevalent cause of shoulder discomfort and dysfunction in everyday and occupational life.3 Transcutaneous electrical nerve stimulation is classified as an electro-analgesic resource and is based on the application of alternating medium-frequency current (4000 Hz) with amplitude modulation at low frequency (0-250 Hz) (0-250 Hz).4 Interferential current (IFC) therapy provides more effective analgesia for the patient in the targeted tissue by penetrating more effectively and more deeply in the targeted treatment area due to its ability to reduce skin impedance.5 In addition, another advantage over TENS is its ability to provide lower neural adaptation. For these reasons, it is used in the treatment of SIS and other MSS pathologies.4Electrotherapy methods are essential in treating shoulder pain pathologies due to their analgesic, anti-inflammatory, and local vasodilator effects. Transcutaneous electrical nerve stimulation (TENS), a low-frequency electrical current, is widely used in SIS and other musculoskeletal system (MSS) pathologies due to its ease of use and portability.7 A few studies have compared the effectiveness of IFC and TENS treatments. Ucurum et al3 evaluated IFC and TENS with no sham-treated control group and found no statistically significant difference in the 2 therapies’ effectiveness.A limited number of studies evaluated the effectiveness of IFC treatment in patients with SIS and compared it with other physical therapy treatment methods.We aimed to evaluate the effectiveness of IFC treatment on a range of motion (ROM) of joint and shoulder pain, functional status, and quality of life in patients with SIS and to compare IFC with TENS and sham IFC (S-IFC).This prospective, randomized, controlled clinical study was conducted between July 2020 and July 202 in the AtatürkUniversity, Faculty of Medicine, Department of Physical Medicine and Rehabilitation.Patients who participated in the study were informed of its objective, duration, method of administration, adverse effects, and potential complications. In addition, all patients signed a document requesting their informed consent. This research was approved by the Ethics Committee of Atatürk University, Faculty of Medicine . The study was conducted in conformity with the Helsinki Declaration’s standards.Patients who applied to the Department’s polyclinic with the complaint of shoulder discomfort were considered for participation in the study. After examination by anamnesis, clinical examination, and shoulder magnetic resonance imaging, the patients have been diagnosed with SIS (MRI). The participation of 52 patients in the trial was entirely voluntary.Neer, Hawkins, painful arc, drop arm, Yergason, supraspinatus, and active ROM tests were performed for clinical diagnosis. Patients were enrolled in the study if they met the following criteria: (1) they were diagnosed with subacute or chronic SIS clinically and radiologically (diagnosed by a radiologist on MRI); (2) they were aged between 18 and 65 years; and (3) they had tendinitis or a partial rupture in the supraspinatus.Patients who had adhesive capsulitis or bicipital tendinitis, total rupture of the rotator cuff or supraspinatus muscle, undergone shoulder joint operation, inflammatory disease in the shoulder region, cervical radiculopathy, metabolic bone diseases, and diabetes mellitus were excluded from the study. In addition, patients who had received conservative physical therapy to the shoulder within the past 6 months and a local steroid injection treatment within the past 3 months were also excluded.Patients eligible for the study were given a number corresponding to the sequence in which they were admitted. Then the patients were randomly assigned to 1 of 3 groups using an online randomization program (randomizer.org). Hot pack + transcutaneous electrical nerve stimulation was administered to the first group, HP + IFC to the second group, and HP + S-IFC to the third group . Throughout the therapy period, therapeutic shoulder exercises were administered to all groups. Before the treatment , in the middle of the treatment , and after the treatment were utilized to collect data for the assessment of the patients .Evaluations were made before the treatment , in the middle of the treatment , and at the end of the treatment  using active ROM and visual analog scale (VAS) for pain, the Arm, Shoulder, and Hand Problems Questionnaire (DASH) for functional status, and Short Form-36 (SF-36) for quality of life.8 Therefore, we examined ROM values during the active flexion, abduction, and internal rotation.Using a conventional goniometer, the active shoulder ROM was measured. Active shoulder ROM measures are restricted in SIS patients, particularly during abduction and internal rotation. Since shoulder motions exacerbate compression and discomfort, patients avoid arm movement in these directions.9The scale is called VAS, and it has a 10 cm character. Patients were asked to identify the average level of pain they had experienced during the previous week, with “0” indicating no pain, “5” denoting mild discomfort, and “10” denoting the most severe pain. The VAS values for rest (VAS-R), activity (VAS-A), and night were determined (VAS-N).10The DASH questionnaire has been approved for use in certain arm disorders. The patients responded to all inquiries using the proper 5-point Likert scale . Scores range from 0 to 100 .11The SF-36 is a short-form, multipurpose health questionnaire with just 36 items. It provides a profile with a score on 8 scales and brief, concise measurements of physical and mental health. Physical function (10 items), physical role (4 items), body pain (2 items), general health (6 items), vitality (4 items), social function (2 items), emotional role (3 items), and mental health make up the SF-36’s 8 subscales and 36 questions (5 items). Short Form-36 ratings vary from 0 to 100, with higher scores indicating more excellent health. The scale is examined in light of the previous 4 weeks.To minimize muscular spasms, all patients had 15 sessions of 20-minute H-P 5 times per week for 15 weeks. After this warm-up and relaxation period, electrotherapy was administered to the patients. In group 1, 4 electrodes were inserted across the glenohumeral joint with the glenohumeral joint in the center. Then, a 20-minute IFC therapy was administered, producing an amplitude of 80-150 Hz. In group 2, the painful shoulder region was treated with TENS using an active electrode with a pulse length of 20-60 μs and a stimulation frequency of 95 Hz.There were fifteen 30-minute sessions each day, 5 days per week. In group 3, the electrodes and patient location were modified according to the IFC technique. The S-IFC therapy was administered by turning on the device’s lights in the same manner, shutting off the device without supplying electricity, and emitting the end signal sound. The same physiotherapist did active–passive ROM, stretching (posterior capsule), Codman, wheel, finger chart, and isometric strengthening exercises following each session. In addition, patients were given an illustration of the exercises for use at home. Each exercise had to be performed 3 times each day, at least 10 times. The identical workout program was administered to all 3 groups. In addition, the patients were given instructions, such as avoiding overhead activities, for the relative rest of the affected shoulder. The patients’ adherence to exercise was checked daily by telephone before and after therapy. There were no complications identified among the patients. During the study, no analgesics were authorized . Paracetamol intake was also prohibited before measurements. Diagnosis and evaluations of the patients were made by 2 authors of the study (M.T and A.K.).3: the pretreatment VAS-R (mean SD: 3.05) and the posttreatment VAS-R third months  values (effect size = 0.793) were calculated with the G power program, and