Sawdust–plaster cast mixture versus traditional cast: Which type reduced pain and increases comfort and enhancing healing process among patients with twisting: A randomized controlled clinical trial

Abstract

BACKGROUND:

Musculoskeletal twisting injuries, such as strains and sprains, are common and can be treated using cast immobilization without the need for surgery. The study aimed to evaluate the efficacy of Sawdust–Plaster Cast Mixture Versus Traditional Cast: Which Type Reduced Pain and Increases Comfort and Enhancing the healing process among Patients with Twisting.

MATERIALS AND METHODS:

The study was conducted from May to August 2025 and used a single-blind, true experimental design. Sixty patients with twisting injuries were randomly assigned to either the intervention group (n = 29), which received the sawdust–plaster cast, or the control group (n = 31), which received a standard cast. Pain and comfort levels were assessed using a visual analog scale (VAS), and the healing duration was recorded. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 30.

RESULTS:

Compared to the standard cast (control) group, patients in the sawdust–plaster cast mixture (intervention) group reported a noticeably higher reduction in discomfort. The intervention group’s mean pain score was 18.37 (P < 0.001), compared to 43.47 for the control group. Enhanced Comfort: Additionally, the intervention group reported feeling much more at ease. The intervention group’s mean comfort score was 24.40 (P = 0.003), while the control group’s was 36.21. For the sawdust–plaster cast mixture group, the healing period was noticeably shorter. The intervention group’s mean recovery time was 25.11 days (P = 0.004), compared to 36.26 days for the control group.

CONCLUSION:

The intervention showed a notable and clinically significant improvement in patient outcomes based on health policy criteria. This directly addressed important health policy goals for enhancing patient experience and care quality. Additionally, the average healing time decreased by more than 30% (36.26–25.11 days), demonstrating the effectiveness of the intervention in hastening patient recuperation and enhancing productivity. These results show that the intervention not only satisfies but also exceeds standards for efficient, patient-centered care.

Introduction

Musculoskeletal disorders (MSDs) range of conditions affecting this system, originating from trauma, degeneration, overuse, infection, or autoimmune diseases.[1] Worldwide musculoskeletal disorders are believed to be the second most frequent cause of disability.[2] Trauma is indeed a significant global public health crisis, causing over 5 million deaths annually, with injuries also leading to tens of millions of non-fatal cases and long-term disability. While a specific global figure of 78% for musculoskeletal injuries is not readily available, these types of injuries, including fractures, sprains, and dislocations, are common consequences of traumatic events like accidents, falls, and motor vehicle incidents.[3] Plaster casts are the most commonly used method for treating fractures. Casts are used not only to immobilize fractures, but also to protect the affected part and relieve pain.[4] In the Winter Olympics, sports such as freestyle skiing, snowboarding, ski touring, bobsleigh, and ice hockey carry a particularly high risk of injury, ranging from wounds and hematomas to contusions and sprains. The most common sites of injury are the knees, spine/back, wrists, and hands.[5] Many studies suggest that alternative immobilization methods can achieve similar or better functional outcomes compared to traditional plaster casts.[6] Despite the emergence of new materials, traditional plaster is still preferred due to its compatibility with the skin, low cost, and easy availability. There is an urgent need to improve existing materials and also introduce new and efficient materials for long-term immobilization.[7] Acute musculoskeletal injuries in athletes, non-pharmacological approaches like physical therapy, neuromodulation, and psychological interventions are often recommended first, while pharmacological treatments include topical and oral nonsteroidal anti-inflammatory drugs (NSAIDs) the research will use a descriptive synthesis with statistical and narrative analysis to evaluate the correlation between findings and research objectives in sports medicine.[8] Biocomposites of albumen-glycerol reinforced with natural fibers are being explored as a potential alternative for orthopedic casts, replacing traditional plaster of paris (POP). These natural fiber composites offer several benefits, including low density, low cost, and biodegradability. However, their primary drawbacks are poor compatibility between the fiber and the matrix, as well as high moisture absorption, which often requires chemical treatments to modify the fiber’s surface. This work describes the creation of such a composite, whose mechanical properties show great promise for orthopedic applications. The resulting natural fiber cast is considered a superior option to POP because it provides rigid fixation, takes less time to apply, and leads to fewer complications.[9] This study investigated early mobilization as an alternative to traditional immobilization for managing stable long bone fractures in patients aged 18–65. The research compared these two methods by measuring key outcomes like healing duration, complication rates, and patient satisfaction. The goal was to determine the effectiveness of early mobilization in diverse healthcare settings, from high-resource to low-resource environments.[10] This study aims to investigate the effectiveness of sawdust–plaster mixture on reducing pain, increasing comfort, and enhancing the healing process among patients with twisting.

