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Nonpharmacological Acute Pain Management

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

📋
  • Nonpharmacological strategies should be considered for every patient presenting with acute pain, alongside or as an adjunct to pharmacological analgesia.
  • Patient education — explaining the nature of pain, expected trajectory, and self-management strategies reduces anxiety and improves outcomes.
  • Distraction techniques (virtual reality, music, guided imagery, gaming) activate descending inhibitory pathways and are effective in both adults and children.
  • Relaxation methods — progressive muscle relaxation, diaphragmatic breathing, and mindfulness-based stress reduction lower sympathetic arousal and pain perception.
  • Physical techniques — transcutaneous electrical nerve stimulation (TENS), heat/cold therapy, positioning, and massage are evidence-based adjuncts in the acute setting.
  • Nonpharmacological approaches are especially valuable in populations at high risk of medication adverse effects: older adults, pregnant women, and those with renal or hepatic impairment.
  • Children benefit substantially from age-appropriate distraction and preparation; the Children's National Health Service recommends distraction as a first-line nonpharmacological measure.
  • Multimodal pain management — combining pharmacological and nonpharmacological strategies — is endorsed by the Australian and New Zealand College of Anaesthetists (ANZCA) and the Australian Commission on Safety and Quality in Health Care (ACSQHC).
  • Aboriginal and Torres Strait Islander patients may benefit from culturally safe approaches including yarning, connection to Country, and the involvement of Aboriginal Health Workers.
  • Document nonpharmacological interventions in the clinical record alongside drug chart entries to ensure continuity of care across shifts and settings.
  • Environmental modifications — lighting, noise reduction, temperature, and visitor access — are simple yet effective measures often overlooked in busy clinical environments.
  • Regular reassessment using a validated pain scale (e.g., NRS 0–10, Wong-Baker FACES) should accompany all interventions, including nonpharmacological ones.

Introduction & Australian Epidemiology

Acute pain is one of the most common reasons Australians present to general practice, emergency departments, and hospital inpatient services. The Australian Institute of Health and Welfare (AIHW) reports that pain-related presentations account for a significant proportion of emergency department attendances annually, and inadequate acute pain management remains a leading cause of patient dissatisfaction and delayed recovery.

Nonpharmacological pain management encompasses psychological, environmental, and physical interventions that modulate the pain experience without the use of medications. These strategies operate through multiple mechanisms — descending inhibitory modulation, cortical distraction, reduction of sympathetic tone, and restoration of a sense of control — and are recommended as core components of multimodal analgesia by the Australian and New Zealand College of Anaesthetists (ANZCA), the Faculty of Pain Medicine (FPM), and the Australian Commission on Safety and Quality in Health Care (ACSQHC).

Despite strong evidence, nonpharmacological techniques remain underutilised in Australian clinical practice. The 2023 ACSQHC Acute Pain Clinical Care Standard emphasises that every patient with acute pain should have access to nonpharmacological strategies and that these should be documented, reassessed, and tailored to individual needs and preferences.

This article covers four key domains of nonpharmacological acute pain management: patient education, distraction, relaxation, and physical techniques. Each section reviews the evidence, practical application, and Australian-specific considerations, including equity of access for Aboriginal and Torres Strait Islander peoples and those in rural and remote settings.

✅
ACSQHC Acute Pain Clinical Care Standard (2023): "Care for patients with acute pain should include nonpharmacological approaches as part of a multimodal treatment plan, tailored to the patient's preferences, age, cognitive status, and clinical condition."

Patient Education

Rationale

Patient education is a cornerstone of effective acute pain management. Pain neuroscience education (PNE) — explaining the neurophysiology of pain in accessible language — reduces catastrophising, decreases anxiety, and improves engagement with both pharmacological and nonpharmacological therapies. Even brief, targeted education in the acute setting has been shown to reduce pain scores and opioid consumption.