it was determined that there needed to be at least 19 patients included in the study to achieve 95% CI and 93% power level in the groups. We collected various general descriptive statistics, including the mean, median, and SD values of continuous variables. The Shapiro–Wilk and Kolmogorov–Smirnov tests were used to evaluate the normalization of the numerical data’s distribution. The chi-square or Fisher analysis was used to conduct the discrete distribution study between the groups. “t-test between the 2 groups” was the statistical analysis performed on data exhibiting normal distribution. Analyzing the differences between the 2 independent groups of continuous variables required the application of the Mann–Whitney U-test. This test was applied to the data with a non-normal distribution. The “paired t-test” was used to analyze data that exhibited normal distribution. The Wilcoxon test was used for the data showing a non-normal distribution to analyze the disparities between 2 dependent groups of continuous variables. A comparison was made between the Kruskal–Wallis test, used for non-normally distributed data, and the analysis of variance, used for regularly distributed data in more than 2 independent groups. The repeated measures analysis of variance for normally distributed data was contrasted with the Friedman test, which was used for non-normally distributed data, in the context of the group comparison of repeated measurements. It was established by applying the post hoc tests as well as the Wilcoxon tests on the various groups. The significance level of the findings was determined to be P = .05, and the CI was calculated to be 95%.The Statistical Package for Social Sciences v.22 for Windows  was used to analyze the study’s collected data. The sample size estimation is based on the findings of a previous studyP > .05)  subparameter scores showed significant improvements in the T0-T1 period in the IFC group. This improvement was also obtained at flexion, VAS-A, VAS-R, and DASH scores in the T1-T2 period, and at flexion, abduction, internal rotation, and VAS-A, VAS-N, VAS-R, and DASH scores in the T0-T2 period in this group .Abduction, VAS-A, VAS-R, VAS-N, and DASH scores showed significant improvements at T0-T1 period in the TENS group. The VAS-N scores in the T1-T2 period showed significant improvement. Flexion, abduction, internal rotation, VAS-A, VAS-N, VAS-R, and DASH scores in the T0-T2 period, as well as from body pain score, which is the SF-36  showed sP  (P < .05).P > .05) . As a reAccording to the findings of our research, all of the IFC, TENS, and S-IFC treatments, in addition to the HP+ exercise therapy for SIS, had significant curative effects (T1) by demonstrating their effectiveness on a ROM, pain, function, and quality of life in a relatively short amount of time. In addition, there were statistically significant improvements in all of the ROM, pain, and function values that were examined at the conclusion of the therapy (T2) in all of the groups. Furthermore, in terms of quality of life, some substantial improvements were noted in the scores of many other quality-of-life subparameters. On the other hand, there was not a discernible difference between the groups after therapy had been completed (T2).12 Nowadays, therapeutic exercises are accepted as an effective treatment method in terms of pain, function, and quality of life.15 In addition, Granviken et al16 determined that both indoor and supervised exercises showed similarly effective improvement in pain and function in the treatment of SIS. During our study, HP and an identical exercise treatment were administered to all groups using various electrotherapy techniques. The applied exercise program consisted of activities that were carried out both indoors and while being supervised. As a result, the groups considerably reduced their pain and dysfunction levels. However, there was no discernible change in ROM, pain levels, functional ability, or quality of life between the S-IFC group, which served as a control, and the groups treated with IFC and TENS. In this light, it was concluded that the exercise therapy we employed in the treatment of SIS was successful, and the findings of our study were consistent with the findings of the other research. In addition, it has been shown in the study that prolonged physical activity benefits the overall quality of life following therapy.17 Exercise therapy was the only treatment administered in this research project’s group (HP + exercise + S-IFC), which showed a substantial improvement in the bodily pain subcomponent of quality of life compared to the previous condition state. The lack of progress in other aspects may be attributable to the fact that our study was just 15 sessions long, and there needed to be a long-term follow-up.Subacromial impingement syndrome is the most prevalent cause of shoulder discomfort. The goal of conservative therapy for SIS is to enhance function and quality of life while reducing pain, discomfort, and inflammation in the subacromial space. Anti-inflammatory medicines, superficial thermal treatments (cold pack and HP), exercise therapy, and electrotherapy modalities are only some of the many therapeutic possibilities available. However, the most effective therapy for SIS is still a contentious topic of debate.21 In our study, several electrotherapeutic agents, such as IFC, TENS, and S-IFC, were applied to the affected areas of the participants in conjunction with high-pressure and exercise treatment. Interferential current treatment is a kind of electrical stimulation based on 2 medium-frequency alternating currents of different frequencies. This impacts deep tissues like a low-frequency current, a method often used in electrotherapy. On the other hand, more data about its efficiency need to be collected.4 A systematic review and meta-analysis of Fuentes et al4 studied the efficacy of IFC treatment in musculoskeletal pain. The authors reported that the IFC therapy, a multimodal treatment, may be successful in terms of analgesics in acute or chronic painful situations in various musculoskeletal disorders. This is compared to individuals who do not get any treatment or receive a placebo. However, these authors also found that IFC therapy was not substantially superior to a placebo or other therapies at the study’s discharge or the follow-up stages. In addition, Van der Heijden et al22 compared exercise therapy alone (active and passive ROM of the shoulder) to IFC and placebo IFC in addition to exercise therapy in the treatment of soft tissue disorders in the shoulder; as a result of this, they reported that there was no difference between the groups in terms of pain and functional capacity in short- and long-term follow-ups; therefore, there was no benefit of adding IFC therapy as an adjuvant to exercise therapy. Our study found no significant difference between the 2 groups; however, the groups who got exercise therapy in addition to IFC or S-IFC treatments exhibited substantial improvement in ROM, discomfort, function, and overall quality of life. As a result, the IFC treatment combined with HP and exercise therapy did not result in any further benefits for a ROM), discomfort, function, or quality of life. On the other hand, our investigation did not include a separate IFC group, which may be a limitation of our study. This may be why we could only get limited information regarding the efficiency of the IFC therapy.It is still unclear how many electrotherapeutic compounds alleviate pain, boost mobility, and prepare tissues for activity work.3 One of the primary hypotheses for the mechanism of action of analgesics is based on the gate-control theory. According to this theory, peripheral inhibition of pain can be obtained as a result of stimulation of large non-nociceptive afferent fibers. This hypothesis is one of the primary hypotheses for the mechanism