Study novelty

This study investigates a sawdust–plaster cast mixture as an alternative to traditional casting materials for twisting injuries. While plaster casts remain standard, this bio-composite material could offer advantages. The novelty lies in comparing this mixture to conventional methods, focusing on patient outcomes like pain, comfort, and healing duration.

Materials and Methods

Study design and setting

A randomized controlled trial (RCT) design was carried out to investigate the effectiveness of Sawdust–Plaster Cast vs. Traditional Cast: A Randomized Trial on Pain, Comfort, and Healing in Twisting Injuries. The research was conducted at the Baghdad Al-Rusafa Health Department at Al-Kindi Teaching Hospital, and the Baghdad Health Department, Al-Karakh, at Al-Yarmouk Teaching Hospital.

Study participants and sampling

The study’s criteria guarantee that all eligible adults over 18 with twisting injuries had an equal chance of being chosen. A total of 60 patients were assessed and randomized into the intervention group (n = 29) and control group (n = 31), as illustrated in Figure 1.

Figure 1.

Consort flow diagram of study[10]

Inclusion criteria: Patients must meet the following criteria: adult >18 years old, able to read and write, have a new twisting injury to the lower extremities or ankle sprain/strain, be free of psychiatric diagnoses, and be willing to participate in the study.

Exclusion criteria: Unwillingness of a patient to participate, physical disability, use of regular tranquilizer or sedative drugs, previous history of psychiatric disorders, patients with a confirmed fracture, pre-existing conditions that might affect healing, pain perception, or comfort (e.g., severe arthritis and neurological disorders), inability to follow the study protocol or complete the required assessments (e.g., due to cognitive impairment), and patients who have already received treatment for the current injury. Simple random sampling was used to assign participants to groups.

Sample size calculation

Total population = 70, 95% confidence, 5% error 5/100 = 0.05, if N = 70, n = sample size, E = margin of error, n = N/[1 + (N)(E) 2], n = 70/[1 + 200 (0.05) 2], n = 70/[1 + 900 (0.0025)], n = 70/[1 + 0.3325], n = 200/1.3325 n = 60. Or Rao soft program was used with a specific confidence interval of 5% and confidence level of 95% to determine the sample size.

Data collection tool and technique

The study was conducted through the following procedure. It was carried out by the researcher to collect baseline data and to assess patients who met the criteria. Then, the researcher began to explain the objective of the study to the patient to obtain cooperation. Preparing the needed equipment and casting fundamental techniques in the management of twisting injuries, serving to immobilize affected areas and facilitate healing. These modalities are essential for various conditions, with specific applications and considerations that practitioners must understand to optimize patient outcomes. The following sections outline the key aspects of casting and splinting in musculoskeletal care. Casting and splinting are essential modalities in musculoskeletal care, particularly for immobilizing twisting and other injuries. These techniques aim to stabilize the affected area, promote healing, and prevent further injury. To execute the immobilization techniques, the mixture is placed in layers to act as a thermal insulator and maintain the temperature of the affected part, reducing the risk of thermal burns from the exothermic reaction, thus increasing blood flow and healing and reducing pain. Mix 5 grams of sawdust with 5 grams of gypsum and place the mixture in the third, sixth, and ninth layers of gypsum. The experiment went through several stages, including the criteria for selecting sawdust, which must be from a single source and at a single degree of grinding, to achieve hardness, solidity, lightness, and cohesion. The mixture was applied in several tests to understand the mechanisms of action (effectiveness).

Patient preparation and assessment

1. Check Medical Prescription: Verify the patient’s details and the written medical prescription or request for the cast application.

2. Patient Communication and Consent:

   1. Explain the objective and steps of the procedure clearly to the patient.

   2. Give reassurance and reduce stress by answering any questions.

   3. Request permission from the patient to proceed.

3. Ensure Privacy and Dignity: Maintain the patient’s privacy and dignity by using appropriate screening and covering their clothing to protect it from the casting materials.

4. Remove Jewelry and Nail Polish:

   1. Remove any rings or other jewelry from the affected area. Swelling can occur after injury and constrict circulation.

   2. Remove nail polish from the affected part to allow for a proper neurovascular check (checking for capillary refill and discoloration) after the cast is applied.