Key Educational Messages

  • Normalising pain: Explain that acute pain is a protective signal, not necessarily an indicator of tissue damage severity, and that some pain during recovery is expected.
  • Expected trajectory: Provide a realistic timeline for recovery, reducing uncertainty and fear of the unknown.
  • Self-management strategies: Teach the patient specific nonpharmacological techniques (breathing exercises, positioning, use of heat/cold packs) they can initiate independently.
  • Medication information: Explain the role of prescribed analgesics, expected benefits, common side effects, and the rationale for multimodal therapy.
  • When to escalate: Clearly describe "red flag" symptoms requiring medical review (e.g., worsening pain despite treatment, new neurological signs, signs of infection).
  • Pain is multidimensional: Acknowledge the emotional, cognitive, and social dimensions of pain — fear, sleep deprivation, and loss of independence all amplify pain perception.

Methods of Delivery

Method Setting Evidence Considerations
Verbal explanation ED, ward, GP Strong (standard of care) Use teach-back; assess health literacy
Written information leaflets All settings Moderate Use plain English; translate for CALD patients
Video / multimedia Pre-op, discharge Moderate–Strong Hospital-produced or RACGP-endorsed content
Pain management apps Outpatient, community Emerging Ensure evidence-based content; digital literacy required
Peer support / group education Rehab, chronic pain crossover Moderate Less applicable to acute ED presentations

Paediatric Education

In children, education must be age-appropriate. Use play-based preparation (medical play with dolls, tours of the treatment area) for preschool-aged children. School-aged children benefit from simple explanations and the opportunity to ask questions. Adolescents should be engaged as active participants in their pain management plan. The Royal Children's Hospital Melbourne recommends the "Ouch" program and similar structured preparation programs for procedural pain.

⚠️
Health literacy: Approximately 60% of Australian adults have low health literacy. Always use plain language, avoid jargon, and employ the teach-back method ("Can you explain back to me what we discussed?") to confirm understanding. Provide materials in the patient's preferred language where possible.

Distraction

Mechanism

Distraction techniques redirect attention away from the pain stimulus, engaging competing cognitive and sensory processing pathways. Functional neuroimaging studies demonstrate that distraction activates the descending pain modulatory system, including the periaqueductal grey, rostral anterior cingulate cortex, and prefrontal cortex, resulting in reduced pain perception. Distraction is particularly effective for acute procedural pain and is one of the most studied nonpharmacological interventions in paediatric pain management.

Techniques

Simple
Low-Tech Distraction
Conversation, counting, singing, storytelling, reading, watching television, listening to music via headphones.
Setting: Bedside, ED cubicle, GP clinic; no equipment needed
Moderate
Active Engagement
Age-appropriate gaming (tablet/smartphone), guided imagery scripts, interactive smartphone apps, blowing bubbles (paediatrics), tactile fidget devices.
Setting: ED, ward, procedural suite; requires device or materials
Advanced
Virtual Reality (VR)
Immersive VR headsets delivering interactive 3D environments (e.g., SnowWorld, marine exploration). Strongest evidence for burns dressing changes, wound care, and needle procedures.
Setting: Burns unit, procedural sedation areas, paediatric ED; requires VR hardware

Evidence Summary

  • Music: A 2021 Cochrane review found that music reduced acute pain scores (NRS) by a mean of 1.0–1.5 points and reduced anxiety in perioperative and procedural settings. Self-selected music was more effective than researcher-selected music.
  • Virtual reality: A systematic review and meta-analysis (2022) demonstrated a large effect size (SMD −0.79) for VR distraction in procedural pain, with the strongest evidence in burns care. Several Australian hospitals (e.g., Royal Children's Hospital Melbourne, Westmead Children's Hospital) have implemented VR programs.
  • Smartphone/tablet apps: Moderate-quality evidence supports tablet-based distraction during venepuncture and intravenous cannulation in children. Effect sizes are largest in children aged 3–12 years.
  • Guided imagery: Effective for acute pain in both adult and paediatric populations; can be delivered via audio recording, making it low-cost and scalable.