of action of analgesics. Transcutaneous electrical nerve stimulation offers patients several benefits, the most notable of which are that it is inexpensive, secure since it has few adverse effects, and easy for patients to use on their own.24 In a recent randomized controlled study that examined the efficacy of TENS therapy on pain and function in rotator cuff tendinopathy, it was shown that TENS application is an effective modality. The study was carried out to investigate the efficiency of TENS treatment.25 In this context, many studies studied the effects of TENS treatment, and they found it an effective treatment method for pain and function in many musculoskeletal pathologies .27 However, as a result of the review studies of Desmeules et al19 in which they examined the effectiveness of TENS in rotator cuff tendinopathies, they reported that due to the high bias in the studies included in the review, a conclusion could not be reached about the effectiveness of TENS, that better quality studies are needed methodologically, and that until then, clinicians should prefer other evidence-based rehabilitation practices that have proven to be effective in treating patients with rotator cuff tendinopathy. In addition, similar findings regarding the efficacy of TENS therapy for shoulder pain were validated owing to the methodological constraints of current studies as a result of a Cochrane review that evaluated TENS treatment for shoulder pain.28 In our study, it was discovered that the other groups did not vary. However, the group that had TENS treatment in addition to exercise therapy showed considerable improvement in terms of ROM, discomfort, function, and quality of life. Therefore, it was determined that adding TENS treatment to HP + exercise therapy did not provide any further benefits for ROM, pain, function, or quality of life. This result was consistent with the findings of previous large-scale Cochrane studies. However, the lack of the S-TENS group in our research may be regarded as a limitation.The TENS treatment is one of the most common applications utilized in shoulder tendon diseases because it improves blood circulation and prepares the patient for activity by lowering discomfort.3 it was determined that there was a significant improvement in the physical and mental components of pain, function, and quality of life 4 weeks after IFC treatment and a similar improvement in the physical component of pain, function, and quality of life after TENS treatment. When the treatments were compared, it was found that there was no difference between them in terms of pain, function, and the physical component of quality of life and that they showed a similar improvement. In addition, it was determined that there was no difference between them regarding the physical component of quality of life. However, the authors pointed out that this study was flawed because a sham group was included. Regarding our research, having an additional S-IFC group in addition to the groups that were treated with IFC and TENS in a manner comparable to the study that came before ours may be a potential benefit. It was shown that the effects of each group on a ROM, pain, and function were comparable to the research presented before. While an improvement was seen in scores for physical function, vitality, body pain, and general health perception, all of which are subcomponents of quality of life, especially after IFC treatment, a significant improvement was seen only in the subcomponent of body pain in the TENS and S-IFC groups. This was the only subcomponent of quality of life that significantly improved. On the other hand, when the quality of life of each group was compared to one another, it was found that the only subcomponent of quality of life that differed significantly in favor of the TENS group was the overall health perception subcomponent. When the findings of our research are analyzed, it is found that the combination of HP and exercise therapy can be effective on a ROM, pain, function, and quality of life; however, the addition of IFC or TENS therapy in addition to exercise therapy does not provide a significant advantage. Therefore, it demonstrates that more placebo-controlled, randomized, controlled studies involving IFC and TENS therapy are still required. These studies should also have a longer follow-up period, a greater number of patients, and improved methodology and should be conducted independently of HP and exercise therapy. Consequently, clearer views can be put forth in the light of investigations concerning the effects of IFC and TENS therapies, how much and how their effects are, and how their effects are.We compared the efficacy of individual IFC and TENS treatments for SIS. In the study by Ucurum et al,Due to the short follow-up period, the long-term efficacy of the treatments could not be evaluated. Additionally, the results could not be examined in a larger population due to the low patient participation in our study during the coronavirus disease-2019 pandemic. Other possible limitations of our study include the inability to compare the efficacy of electrotherapy modalities alone with the sham groups and the inability to form a group that was not treated due to ethical problems.Interferential current and TENS exhibited equivalent results regarding the ROM, pain, function, and quality of life of patients with SIS, with no significant difference between IFC and TENS. Adding IFC or TENS treatment to HP + exercise therapy did not result in any extra benefits to the patient.


Pain is the most common challenge that most hospitalized patients complain of and is influenced by several patients, nurses, and institutional-related factors. Most studies in Ethiopia on pain were focused on surgical illnesses only.To assess nurses’ pain management practice and associated factors for admitted patients at Comprehensive Specialized Hospitals.: A multi-center institution-based cross-sectional study was conducted at the five randomly selected Comprehensive Specialized Hospitals of the Amhara region from May 01 to June 01, 2022. A multi-stage sampling method was employed to select a total of 430 nurses and patients for whom the nurses were responsible. Data were collected using standard self-administered, structured, and checklist questionnaires from nurses, patients, and patients’ charts respectively. The modified Bloom’s criteria categorized the overall practice as good, moderate, and poor. Data were checked, coded, and entered into Epi-Data version 4.6 and exported to SPSS version 25. An ordinal logistic regression model was applied, and variables with a p-value < 0.05 with a 95% CI in the multivariable analysis were considered significant.The study evaluated the pain management practices of 430 nurses and only a quarter had good pain management practices. Those nurses with first degrees and above education level (AOR = 2.282) and who attended in-service training (AOR = 2.465) were found to have significantly higher pain management practice. Expected though patients with painful procedures (AOR = 5.648) and who had severe pain (AOR = 2.573) were receiving better pain management practices from their nurse care provider. Nurses working in the institutions with a pain-free initiative focal person (AOR = 6.339) had higher pain management practices.: Overall, the majority of nurses had poor pain management practices. Higher educational levels, in-service training, and assigning a pain-free focal person had an impact on pain management services. Patients with higher pain levels and painful procedures were getting better attention. Hospital administrations need to provide due attention to the pain management of hospitalized patients by providing in-service training and educational opportunities to improve the capacity of nurses. Patients would be benefited considerably if hospitals focus on assigning focal persons