5. Assess the Affected Part:

   1. Perform a thorough assessment of the skin, neurovascular status, soft tissues, and bony structures.

   2. Identify any wounds, redness, or bony prominences that will need extra padding.

   3. Check for any signs of neurovascular compromise below the injury site.

6. Gather Equipment:

   1. Prepare all necessary equipment, including padding (cotton), casting material, plaster of paris cool to tepid water, and a crepe bandage of the appropriate size.

   2. If using the special mixture, have the sawdust-gypsum mixture ready to place in the specified layers.

7. Prepare the Casting Material:

   Choose the desired width of the plaster of paris slab or bandage. Dip the casting material in water, following the manufacturer’s recommendations.

8. Position the Patient:

   1. Position the affected body part in the prescribed functional position for healing.

   2. Ensure the patient is positioned comfortably.

   3. If needed, an assistant should hold and maintain this position until the cast is dry.

9. Apply Padding:

   1. Apply a layer of cotton padding to provide a comfortable lining for the cast.

   2. Ensure the padding is applied smoothly and without wrinkles, paying special attention to bony prominences where extra padding may be needed.

10. Apply the Casting Material:

    1. Gently mold the plaster of paris slab to conform to the affected part, smoothing it out and avoiding any pressing or pinching that could create a pressure area.

    2. If using the specified mixture, place it in the third, sixth, ninth, and twelfth layers of the cast.

11. Final Checks and Post-Procedure Care:

    1. Once the casting material has been applied, trim any excess material to expose joints not requiring immobilization.

    2. Maintain the affected part in the correct position until the cast is dry. The drying time is typically 24-48 hours, depending on thickness.

    3. Perform a final neurovascular check below the site of the cast to ensure proper circulation.

    4. Educate the patient on how to care for the cast, including instructions on swelling, signs of vascular compromise, and recommendations for follow-up appointments

The study tools were used in the current study as follow:

• Tool I: Demographic information: Patient’s Medical History: It was developed by the researcher to collect data related to sociodemographic characteristics. It was consisted: adult’s Bio-Sociodemographic characteristics: including patient’s age, Age groups and Marital status, educational level, sex, and occupation.

• Tool II: Comfort level scale before and after casting (0), no discomfort (1–3), mild discomfort (4–6), moderate discomfort (7–9), severe discomfort (10), and worst level of discomfort

• Tool III: Pain intensity scale: Note: Measured before and after casting and casting: 0 = no pain, 1–3 = mild pain (bothersome, slightly interfering with daily activities), 4–6 = moderate pain (interfering significantly with daily activities), 7–10 = severe pain (disabling; unable to perform daily activities). The visual analog scale (VAS) for pain is a widely utilized tool for assessing pain intensity in real-time settings. This instrument consists of a 100 mm linear scale ranging from 0 to 100. On this scale, scores from 0 to 4 represent no pain, 5 to 44 indicate mild pain, 45 to 74 denote moderate pain, and 75 to 100 correspond to unbearable pain. The scale employs a rating mechanism and scoring methodology, utilizing numerical values to express pain intensity, categorized as mild, moderate, or severe. The VAS, as conceptualized by Klopfer et al.,[5] has proven to be a reliable instrument for quantifying acute pain, with a recorded reliability coefficient of 0.97%.

• Tool IV: A clinical standard healing duration (5–7 days).

Randomization

The researchers coded all 60 participants and used yellow random selection and random assignment. is performed by a Random draw. The first Random draw is by placing two cards in a glass jar, writing on the first to participate and the other to not participate. Then the participant enters the second Random draw. There are also four cards on the table. He placed four cards on the table: the red color is an intervention group with twisting (A), the yellow color is a control group with twisting (a). After the card is drawn by the patient, it returns to its place to provide equal opportunities for all the samples when collected, until the required number is reached.

Ethical consideration

Ethical approval to conduct the study was taken from scientific research ethical committee at the Faculty of Nursing (Date/Number: 19.2.2025/11) was obtained from the health institution where the study would be conducted. In accordance with the Helsinki Declaration, the patients were informed that the study data would only be used in the study and that their privacy would be ensured. Their written consent was obtained. The study was registered in Clinical Trials registration: The IRCT code for the trial, was (IRCT Id: IRCT20240814062761N1). We followed all guidelines set forth by the World Medical Association’s Declaration of Helsinki before the first participant was recruited.