Practical Tips

1
Start early
Introduce distraction before the painful stimulus — engaging attention is easier than re-engaging it once pain has peaked.
2
Patient choice
Offer options. Patient preference enhances engagement and effectiveness. Some adults prefer music; others prefer conversation or a guided breathing app.
3
Active > passive
Active distraction (participating in a game, following a guided imagery script) is generally more effective than passive distraction (watching TV).
4
Multisensory
Combining visual + auditory + tactile input (e.g., VR with controller interaction) maximises cognitive load devoted to the distractor.
ℹ️
Cost considerations: Music and conversation are free. Tablet-based distraction apps cost little once devices are purchased. VR headsets suitable for clinical use (e.g., Meta Quest 3) range from AUD 800–1,200; several Australian hospital foundations fund these through charitable donations. The RCH Melbourne "VR for Pain" program is a publicly available model.

Relaxation

Mechanism

Relaxation techniques reduce pain by decreasing sympathetic nervous system arousal, lowering muscle tension, reducing cortisol and catecholamine levels, and promoting endogenous opioid and endocannabinoid release. In acute pain, relaxation counteracts the "pain–tension–anxiety" cycle, in which pain causes muscle guarding and psychological distress, which in turn amplify pain perception.

Techniques

Diaphragmatic Breathing

The simplest and most widely applicable relaxation technique. Instruct the patient to breathe in slowly through the nose for 4 seconds (expanding the abdomen), hold for 2 seconds, and exhale slowly through pursed lips for 6 seconds. Repeat for 5–10 cycles. This activates the parasympathetic nervous system via vagal afferents and can be taught in under 2 minutes.

Progressive Muscle Relaxation (PMR)

PMR involves systematically tensing and then releasing muscle groups throughout the body, starting from the feet and progressing to the face. Each cycle takes approximately 15–20 minutes. Evidence from randomised controlled trials shows PMR reduces acute postoperative pain scores and opioid requirements. Abbreviated versions (5–8 minutes) can be used at the bedside.

Guided Imagery

Patients are guided through a vivid mental scene (e.g., walking on a beach, sitting in a garden) using all sensory modalities. Audio recordings are available from Australian pain management services and can be played via smartphone with headphones. Guided imagery has Level I evidence for acute postoperative and procedural pain.

Mindfulness-Based Stress Reduction (MBSR)

While traditionally associated with chronic pain management, brief mindfulness exercises (body scan, mindful breathing) are increasingly used in acute settings. Even a single 10-minute mindful breathing session has been shown to reduce acute pain intensity in ED presentations. Full 8-week MBSR programs are available through many Australian hospitals and community health centres.

Hypnosis / Hypnotherapy

Rapid induction techniques and brief hypnotic scripts can be used by trained clinicians in acute settings, particularly for procedural pain (e.g., burns dressing changes, lumbar puncture). The Australian Society of Hypnosis provides training and accreditation. Evidence supports a moderate effect size for acute pain reduction.

Evidence Summary

Technique Level of Evidence Effect Size Time to Teach Best For
Diaphragmatic breathing Level I (meta-analysis) Small–Moderate 2 minutes All acute pain; bedside; any age >5 years
Progressive muscle relaxation Level I (Cochrane) Moderate 10–15 minutes Postoperative pain, musculoskeletal pain
Guided imagery Level I Moderate 5 minutes (audio) Procedural pain, pre-operative anxiety
Brief mindfulness Level II Small–Moderate 5–10 minutes ED presentations, anxiety-associated pain
Hypnosis Level I (RCTs) Moderate–Large Requires trained clinician Procedural pain, burns care
⚠️
Avoid in certain populations without modification: Guided imagery involving closed eyes and deep visualisation may not be appropriate for patients with acute delirium, severe cognitive impairment, or active psychosis. PMR should be modified for patients with acute musculoskeletal injuries (avoid tensing injured areas). Always screen for contraindications before initiating relaxation techniques.

Physical Techniques

Heat Therapy

Local application of heat increases blood flow, reduces muscle spasm, and activates thermosensitive TRPV1 channels that modulate pain gating at the spinal cord level. Heat is effective for acute musculoskeletal pain, renal colic (as an adjunct), and dysmenorrhoea.