for advocating regular pain management for admitted patients regardless of their pain level.The online version contains supplementary material available at 10.1186/s12912-023-01528-x. The International Association for the Study of Pain (IASP) defined pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage . It is aPain management practices refer to those activities done by health care providers, particularly nurses to relieve those who are in pain, which includes pain assessment using organizationally accepted tools, providing pharmacological and non-pharmacological pain management, and evaluation of pain management by reassessing patients’ status. It is effective when patient outcomes, satisfaction levels, and quality of life are all improved , 6.Despite regular pain assessments and management protocols, the burden of pain among hospitalized patients remains significant. More than half of admitted patients complain of pain during most of their hospital stay –10. CertThere have been different patient-related factors influencing the pain management practices of nurses according to the findings of different studies in Ethiopia. For instance, patients’ gender was one of the factors in which being female was about five times higher level of pain as compared to males which in turn influenced the pain management practices of nurses according to Debre Tabor of Ethiopia . A studyAccording to the findings of different studies; knowledge of nurses to the pain assessment and management, age, educational qualification, work experience, and in-service training were nurse-related factors that had significant association with the pain management practices of nurses for hospitalized patients , 17–20. The factors; particularly the patient-related factors that influence the nurses’ pain management practices were not studied well in Ethiopia. Another limitation of Ethiopian studies on pain management practices is they frequently rely on surgical patients, particularly post-operative ones. Therefore, the current study aimed to investigate pain management practices and factors that act as barriers or facilitators to nurses’ pain management practices which subsequently increase the burden of pain among hospital admitted patients.An institutional-based multi-center cross-sectional study was conducted among nurses working at five randomly selected referral hospitals  of Ethiopia and patients admitted at these hospitals from May 01 to June 01, 2022.All nurses working in the inpatient departments of the selected Hospitals during the study period were considered in this study.All patients admitted to the inpatient departments of the selected Hospitals during the study period were considered in this study.Nurses on annual leave or sick leave during the data collection period were excluded from the study. Patients with critical illness and impaired level of consciousness were excluded from the study.The sample size was determined using a single population proportion formula by taking a proportion of 23.53% from Jimma University Medical Center (JUMC) . By addiThe same number (437) of patients were included in the sample to assess pain intensity directly from the patients and the pain management practices of nurses from the corresponding patient’s chart.Nurses play a key role in the management of patient’s pain and they are in charge of patient care during their scheduled working hours as well as the patients that they are assigned for. The pain management practice of nurses was evaluated from the records of the patient’s charts for whom he/she was responsible. That is why an equal number of nurses and patients were intended to be studied. Before selecting a nurse for the study, the bed numbers that he/she was responsible for were determined. Then, one of the patients for whom the nurse is responsible was chosen at random so that the chart could be reviewed and patient-related characteristics could be evaluated. From the patients’ charts, data about administered medications such as anti-pains and vital signs incorporating the latest pain score were collected. The charts were reviewed about four hours back to evaluate the corresponding nurses’ pain management practices. During this time the nurse involved in this study was assumed to be responsible for the care and records that have been done to the patients participated. Because nurses are only assigned to a certain number of patients for a specified amount of time in hospital settings.A multi-stage sampling technique was employed to select the study samples. First of all, a list of all comprehensive specialized hospitals had been obtained from the Amhara health bureau. Five hospitals  were selected randomly from the eight comprehensive specialized hospitals. Following that, each institution provided the number of nurses employed in both the outpatient and inpatient departments who rotated between the two settings. Then the calculated sample size was proportionally allocated to the size of the population in the selected hospitals. Five inpatient departments  were selected in each hospital, and nurses working in those departments again were allocated proportionally based on their number. Finally, simple random sampling by lottery method was employed to select the study samples.The total number of patients admitted per month was obtained from each department’s Health Management Information System (HMIS) database. A total of 437 patients with their hospital patient charts were selected from the selected units of each hospital to determine pain intensity. Before selecting a nurse for the study, the bed numbers he/she was responsible for were determined. Then, one of the patients that the nurse is responsible for was selected. The details of the sampling procedure is presented below Figure Nurses’ pain management practice.Independent variables are categorized into three groups, which include:-Socio-demographic variables  and Clinical factors .Socio-demographic characteristics , and knowledge were nurses-related variables.In-service training, nurse-to-patient ratio, written policy for pain as the “5th vital sign”, pain assessment tools, pain management guidelines, number of working shifts, and pain-free hospital initiative implementation focal person were institutional-related variables.are those patients who are in pain whose pain score ranged from seven to ten –10 numerAccording to the checklist evaluation, nurses with scores ≥ 75% were regarded as having good pain management practice , 24, 25.Based on the checklist evaluation, nurses with scores between 50 and 74.99% were considered as having moderate pain management practices , 25.Based on the checklist evaluation, nurses with scores less than 50% were considered as having poor pain management practices , 24, 25.When a nurse serves ≤ 6 patients in all units other than the Intensive Care Unit (ICU) which is based on Ethiopian Standard Agency (ESA) for Comprehensive hospitals , 27.Those nurses who scored above or equal to 80% of the knowledge questions were regarded as having adequate knowledge about pain management .Any procedure that could reasonably be anticipated to result in more than mild or transient pain and/or distress in the patients to whom it is applied .Data were collected using a self-administered questionnaire from nurses and an interviewer-administered questionnaire from patients as well as a checklist for chart review and observation. Some parts of the questionnaire prepared for this study whereas, the other parts were taken from previous studies. An 8-item binary scoring (yes/no) data extraction checklist was used to evaluate nurses’ pain management practices. Those who scored ≥ 75%  were regThe data quality was maintained by using a carefully designed questionnaire collected by well-trained data collectors and supervisors. Three diploma nurses and two BSC nurses were recruited to collect and supervise the