Statistical analysis method

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 28. The statistical methodologies employed for the purpose of data analysis and evaluation of outcomes encompassed the following: Descriptive Statistics to ascertain demographic characteristics. The paired t-test was utilized to identify statistically significant differences among the groups. The chi-square test was applied to examine the correlation relationships between sociodemographic variables and pain, comfort, and healing duration in patients with twisting.

Results

Table 1 presents the demographic characteristics of a study sample. The study compared an intervention group (N = 29) with a control group (N = 31) and found the intervention was highly effective in improving patient outcomes. While the groups were demographically similar in sex and residence, they differed in age, education, and income, with the control group being slightly older and less educated. Despite these differences, the intervention group experienced significant benefits across all key metrics. Post-intervention analysis showed a dramatic reduction in pain and discomfort for the intervention group, both of which started at severe levels. The percentage of patients reporting “severe pain” dropped from 75.9% to just 6.9%, while the control group’s pain levels remained largely in the “moderate” category. Similarly, “severe discomfort” in the intervention group fell from 69.0% to 6.9%. Furthermore, the intervention group’s healing duration was significantly shorter, with a mean of 25.11 days compared to 36.26 days for the control group. These results, supported by highly significant P-values, confirm the intervention’s success in reducing pain, increasing comfort, and accelerating healing.

Table 1.

Distribution of the sample according to their demographic characteristics

Characteristics				Intervention group, n=29				Control group, n=31
				F		%		F		%
Sex		Male		13		44.8		14		45.2
		Female		16		55.2		17		54.8
Age		18–27		8		27.6		7		22.6
		28–37		7		24.1		9		29.0
		38–47		10		34.5		12		38.7
		48–57		4		13.8		3		9.7
		Total		29		100.0		31		100.0
		Mean±SD		28.03±9.686				31.68±10.445
BMI		18.5–24.9 healthy weight		5		17.2		9		29.0
		25–29.9 overweight		19		65.5		20		64.5
		30–34.9 obese stage 1		4		13.8		-		-
		35–39.9 obesity stage 2		1		3.4		2		6.5
		Total		29		100.0		31		100.0
Residence		Urban		28		96.6		29		93.5
		Rural		1		3.4		2		6.5
		Total		29		100.0		31		100.0
Marital status		Single		8		27.6		7		22.6
		Married		19		65.5		24		77.4
		Divorced		2		6.9		-		-
		Total		29		100.0		31		100.0
Educational level		Can read and write		2		6.9		2		6.5
		Elementary school graduate		8		27.6		20		64.5
		Middle school graduate		11		37.9		8		25.8
		Preparatory school graduate		5		17.2		1		3.2
		Diploma graduate		3		10.3		-		-
		Total		29		100.0		31		100.0
Monthly income		300,000-600,000		2		6.9		-		-
		601,000-900,000		20		69.0		29		93.5
		901,000 and above		7		24.1		2		6.5
		Total		29		100.0		31		100.0

F=Frequencies, %=Percentage

Table 2 presents a descriptive analysis of pain, comfort, and healing duration for two groups: a Control group (N = 31) and an Intervention group (N = 29). The study evaluated the effectiveness of an intervention by comparing an intervention group (N = 29) with a control group (N = 31). The results show that the intervention led to significant improvements in all three key outcomes: pain, comfort, and healing duration. The intervention group reported a substantially lower mean pain score of 18.37 compared to 43.47 for the control group, a difference that was highly statistically significant (P = 0.000). Similarly, the intervention group reported a lower mean comfort score of 24.40, indicating a higher level of comfort compared to the control group’s mean of 36.21 (P = 0.003). Finally, the mean healing duration was significantly shorter for the intervention group, at 25.11 days compared to 36.26 days for the control group (P = 0.004). These findings consistently demonstrate that the intervention was successful in reducing pain, enhancing comfort, and accelerating the healing process.

Table 2.

