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Pain Assessment

Last updated 1 Jun 2026 Β· Pain & analgesia

πŸ“‹ Key Information Summary

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  • Comprehensive pain assessment identifies pain type (nociceptive, neuropathic, nociplastic), cause, severity, functional impact and relevant psychosocial contributors β€” it is the foundation of safe, effective analgesic prescribing.
  • A structured pain history uses the OLDCARTS mnemonic (Onset, Location, Duration, Character, Aggravating/relieving factors, Radiation, Timing, Severity) supplemented by a neuropathic pain screen.
  • Always document pain severity with a validated tool: Numeric Rating Scale (NRS 0–10), Visual Analogue Scale (VAS), or β€” for non-verbal adults β€” the Abbey Pain Scale; use the FLACC or Wong-Baker FACES scale in paediatric patients.
  • Neuropathic pain features (burning, shooting, allodynia, dysaesthesia) should prompt use of a screening tool such as the DN4 or painDETECT; positive screens guide pharmacotherapy towards adjuvant agents (gabapentinoids, TCAs, SNRIs).
  • Functional impact is assessed by documenting effects on activities of daily living (ADLs), sleep, mood, work capacity and social participation β€” use the Brief Pain Inventory (BPI) or Γ–rebro Musculoskeletal Pain Screening Questionnaire.
  • Psychosocial yellow flags (catastrophising, fear-avoidance, secondary gain, depression, anxiety) predict chronicity and poor outcomes; screen early with the STarT Back tool, PHQ-9, GAD-7 or DASS-21.
  • Physical examination must include targeted musculoskeletal and neurological examination, with assessment for red flags suggesting serious underlying pathology (malignancy, cauda equina, fracture, infection, vascular compromise).
  • Investigations are guided by clinical suspicion β€” plain imaging is not routinely indicated for non-specific low back pain < 6 weeks; reserve MRI for red-flag presentations or failure to improve with conservative care.
  • Special populations (elderly, pregnant, paediatric, renal/hepatic impairment) require adapted assessment tools and modified pain severity thresholds for intervention.
  • Aboriginal and Torres Strait Islander patients may express pain differently; culturally safe assessment requires awareness of language barriers, historical distrust, and the role of family and community in decision-making.
  • Reassessment is mandatory β€” document pain scores at baseline, after each intervention, and at every follow-up to guide escalation or de-escalation of analgesic therapy.
  • Chronic pain assessment should be framed within a biopsychosocial model rather than a purely biomedical one, consistent with the Australian National Pain Strategy and Pain Australia recommendations.

Introduction & Australian Epidemiology

Pain is the most common reason Australians seek medical care and is the leading cause of disability nationally. Effective pain management begins with a structured, comprehensive assessment that identifies the pain mechanism, its severity, its functional consequences, and the psychosocial factors that modulate the pain experience. A thorough assessment informs appropriate pharmacological and non-pharmacological therapy, reduces the risk of opioid over-prescribing, and improves patient outcomes.

The International Association for the Study of Pain (IASP, 2020) revised its definition of pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." This definition emphasises that pain is a subjective, multidimensional experience that cannot be reliably inferred from imaging, pathology or behaviour alone.

Australian Burden of Pain

  • Approximately 3.4 million Australians (16% of the population) live with chronic pain (lasting > 3 months), according to Pain Australia and AIHW data (2023).
  • Chronic pain costs the Australian economy an estimated 9 billion annually in direct healthcare costs, lost productivity and reduced quality of life (Deloitte Access Economics, 2019).
  • Low back pain is the leading cause of disability burden in Australia (GBD 2019), followed by neck pain, migraine and osteoarthritis.
  • Aboriginal and Torres Strait Islander Australians experience chronic pain at approximately twice the rate of non-Indigenous Australians, with significant disparities in access to pain services.
  • The Australian National Pain Strategy (2010) and Pain Australia's National Strategic Action Plan for Pain Management (2019) advocate for a biopsychosocial, patient-centred approach to pain assessment across all healthcare settings.