data collection process in each hospital. The data collectors and supervisors were trained for one day on procedures, techniques, and ways of collecting the data. Data were checked for completeness and consistency. A pretest was conducted at the University of Gondar Comprehensive Specialized Hospital (UoGCSH) on 22 nurses.Data were checked, coded, and entered into Epi-Data version 4.6 and exported to SPSS version 25 for analysis. Descriptive statistics such as frequency distribution, proportion, and percentages were done. The extent of multi-collinearity between independent variables was checked using variance inflation factor (VIF) and tolerance and the values of both statistics for all independent variables were within an acceptable range (VIF < 10 and Tolerance > 0.1). Regression model assumptions were checked using a test like the Hosmer & Lemeshow goodness of fit with a P-value (Pearson chi-square = 0.096 and Deviance-0.776). The proportional odds assumption was checked with a test of parallel lines with a P-value ≥ 0.05 which is an indicator for the fulfillment of the assumption. A P-value for the test of parallel line for this study was 0.421.A bivariable ordinal logistic regression model was fitted for each explanatory variable. Accordingly, those variables having a p-value ≤ 0.25 in the bivariable regression analysis were taken as the candidates for the multivariable ordinal logistic regression model. In multivariable regression, variables with a P-value of less than 0.05 with a 95% CI were considered statistically significant.The study included 430 nurses in total, with a response rate of 98.4%. Over half 228 (53%) were males and the mean age was 30.44 with a standard deviation (SD) of 4.311. Majority 374 (87%) of nurses had an educational qualification of degree and above. Majority 206 (47.9%) of nurses had a work experience of 5–10 years . Only 58 (13.5%) of nurses had attended in-service training regarding pain management in the past two years  and the mean age was 45.32 years with a range of 18–86 years. Regarding the educational status of the patients, 148 (34.4) were unable to read and write, while 132 (30.7%), 67 (15.6%), and 83 (19.3%) had primary, secondary, and diploma and above educational levels respectively. Most of the patients were farmers (25.3%) and housewives (35.1%)  had poor knowledge of pain management practices  of all patients’ pain was recorded within 24 h before the chart review. More than half of 238 (55.3%) patients had undergone painful procedures. When assessed using NRS, 351 (81.63%) had reported mild to severe pain with a median and IQR of 3 and 4 respectively  of the five hospitals had two working shifts and 3(60%) hospitals had a 1 to 6 nurse-to-patient ratio for working hours. Of those hospitals, 4 (80%) had a written policy for pain as the 5th vital sign, 3 (60%) had pain management guidelines, and only one (20%) of the institutions had a pain-free hospital initiative focal person.About 222 (51.6%) of the charts revealed pain was assessed and recorded at least once within the past four hours by the nurses. Among those nurses evaluated by chart review of their particular client, only 152 (35.3%) had performed a regular pain assessment during their stay at the workplace. Regarding the level of practice, only 111 (25.8%) of nurses had good pain management practices while 118 27.4%) and 201 (46.7%) had moderate and poor pain management practices respectively  higher on average for those having an educational qualification of degree and above as compared to those having a diploma.In-service pain management training was found to be significantly associated with pain management practices. The odds of being in a higher category of pain management practices was 2.47 times (AOR = 2.465 with 95%CI:[1.317–4.614]) higher on average for those nurses who attended an in-service pain management training as compared to those who didn’t attend. In other words, those nurses who attended pain management training had a 71% probability of having a higher level of pain management practices.From the patient-related factors, patients with painful procedures become a significant predictor of nurses’ pain management practices. The odds of being in a higher category of pain management practice was 5.648 times (5.648 with 95%CI: [3.237–9.856]) higher for those nurses who provide care for patients with painful procedures as compared to the contrary group. Those nurses who follow those patients with painful procedures had an 85% probability of falling in the higher category of pain management practices.The other patient-related significant variable was pain intensity. The odds of being in a higher level of pain management practice was 2.573 times (2.573 with 95%CI: [1.35-5-4.899]) higher on average for those nurses who follow patients with severe pain as compared to those who follow patients with mild pain. Similarly, the odds of being in a higher category of pain management practice was 3.236 times (3.236 with 95%CI: [1.771–5.914]) higher on average for those nurses who follow patients without pain as compared to those who follow patients with mild pain.From institutional factors, a pain-free initiative implementation focal person was found to have a statistically significant relationship with the nurses’ pain management practices. The odds of being in a higher category of pain management practice was 6.34 times (6.339 with 95%CI: [3.611–11.13]) higher on average for those nurses working in the institutions having a pain-free hospital initiative implementation focal person as compared to the contrary group. Those nurses working in the hospitals having a pain-free hospital initiative implementation focal person had an 86.4% probability of having a higher level of pain management practices  with a 95%CI ) of the nurses had good pain management practices, while 118 (27.4%) and 201 (46.7%) had moderate and poor pain management practices respectively. The finding of this study was consistent with the study conducted at Hawassa Referral Hospital (24.4%) . HoweverThis gap could be explained by the difference in sample size, as the sample sizes in the earlier research were generally less than those in this study. On the other hand, the discrepancy may have arisen from the use of an objective tool to evaluate nurses’ pain management practices in the current study. The disparity in the study populations may be another factor contributing to the discrepancy. The studies done in Addis Ababa  was on tThis study was multicenter which was in contrast to the studies of Jimma, Hawassa, and Dire Dawa which might result in a difference in the level of nurses’ pain management practices. The other reason that might have brought the difference in the level of nurses’ pain management practices could be the difference in the provision of pain management training. For example, only 13.5% of professionals attended pain management training in this study which was lower compared to the finding of Jimma in which 23.5% of professionals had attended in-service pain management training which might have resulted in the difference in the level of pain management practices of nurses.The result of this study was relatively higher as compared with the study done in Rwanda in which only 2% of the study participants had good pain management practices . The posAs expected the educational status of nurses was found to have a statistically significant relationship with the nurses’ pain management practices. The odds of being in a higher level of pain management practice was nearly 2.3 times higher on average for those with educational qualifications of a degree and above than those with a diploma. The possible reason would be that nurses with a degree and higher levels of education typically have better knowledge and comprehension of pain, its assessment, and management mechanisms, which in turn leads to better pain management