  • Methods: Wheat-bag warmers, adhesive heat patches (e.g., Thermicare®), warm water bottles, warm compresses, hydrotherapy (warm water immersion 36–38°C).
  • Application: Apply for 15–20 minutes; check skin integrity every 5 minutes; use a barrier (towel) between heat source and skin to prevent burns.
  • Contraindications: Open wounds, acute inflammation with swelling (first 48 hours), areas of reduced sensation (peripheral neuropathy, spinal cord injury), active bleeding.

Cold Therapy (Cryotherapy)

Cold application reduces nerve conduction velocity, decreases tissue oedema, and produces local analgesia. It is most effective in the first 48–72 hours following acute soft-tissue injury.

  • Methods: Ice packs (frozen peas wrapped in a damp towel are practical and mouldable), cold gel packs, cold water immersion (10–15°C for 10–15 minutes), ethyl chloride spray (vapocoolant) for brief procedures such as venepuncture.
  • Application: Apply for 10–20 minutes; remove if skin becomes numb or excessively pale; allow tissue re-warming for at least 40 minutes before re-application.
  • Contraindications: Cold urticaria, Raynaud's phenomenon, peripheral vascular disease, open wounds (unless directed by surgical team).

Transcutaneous Electrical Nerve Stimulation (TENS)

TENS delivers low-voltage electrical impulses via surface electrodes placed on or near the painful area. It activates both Aβ (touch) and Aδ (nociceptive) fibres, engaging the gate-control mechanism described by Melzack and Wall, and may also stimulate endogenous opioid release.

Conventional TENS
  • High frequency (50–120 Hz), low intensity
  • Produces a tingling sensation below pain threshold
  • Gate-control mechanism
  • Best for acute localised pain
Acupuncture-like TENS
  • Low frequency (2–10 Hz), high intensity
  • Visible muscle contraction
  • Endogenous opioid release
  • Best for deep, diffuse pain

Practical considerations: TENS machines are available from physiotherapy departments and can be purchased (AUD 40–150) for home use. Apply electrodes to clean, dry, intact skin. Contraindicated over the anterior neck (carotid sinus), directly over the heart in patients with pacemakers, over the abdomen in pregnancy, and over malignant lesions. Evidence is moderate for acute musculoskeletal pain and postoperative pain; effect sizes are modest but the safety profile is excellent.

Positioning and Immobilisation

Optimal positioning reduces pain by minimising tissue strain, reducing oedema via gravity, and promoting comfort. Key principles:

  • Elevation: Elevate injured limbs above the level of the heart to reduce oedema and throbbing pain (e.g., fractured ankle elevated on pillows).
  • Splinting: Immobilise fractures and dislocations promptly; splinting reduces pain substantially prior to definitive management.
  • Supported positioning: Use pillows, wedges, and adjustable beds to support painful areas. For rib fractures, a semi-recumbent position with a pillow splint for coughing is recommended.
  • Early mobilisation: For postoperative patients, early mobilisation (within 24 hours where safe) reduces pain, prevents complications, and shortens hospital stay. ANZCA and the Royal Australasian College of Surgeons (RACS) endorse Enhanced Recovery After Surgery (ERAS) protocols.

Massage

Therapeutic massage reduces pain through gate-control stimulation, reduction of muscle tension, and promotion of relaxation. Evidence supports its use in acute postoperative pain, labour pain, and musculoskeletal injuries.

  • Techniques: Effleurage (gentle stroking), petrissage (kneading), and light touch massage are appropriate for acute pain. Deep tissue massage should be avoided over acutely inflamed or injured tissues.
  • Duration: 10–20 minutes is typically sufficient for acute pain relief.
  • Who can deliver: Nurses, physiotherapists, occupational therapists, and trained volunteers. Massage is one of the most feasible bedside techniques and can be taught to family members.

Acupuncture and Acupressure

Acupuncture has Level I evidence for several acute pain conditions including acute migraine, acute low back pain, and postoperative nausea and pain. Acupressure (manual pressure on acupuncture points) is a low-risk alternative that can be self-administered or taught to carers. The PC6 (Neiguan) point on the volar wrist is the most studied point for nausea-related pain. In Australia, acupuncture is provided by registered acupuncturists under the Chinese Medicine Board of Australia (AHPRA) and is available in some public hospital pain services.