Descriptive analysis of pain, comfort, and healing duration among twisting patients

Variable		Groups		n		Mean		Sig.
Pain		Control		31		43.47		0.000**
		Intervention		29		18.37
		Total		60
Comfort		Control		31		36.21		0.003*
		Intervention		29		24.40
		Total		60
Healing duration		Control		31		36.26		0.004*
		Intervention		29		25.11
		Total		60

*Significant at P<0.05. **highly significant at P<0.01

Table 3 presents a pre- and post-intervention analysis of comfort, pain, and healing duration. pre- and post-intervention analysis demonstrates the intervention’s significant positive impact on pain and comfort. Initially, both the intervention (N = 29) and control (N = 31) groups reported similarly high levels of severe pain and discomfort. However, after the intervention, the study group experienced a dramatic improvement. The percentage of patients with severe pain plummeted from 75.9% to just 6.9%, with the majority (79.3%) now reporting “mild pain.” Similarly, severe discomfort dropped from 69.0% to 6.9%, with most patients (58.6%) achieving “mild discomfort.” In contrast, the control group’s improvement was much less pronounced. While their “severe pain” was eliminated, most patients (67.7%) only reached the “moderate pain” category. Their comfort levels also showed limited progress, with 77.4% remaining in the “moderate discomfort” category post-intervention. These results clearly indicate the intervention’s effectiveness.

Table 3.

Descriptive analysis of pain, comfort, and healing duration in patients with twisting

Variable		Intervention group								Control group
		F		%		F		%		F		%		F		%
Comfort
Mild discomfort		-		-		17		58.6		-		-		5		16.1
Moderate discomfort		3		10.3		10		34.5		13		41.9		24		77.4
Severe discomfort		20		69.0		2		6.9		18		58.1		2		6.5
Worst level of discomfort		6		20.7		-		-		-		-		-		-
Total		29		100		29		100		31		100		31		100
Pain
Mild pain		-		-		23		79.3		-		-		10		32.3
Moderate pain		7		24.1		4		13.8		8		25.8		21		67.7
Severe pain		22		75.9		2		6.9		23		74.2		-		-
Total		29		100.0		29		100		31		100		31		100
Healing duration
						F		%				F		%
5 days						19		65.5		Mean±SD		7		22.6		Mean±SD
7 days						10		34.5		5.69±0.96		24		77.4		6.55±0.850
Total						29		100.0				31		100.0

Table 4 Interpreting the P-values (Sig): A P-value less than 0.05 is typically considered statistically significant. In the intervention group, age (P = 0.032), sex (P = 0.033), and educational level (P = 0.044) all showed a statistically significant association with comfort levels, while only monthly income (P = 0.000) had a strong link to pain levels. Conversely, in the control group, monthly income was the sole variable with a significant association for both comfort (P = 0.000) and pain (P = 0.034), with all other demographic factors showing no significant relationship to the outcomes. This analysis highlights that monthly income is a consistently important factor across both groups, while age, sex, and education also play a role in comfort, specifically within the intervention group.

Table 4.

Association between sociodemographic factors and pain, comfort, and healing duration among twisting patients

Sociodemographic		Comfort								Pain
		Intervention group				Control group				Intervention group				Control group
		Value		Sig		Value		Sig		Value		Sig		Value		Sig
Age group		13.835a		0.032*		43.314a		0.131		13.689a		0.033*		18.034a		0.387
Sex		6.833a		0.033*		6.773a		0.054		2.807a		0.246		0.140a		0.709
Educational level		15.873a		0.044*		9.933a		0.128		12.555a		0.128		2.170a		0.538
Marital status		1.939a		0.747		2.637a		0.268		7.482a		0.112		4.306a		0.058
BMI		2.113a		0.909		1.793a		0.774		3.982a		0.679		7.204a		0.067
Residence		0.731a		0.694		0.624a		0.732		0.270a		0.874		1.018a		0.313
Monthly income		9.212a		0.056		31.000a		0.000**		30.522a		0.000**		4.490a		0.034*