practice. A higher level of education has an impact on nurses’ pain management practices, i.e. if someone is not equipped with the necessary knowledge and skills important to manage pain, patients will not get an appropriate pain management service from him/her and end up suffering from pain. The knowledge and clinical skills of professionals will be greatly enhanced by advanced nursing education, which will lead to better pain management for patients. Patients would also benefit when they get attention to their pain from skillful professionals throughout their hospital stay. The finding was supported by the studies conducted in Hawassa and Rwanda , 14.This study indicated that in-service pain management training was found to be significantly associated with pain management practices. A higher category of pain management practice was more likely for nurses who participated in in-service pain management training compared to those who did not in the previous two years, by a factor of 2.47. This is because in-service training can provide nurses with more knowledge, insight, and understanding of patients’ pain, which may enhance their pain management practices. In other words, it serves to update the nurses’ pain management knowledge and practical skills and improve the best practices for fulfilling their responsibilities in the regular assessment and management of pain for patients. It also plays an essential role in improving the standard of inpatient pain management practices , 36. ThiIn this study, patients with painful procedures become a significant predictor of nurses’ pain management practices. Nurses who care for patients with painful procedures had 5.65 times higher odds of falling into a higher category of pain management practice than the opposite group. This could probably be because painful procedures increase the likelihood of high-intensity of pain that drives patients to report their pain to their care providers. Nurses who take part in caring for patients with painful procedures might be able to reduce the suffering of patients with procedural pain which put them in the higher category of pain management practices .The other patient-related significant variable was pain intensity. Nurses who care for patients with severe pain had, nearly 2.6 times higher odds of practicing higher levels of pain management than nurses who care for patients with mild pain. The possible reason might be that patients with severe pain are more likely to report their pain status and get more attention from their healthcare providers. According to findings of studies in Gondar  and CentFrom institutional factors, a pain-free initiative implementation focal person was found to have a statistically significant impact with the nurses’ pain management practices. The odds of being in a higher category of pain management practice was nearly 6.34 times higher for those nurses working in the institutions having a pain-free hospital initiative implementation focal person as compared to the contrary group. The possible reason behind this could probably be that nurses may improve their pain management activities if they are guided by trained professionals who feel responsible for the proposed area of practice. Additionally, the pain-free hospital initiative would be implemented when there is a responsible individual who can advocate a regular patient assessment and management of patients with any pain level. Those who are assigned as focal persons have vital importance in the improvement and continual provision of pain management for hospitalized patients. This could be achieved by preparing a work plan, evaluating pain management activities, and coordinating patient education programs , 39.This study found that the majority of nurses had poor pain management practices for admitted patients. Nurses with higher education level and having in-service training were providing better pain management to their admitted patients. Patients with painful procedures and higher pain intensity were receiving better pain management from their nurse care provider. From several institutional factors, the assigned pain-free hospital initiatives implementation focal person was another factor that remained significant to the pain management practices of nurses.Hospitals administrations need to provide due attention to the pain management of hospitalized patients by providing in-service continuous training to improve the capacity of the health care providers. It would improve the service of pain management for admitted patients if there is a focal person for a pain-free hospital initiative implementation who can advocate a regular pain assessment and management for each admitted patient regardless of their pain severity. Finally, future researchers would get better findings if they perform an observational follow-up study to determine the pain management practices of nurses.The study used only patients’ charts to evaluate nurses’ pain management practices for their corresponding patients as it was difficult to observe and follow all of the nurses within the specified period. Social desirability bias during data collection was another drawback of this study. The other limitation was that it didn’t include the pain management practices for patients who were with critical illness and impaired level of consciousness since the pain assessment tool (NRS) was not suitable for them.Below is the link to the electronic supplementary material.Supplementary Material 1


The malignancy scale ISUP ≥ 2 (p = 0.038) and lower PSA value  are associated with higher pain during procedure. Biopsy time was correlated with discomfort . Age (p = 0.65), lesion size (p = 0.29), PI-RADS score (p = 0.86), prostate volume (p = 0.22), and the number of cores (p = 0.56) did not correspond to the pain scale. CONCLUSIONS: The apex is the most sensitive sector of the prostate. ISUP ≥ 2 and patients with low PSA levels more often indicated higher values on the pain rating scale.BACKGROUND: The pain experienced by a patient during a prostate fusion biopsy is cumulative and can also be modulated by many factors. The aim of the study was to assess the association between the degree of pain intensity during prostate biopsy and the region of the biopted organ. MATERIALS AND METHODS: The study included a group of 143 patients who underwent prostate fusion biopsy under local analgesia followed by blockage of the periprostatic nerve. After a biopsy, the patients completed the original questionnaire about the pain experienced during the procedure. RESULTS: There was a statistically significant difference in pain score between cores taken in the apex (median 5 (IQR 2–5)), medium level (median 1 (IQR 1–2)), and prostate base (median 1 (IQR 1–3)) ( Prostate cancer (PCa) is one of the most commonly diagnosed malignant neoplasms in the world. It ranks second (after lung cancer) with over 1.4 million patients . In the Most cancers are detected in the asymptomatic phase, which is possible thanks to the widely developed prophylaxis including the prostate-specific antigen (PSA) blood level test. Digital rectal examination (DRE) is also helpful .The method of treating prostate cancer depends on many factors. These factors include: the patient’s general health (including comorbidities), age, and tumor stage. The analysis of these factors allows the decision on surgical treatment, radiotherapy, systemic treatment, and active surveillance to be made. It is mainly patients with localized cancer that qualify for local treatment (surgery or radiotherapy) .PCa diagnostics is based on imaging tests such as transrectal ultrasound (TRUS) or multi-parametric magnetic resonance (mpMRI). The Prostate Imaging and Reporting and Data System (PI-RADS) scoring system is used to evaluate the obtained images in mpMRI and to prepare descriptions . ImagingFusion biopsy allows for the histological assessment