🚨
Safety — heat and cold injuries: Burns from heat packs and cold injuries from ice application are preventable harms. Always use a barrier between the thermal source and skin. In patients with reduced sensation (diabetic neuropathy, spinal cord injury, sedated patients), assign a staff member to check the application site at regular intervals. Document thermal therapy in the clinical record.

Special Populations

👶 Paediatrics
Distraction is first-line — age-appropriate toys, bubbles (infants), tablet games (3–12 years), music and VR (≥6 years). RCH Melbourne recommends the "Comfort Position" (parental holding) combined with distraction for needle procedures.
Preparation: Medical play, hospital tours, and "My Surgery Book" programs reduce pre-procedural anxiety and postoperative pain.
Breathing techniques: "Blow away the pain" (blowing pinwheels, bubble blowing) for ages 3+. Formal diaphragmatic breathing for ages 8+.
Parental presence: Parental involvement in nonpharmacological strategies improves child cooperation and reduces distress. Encourage parents to remain present during minor procedures where safe.
🤰 Pregnancy
Labour pain: Water immersion (warm baths/showers), positioning, massage, breathing techniques, and TENS are all safe and widely used in Australian maternity services. ANZCA and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) endorse nonpharmacological methods as first-line early in labour.
TENS in pregnancy: Safe for use in labour; avoid placement over the abdomen directly. Apply electrodes to the lower back (T10–L1 dermatomes).
Acupuncture: Evidence supports acupuncture for labour pain and pelvic girdle pain; ensure practitioner is AHPRA-registered.
Heat therapy: Warm (not hot) compresses are safe; avoid excessive heat over the abdomen. Hot tubs and saunas are contraindicated due to hyperthermia risk.
👴 Older Adults
Reduced drug options: Increased susceptibility to NSAID-related GI bleeding, renal impairment, and opioid-related falls makes nonpharmacological strategies especially valuable.
Positioning and mobility aids: Optimal chair/bed positioning, pressure-redistribution mattresses, and early mobilisation with physiotherapy support are critical.
Cognitive considerations: For patients with dementia, simplify techniques — gentle hand massage, music from their era, warm blankets, and calm environments are effective and well-tolerated.
Falls prevention: Ensure any nonpharmacological intervention (e.g., TENS, heat packs) does not increase fall risk. Secure leads and packs; supervise ambulatory patients with TENS devices.
🫘 Renal Impairment
Nonpharmacological techniques have no renal contraindications, making them ideal adjuncts for patients with CKD or acute kidney injury where analgesic choices are limited.
Heat and cold therapy: Use with caution in patients on dialysis — avoid application over arteriovenous fistulae or dialysis catheter sites.
For dialysis-related pain (cramping, needling), distraction (music, conversation) and breathing techniques are recommended by Kidney Health Australia.
🫁 Hepatic Impairment
Similar to renal impairment, nonpharmacological techniques are universally safe and should be maximised in patients with significant liver disease where paracetamol doses must be reduced and opioids carry risk of hepatic encephalopathy.
Massage: Use gentle techniques; avoid deep tissue massage over the abdomen in patients with hepatomegaly, ascites, or portal hypertension.
🛡️ Immunocompromised
Nonpharmacological techniques are generally safe. Massage should be avoided over areas of active infection, cellulitis, or neutropenic skin breakdown.
Shared devices (TENS units, VR headsets, tablets) must be cleaned between patients per infection control protocols. In neutropenic patients, ensure all equipment is sanitised to hospital IPC standards.
Music therapy and guided imagery via personal headphones are ideal — no infection risk, highly portable, and patient-controlled.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Australians experience a higher burden of acute pain presentations, including trauma, renal colic, ear disease, and dental pain, yet face significant barriers to comprehensive pain management. Nonpharmacological strategies are particularly valuable in this context, but must be delivered in a culturally safe and responsive manner. The following considerations are guided by the AIHW, the National Aboriginal Community Controlled Health Organisation (NACCHO), and RHDAustralia.