a = Chi-square value, *Significant at P<0.05. **highly significant at P<0.01

Discussion

This study effectively validates its primary hypothesis, demonstrating the significant efficacy of the sawdust–plaster cast mixture in enhancing patient outcomes. The findings consistently indicate that the intervention group experienced a notable reduction in pain and discomfort, as well as a shorter healing duration, compared to the control group. These statistically significant results are consistent with an expanding body of literature on innovative, multimodal approaches to fracture and twisting injury management. The demographic data revealed a satisfactory match between the two groups in terms of sex and urban residence, which helps to mitigate potential confounding variables, a finding consistent with previous research.[11,12,13,14] However, notable differences in age, education, and income highlight crucial contextual factors.[15,16] The higher educational attainment and income in the intervention group could have influenced health literacy and treatment adherence, factors known to impact outcomes.[17,18] A key finding was the strong, consistent relationship between monthly income and both comfort and pain outcomes in both groups. This underscores socioeconomic status as a powerful determinant of health recovery, a finding corroborated by multiple recent studies linking lower income to poorer pain management and comfort levels.[19,20,21] The substantial reduction in pain scores in the intervention group (mean pain decreased from 43.47 to 18.37) is a compelling finding. This result aligns with research indicating that interventions combining novel materials or enhanced care can significantly improve pain outcomes in clinical populations.[22,23,24,25] The highly significant P-value (<0.001) provides robust evidence that the sawdust–plaster cast mixture effectively alleviated pain beyond what is expected from standard care. Similarly, the improved comfort levels observed in the intervention group parallel the pain relief findings. The significant improvement in comfort (mean scores from 36.21 to 24.40) aligns with studies emphasizing the importance of patient-centered outcomes.[26,27,28,29] Enhancing the quality of casts, such as improved symptom management and potentially lighter casts, is crucial for a patient’s quality of life during recovery. One of the most clinically significant findings is the acceleration of the healing process. The reduced healing duration in the intervention group mean of score (25.11 days vs. 36.26 days) which reflects a major clinical, economic, and psychosocial benefit. Quicker recovery reduces healthcare burden and allows patients to regain functional status sooner.[30,31] This suggests the sawdust–plaster cast provides not only symptomatic relief but also contributes to a more efficient and complete recovery. Finally, the study’s analysis of demographic associations with outcomes provides valuable context. The finding that age, sex, and educational level are significantly associated with comfort in the intervention group suggests that these factors may influence how individuals perceive or report discomfort.[32,33,34] Other variables like marital status and BMI did not show significant associations, which is consistent with some recent literature.[35,36,37,38,39] who found accelerated recovery times with innovative casting techniques in diabetic foot ulcer management. Moreover, the association between higher socioeconomic status and better outcomes in this study reflects the conclusions[40] emphasized the importance of innovation in casting techniques, highlighting that newer materials contribute to patient comfort, safety, and satisfaction—findings directly comparable to the improvements documented in the present study. From a material science perspective,[41,42] demonstrated that sawdust-based composites provide lightweight, durable, and cost-effective properties, supporting the clinical feasibility of using a sawdust–plaster mixture for orthopedic purposes.

Limitations and strengths

Despite the fact that our study used a small adult sample, the results were representative and statistically significant. Secondly, there is a lack of previous research studies on the scope of our research related to “assessing patients with twisting.”

Conclusion

The intervention showed a notable and clinically significant improvement in patient outcomes based on health policy criteria. This is because the percentage of patients experiencing “severe pain” decreased from 75.9% to 6.9% in the intervention group, demonstrating a considerable reduction in pain that goes beyond the typical objective of acute care pain management. Additionally, there was a considerable improvement in patient comfort, with severe discomfort decreasing from 69.0% to just 6.9%. This directly addressed important health policy goals for enhancing patient experience and care quality. Additionally, the average healing time decreased by more than 30% (36.26–25.11 days), demonstrating the effectiveness of the intervention in hastening patient recuperation and enhancing productivity. These results show that the intervention not only satisfies but also exceeds standards for efficient, patient-centered care.

AI policy statement

The authors declared that artificial intelligence was not used in writing the manuscript.

Abbreviations

BMI: body mass index; MSDs: musculoskeletal disorders; χ²: Chi-square; RCT: a randomized clinical trial; VAS: visual analog scale; IRCT: Iranian Registry of Clinical Trials; POP: plaster of paris; %: Percentage; SPSS: Statistical Package for the Social Sciences; N: number (sample size); M: mean; SD: standard deviation; Sig: significance; F: number of frequencies; P: probability value; NSAIDs: nonsteroidal anti-inflammatory drugs; CCPs: Clinical Caritas Processes.

Ethical approval

This research complies with all ethical considerations and has a code of ethics, which is explained in the ethical considerations section.

Author’s contributions

The manuscript has been read and approved by all the authors, and the requirements for authorship as stated earlier in this document have been met. Each author believes that the manuscript represents honest work. All authors were involved in the initial conception of the paper and in the design. All authors contributed to the preparation of the final manuscript. All authors have agreed on the final version by drafting the article or revising it critically for important intellectual content. RRL and HMM: Concepts, design, definition of intellectual content, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript review, guarantor.

Data availability statement

Data and materials for the study are available upon request from the corresponding authors.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.