of neoplastic tissue using the Gleason score scale, which is necessary to predict treatment results and assess the prognosis . The mosThe gold standard in prostate analgesia before biopsy is local analgesia with periprostatic nerve bundle block (PPNB). It is an easy, safe and highly effective method. In the case of young men, as well as among patients with prostate hyperplasia, the periprostatic nerve block itself is not sufficient, and the reduction of pain sensation is possible by using additionally perianal and rectal gel with lidocaine ,15,16.The pain threshold is individual and subjective, and therefore it is difficult to clearly define or estimate. The pain experienced by a patient during a prostate biopsy is cumulative, which means that an increase in the number of punctures directly correlates with an increase in total pain. It can also be compounded by shame and stress before the digital rectal examination, stress before the biopsy itself and fear of sexual dysfunction or diagnosis. Additionally, physical factors such as the size of the prostate and the age of the patient have an impact on the level of pain experienced. Literature data indicate that younger patients experience stronger pain compared with older patients, which is associated with greater tension of the anal sphincter muscle . The intDespite the widespread use of fusion biopsy in cancer diagnostics, the aspect of pain during the procedure still leaves many unknowns. The available literature indicates numerous inconsistencies on this topic. Therefore, in our study, an attempt was made to assess the degree of pain experienced by the patient during the fusion biopsy and to standardize the information on this issue.The aim of the study was to assess the difference between the degree of pain intensity during prostate biopsy and the region of the biopted organ. Additionally, our study confirms the hypothesis that the apical and anterior areas of the prostate are more sensitive to pain. We also examined how factors such as age, lesion size, prostate volume, number of samples taken, PIRADS, ISUP and PSA values affect the level of pain experienced by the patient during prostate fusion biopsy.The study included a group of patients with suspected prostate cancer who underwent prostate fusion biopsy from June 2018 to June 2022 at the Department of Urology, Clinical Hospital number 1 in Zabrze. The biopsy was performed under local analgesia with transrectal access. The procedure was performed using ultrasound with a BK Medical Flex Focus 400-BioJet System . Before the biopsy 11 mL of Lignocaine gel was administered to the rectum, then, around the periprostatic nerve bundle, 5 mL of 1% lignocaine was injected on each side. Analgesia was performed with a Chiba 18 G needle. Samples were taken by The Pro-Mag Ultra biopsy gun with an AIOU 14 G 250 mm needle. Initially, 4 samples were taken from a suspicious lesion in MRI, and then 8–12 samples were systematically taken from the right and left lobes of the prostate. The number of samples depended on the assessment of the quality of the collected material by the operator during the biopsy. If the collected material was not suitable for histopathological evaluation, more specimens were collected. Furthermore, though the MRI fusion biopsies were performed by two trained and experienced urologists, there could nevertheless be some impacts from factors at the physician level on the analyzed outcomes. Before collecting the material for histopathological examination, each patient was interviewed to garner information on their age, weight, height, PSA value, DRE result, nicotine addiction, family history in terms of PCa, the result of any previous biopsies, prostatitis or diseases, and concomitant and previous pelvic surgeries . After bIn the course of the analysis, we examined how factors, such as the PSA value, PIRADS, or the previously performed biopsy, influence anxiety during the procedure. We also assessed whether the prolonged duration of the biopsy correlates with the perceived discomfort, pain and possible development of tolerance. The study also focused on the analysis of whether age, lesion size, prostate volume, number of samples taken and PIRADS, ISUP and PSA values have an impact on the level of perceived pain.Overall, we excluded patients who had neurological disorders or history of neuropathy, had received anticoagulants, or had no evaluable MRI reports.p-value < 0.05 was considered statistically significant, and p-value < 0.10 was considered close to statistical significance. All analyses were performed using R software package version 4.0.1 released on 6 June 2020 .Categorical variables were summarized as frequencies and percentages. Continuous and ordinal data were shown as median values with interquartile ranges  and as mean values with standard deviation ranges as well with min/max ranges, unless otherwise stated. Differences between two groups were determined using Wilcoxon rank sum test (aka Mann–Whitney U test) and for more than two groups, comparisons were performed by Kruskal–Wallis H test. Spearman correlation coefficient was assessed to examine the correlation between variables. The classification of the correlations used to evaluate the analyzed results was as follows: 0.0 ≤ |r| < 0.1 negligible correlation, 0.1 ≤ |r| ≤ 0.39 weak correlation, 0.4 ≤ |r| ≤ 0.69 moderate correlation, 0.7 ≤ |r| ≤ 0.89 strong correlation, 0.9 ≤ r ≤ 1 very strong high correlation . A two-sIn total we included 143 patients aged 41 to 84 years who underwent transrectal fusion prostate biopsies. Of these, 69 (48%) were biopsy naïve, and 74 (52%) had a history of previous prostate biopsy (1–5 biopsies). The median age was 66.4 (IQR 61.2–70.8) years, the median PSA was 7.60 (IQR 5.91–10.11), median volume TRUS (ml) was 50 (IQR 35–63), and median PSAD (PSA/prostate volume) was 0.16 (0.11–0.26) . Ninety-Notably, targeted lesions were located in apex in 24% of patients, in mid in 46%, and base in 30%. In 57% of patients targeted lesions were located in the posterior zone of the prostate and in 43% in the anterior zone of the prostate. Following collection of median 14 cores (IQR 12–16), 29% of patients had ISUP GG ≥ 2. The mean biopsy time was 31 min. Most biopsies were localized in sector 8 (22 out of 143 performed biopsies), which accounted for 15% of the respondents . None ofn = 34; median 1 (IQR 0–2.75)); medium level ; base )) did not show significant differences (p = 0.97). Forty-five percent reported a low level of anxiety (score 0–1).The maximum pain score  for separate parts of fusion biopsy were as follows: USG insertion 5, periprostatic block 6, DRE 6, ultrasound manipulation 5, sample cores collection 8. Of note, only 11% of patients reported zero pain for core collection. Most of the patients reported some level of pain, however none indicated a maximum score of 9–10. Overall, 56% reported a good tolerance of fusion biopsy (score 0–1). With regard to tolerance, the median pain score for the entire study group was 1 (IQR 0–2). Comparison of the development of tolerance among the subjects by subgroup (apex (p = 0.099). On the other hand, there were statistically significant differences in pain score between cores taken in the apex (median 5 (IQR 2–5), medium level (median 1 (IQR 1–2)) and prostate base (median 1 (IQR 1–3)) (p < 0.001) (p = 0.84), PI-RADS (p = 0.47) or history of prostate biopsies (p = 0.49). Increasing biopsy duration was correlated with increased discomfort .We found some evidence for higher median pain scores for cores located in the posterior zone compared with the anterior zone of the prostate, however it did not reach a statistical level of significance (2 (IQR 1–4) vs. 1 (IQR 1–2), < 0.001) , Table 2p = 0.65), lesion size (p = 0.29), PI-RADS score (p = 0.86), prostate volume (p = 0.22), and, importantly, number of cores (p = 0.56) did not correspond to pain scale.We