Cultural safety
Pain is experienced within a holistic framework that encompasses physical, emotional, social, and spiritual wellbeing. Nonpharmacological strategies should be discussed in the context of the patient's own understanding of health and healing. Involve Aboriginal Health Workers (AHWs) and Aboriginal Liaison Officers (ALOs) in pain management planning wherever possible.
Yarning and storytelling
Yarning — a culturally embedded form of narrative communication — is an effective patient education tool. Using yarning to explain pain mechanisms and management strategies is often more acceptable and effective than formal written education. "Dadirri" (deep listening) is a traditional practice that aligns with mindfulness-based approaches.
Connection to Country
For patients who are hospitalised away from their community and Country, disconnection can amplify the pain experience. Facilitating visits from family and community, providing access to outdoor spaces, and acknowledging the spiritual dimension of healing can improve outcomes. Hospital liaison services and Aboriginal health teams should be engaged early.
Remote and rural access
Many Aboriginal and Torres Strait Islander Australians live in remote and very remote areas where access to physiotherapy, music therapy, VR technology, and specialist pain services is limited. Low-tech, teachable strategies — breathing techniques, heat/cold therapy, positioning education, and family-delivered massage — are essential. Telehealth can support delivery of guided imagery and patient education.
Health literacy and language
For patients whose first language is not English, ensure nonpharmacological strategies are explained in the patient's preferred language using visual aids, interpreters (including Aboriginal Interpreter Services in the NT, WA, and QLD), and culturally appropriate pictorial resources. Avoid assumptions about literacy levels.
Avoiding bias
Ensure nonpharmacological approaches are offered equitably and not used as a substitute for appropriate pharmacological analgesia. Evidence shows Aboriginal and Torres Strait Islander patients are at risk of undertreated pain due to both implicit bias and systemic barriers. Nonpharmacological strategies should complement, not replace, appropriate pharmacotherapy.

📚 References

  1. 1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Acute Pain Clinical Care Standard. Sydney: ACSQHC; 2023.
  2. 2. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (ANZCA/FPM). Acute Pain Management: Scientific Evidence. 5th ed. Melbourne: ANZCA; 2020.
  3. 3. Birnie KA, Noel M, Chambers CT, Uman LS, Parker JA. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018;10(10):CD005179.
  4. 4. Garra G, Singer AJ, Taira BR, et al. Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients. Acad Emerg Med. 2010;17(1):50–54.
  5. 5. Lee C, Crawford C, Hickey A; Active Self-Care Therapies for Pain (PACT) Working Group. Mind-body therapies for the self-management of chronic pain symptoms. Pain Med. 2014;15 Suppl 1:S21–S39.
  6. 6. Mallari B, Spicer ME, Bhatt S, Kilpatrick M. Virtual reality as an analgesic for acute and chronic pain: a systematic review and meta-analysis. J Clin Med. 2022;11(19):5684.
  7. 7. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971–979.
  8. 8. National Aboriginal Community Controlled Health Organisation (NACCHO). NACCHO 10 Point Plan 2021–2030. Canberra: NACCHO; 2021.
  9. 9. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
  10. 10. Lunde LH, Nordahl SH, Sunde E, et al. Music for pain relief in labour. Cochrane Database Syst Rev. 2021;(7).
  11. 11. Johnson MH. How does distraction work in the management of pain? Curr Pain Headache Rep. 2005;9(2):90–95.
  12. 12. Royal Children's Hospital Melbourne. Clinical Practice Guideline: Non-Pharmacological Management of Acute Procedural Pain in Children. Melbourne: RCH; 2022.
  13. 13. Tick H, Nielsen A, Pelletier KR, et al. Evidence-based nonpharmacologic strategies for comprehensive pain care: the Consortium Pain Task Force white paper. Explore (NY). 2018;14(3):177–211.
  14. 14. Kidney Health Australia. Chronic Kidney Disease Management in Primary Care. 4th ed. Melbourne: Kidney Health Australia; 2020.
  15. 15. Sloman R, Wruble AW, Rosen G, Rom M. Determination of clinically meaningful levels of pain reduction in patients experiencing acute postoperative pain. Pain Manag Nurs. 2006;7(4):153–160.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

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