further tested if established PCa risk factors, including age, MRI lesion diameter, PI-RADS, ISUP GG, PSA, number of cores and prostate volume are associated with our biopsy pain score . Overallp = 0.046). However, the analysis of medians and IQR, despite the visible slight trend, did not show statistically significant differences (p = 0.16) between the studied groups  ; = 0.038) , Table 2p = 0.002). Moreover, older patients relatively more often indicated lower values of the VAS pain scale compared to younger patients, however, this result was not statistically significant (p = 0.18).Smaller prostate volume was also correlated with higher pain during rectum examination . Only one person reported level 8 of perceived pain during the sampling stage (which accounted for 0.7% of the respondents), and 11% indicated the lack of pain at this stage of the study. The remaining stages of the procedure, such as administration of analgesia, DRE, insertion of the ultrasound transducer, or manipulation of the ultrasound transducer were assessed at a maximum of 5–6 points. The median tolerance during the fusion biopsy procedure was 1.p < 0.001). For comparison, the subjects included in group 1 described the fusion biopsy as a painless procedure, assessing it at 3.10 +/− 2.32 on the pain scale. Additionally, patients who did not receive analgesia classified it as painless [Similar results were also presented in the available literature, where the fusion biopsy, in the assessment of patients, was associated mostly only with the feeling of acceptable discomfort. Already in the 1990s, scientists showed that 95% of the subjects felt only slight discomfort during the insertion or manipulation of the ultrasound head. Ninety-two percent of patients felt discomfort during biopsy. A similar effect was obtained during research conducted at the Medical University of Marseille, where 131 patients who underwent prostate fusion biopsy without analgesia were analyzed. The vast majority of respondents assessed the procedure as painless, with acceptable discomfort. In turn, Bosnian scientists conducted a similar study on a group of 90 patients, dividing them into three subgroups: The first received a blockade of the periprostatic nerve, the second received Voltaren suppositories, and the third underwent an examination without analgesia. The average pain rating  in group 3 was 6.06 +/− 2.95, which turned out to be statistically significant , which increased with the increasing duration of the procedure, turned out to be statistically significant. A similar study was conducted in Japan, but only the correlation between the duration of the procedure and the pain experienced was analyzed. Pain was assessed at each puncture  and immediately after withdrawing the transrectal probe. There was a clear correlation between the duration of the biopsy and the pain experienced [It was also examined whether the duration of the biopsy correlated with the perceived discomfort, the level of pain and the possible development of tolerance. The effect on the perceived discomfort (erienced .p < 0.001). The apex of the prostate is an extremely pain-sensitive site during biopsy due to the predominant presence of somatic nerves in the area below the dentate line. The result obtained by us coincides with the assumption of our work and conclusions published in the available literature [The obtained results of the statistical analysis assessing the difference between the region of the sample taken and the level of perceived pain clearly indicate that the most sensitive sector is the peak part  and pain increased with the duration of the procedure. In the second group, the level of perceived pain was low and did not increase with time [Increased sensitivity of the apical part of the prostate was also demonstrated by scientists from Yonsei University College of Medicine, who divided the 312 participants into two subgroups . The pain score increased from base to apex (ith time . The samith time . These rp = 0.099). This hypothesis was dictated by the difficult access to this part of the organ [Additionally, we assessed which of the prostate zones (anterior/posterior) is characterized by increased sensitivity. Unfortunately, the obtained result does not confirm the earlier assumption that the anterior biopsy is more painful (he organ . The lacp = 0.38).In the course of the analysis, we examined whether the earlier undergoing of a biopsy and the awareness of the PSA and PIRADS results had an impact on the anxiety experienced before the procedure. None of the above-mentioned factors turned out to be statistically significant. However, the literature data indicate the presence of a positive correlation between the declared previous biopsy and pain during the subsequent procedure ,29,30. Ip = 0.65). Initially, it was assumed that younger age would be associated with greater pain, as younger patients were characterized by greater anal sphincter muscle tone [The analysis of the influence of the patient’s age on the level of perceived pain, did not indicate a correlation between these factors  indicates no correlation. A different result was obtained by French and Korean researchers, who showed that the size of the neoplastic lesion is significantly related to the level of perceived pain [Another factor that we examined was the influence of the size of the lesion on pain. The result obtained . A similar trend has also been demonstrated in the available literature [p = 0.16) between the study groups. This result indicates that it would be worth repeating the study (without limitations) in terms of assessing the impact of PSA value on pain experienced during biopsy.The correlation between the PSA value and the level of pain experienced by the patient was also analyzed. Initially, it was noted that patients with higher PSA values were more likely to indicate lower pain scores . This result is relatively pioneering due to the lack of access to similar studies. For this reason, it is worthwhile to design a retest focused solely on the correlation between ISUP 2–5 and biopsy pain with more test subjects and thereby eliminate most of the limitations of our work.A visible relationship was found between the ISUP value and the intensity of pain associated with prostate fusion biopsy. Patients with ISUP ≥ 2 indicated more severe pain in comparison with patients with ISUP 0–1 (p = 0.74). The previously mentioned analysis by Japanese researchers also excludes this relationship [The group of patients we studied was diversified in terms of the number of collected biopsies. This allowed for the finding of no difference between the number of samples and the pain associated with the biopsy  does not allow us to confirm this hypothesis. Scientists from Marseilles are of the opposite opinion [Initially, it was assumed that the increased volume of the prostate, due to the need to collect more biopsy samples and the prolonged duration of the procedure, would positively correlate with increased pain sensation. The obtained result  and from the patients’ different responses to the analgesia, each of which are results of the individualized conditions. It is also important that the procedure was not performed only by one operator. It should also be noted that the patient’s pain assessment was not performed after each sample collection.The apex of the prostate is the most sensitive sector of the prostate due to its strong innervation. The prolonged duration of the fusion biopsy increases the severity of pain experienced by the patient. ISUP ≥ 2 and patients with low PSA levels more often indicated higher values on the pain rating scale. The age, size of the lesion and the number of samples taken do not correlate with a stronger feeling of pain. Similarly, PI-RADS, prostate zone anterior/posterior, and biopsy anxiety level showed no effect on the level of pain experienced during the procedure.