Pain Classification (IASP Taxonomy)

Pain Type Mechanism Typical Descriptors Common Causes
Nociceptive β€” Somatic Activation of peripheral nociceptors by tissue damage or inflammation Sharp, aching, throbbing, well-localised Fractures, surgical wounds, osteoarthritis, soft-tissue injury
Nociceptive β€” Visceral Activation of visceral afferents from organ distension, ischaemia or inflammation Deep, cramping, squeezing, poorly localised, may refer Renal colic, appendicitis, mesenteric ischaemia, bowel obstruction
Neuropathic Lesion or disease of the somatosensory nervous system Burning, shooting, electric-shock, tingling, allodynia, dysaesthesia Diabetic neuropathy, post-herpetic neuralgia, radiculopathy, spinal cord injury
Nociplastic Altered nociception without clear tissue damage or somatosensory lesion Diffuse, widespread, fatigue-associated, disproportionate to findings Fibromyalgia, chronic widespread pain, irritable bowel syndrome, chronic fatigue
Mixed Combination of two or more mechanisms Variable β€” features of more than one type Cancer pain, failed back surgery syndrome, chronic regional pain syndrome
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Red flags requiring urgent investigation: New-onset pain in patients > 50 years with unexplained weight loss, night pain, history of malignancy, saddle anaesthesia, bladder/bowel dysfunction, progressive neurological deficit, fever, IV drug use, immunosuppression, or trauma with suspected fracture. These features mandate urgent imaging and specialist referral.

Pain History

A systematic pain history is the cornerstone of pain assessment. It establishes the pain mechanism, identifies potential causes, screens for red flags, and informs the initial management plan. Allocate sufficient time β€” a comprehensive pain history typically requires 15–20 minutes in general practice.

Systematic Approach β€” OLDCARTS Mnemonic

Element Questions to Ask Clinical Significance
Onset When did it start? Sudden or gradual? What were you doing? Acute onset with identifiable mechanism suggests nociceptive; insidious onset may suggest inflammatory or neoplastic pathology
Location Where exactly? Can you point with one finger? Does it move? Well-localised β†’ somatic; diffuse/widespread β†’ nociplastic; dermatomal β†’ neuropathic; referred patterns β†’ visceral
Duration How long have you had it? Constant or intermittent? How long does each episode last? < 3 months = acute/subacute; > 3 months = chronic (requires biopsychosocial framework)
Character What does it feel like? Sharp, dull, burning, shooting, cramping, aching, electric? Burning/shooting/electric β†’ neuropathic; throbbing/aching β†’ nociceptive; cramping β†’ visceral
Aggravating factors What makes it worse? Movement, rest, eating, stress, time of day? Worse with movement β†’ mechanical/musculoskeletal; worse at rest β†’ inflammatory or neoplastic; worse with eating β†’ visceral
Relieving factors What makes it better? Rest, heat, cold, medications, position? Response to specific agents helps confirm mechanism (e.g. GTN β†’ oesophageal; anti-inflammatory β†’ inflammatory)
Radiation Does it travel or spread anywhere? Down the leg? Into the shoulder? Into the jaw? Dermatomal radiation β†’ radiculopathy; shoulder tip β†’ diaphragmatic irritation (Kehr sign); jaw/arm β†’ cardiac ischaemia
Timing Is there a pattern? Morning stiffness? Nocturnal pain? Post-prandial? Morning stiffness > 30 min β†’ inflammatory arthritis; nocturnal pain waking from sleep β†’ neoplastic/inflammatory; post-prandial β†’ mesenteric or biliary
Severity On a 0–10 scale, where 0 is no pain and 10 is the worst imaginable? At rest? At its worst? On average? Baseline severity guides initial analgesic choice; track over time to assess treatment response

Pain Severity Assessment Tools

Use a validated self-report tool appropriate to the patient's age, cognitive status and communication ability. Document the tool used, the score obtained, and the context (at rest, on movement, worst in last 24 hours).

Tool Population Description Score Interpretation
Numeric Rating Scale (NRS) Adults & adolescents β‰₯ 12 years with normal cognition Patient rates pain 0–10 verbally or in writing 0 = none; 1–3 = mild; 4–6 = moderate; 7–10 = severe
Visual Analogue Scale (VAS) Adults and older children (requires literacy/visual acuity) 100 mm line from "no pain" to "worst pain" < 30 mm = mild; 30–69 mm = moderate; β‰₯ 70 mm = severe
Wong-Baker FACES Children aged 3–7 years; adults with communication difficulties Six faces from smiling to crying; patient points to face matching their pain 0, 2, 4, 6, 8, 10
FLACC Scale Children aged 2 months – 7 years; non-verbal adults Observer-rated: Face, Legs, Activity, Cry, Consolability (each 0–2; total 0–10) 0 = relaxed; 1–3 = mild; 4–6 = moderate; 7–10 = severe
Abbey Pain Scale Non-verbal adults (dementia, intellectual disability, critically ill) Observer-rated: vocalisation, facial expression, change in body language, behavioural change, physiological change, physical changes (each 0–3; total 0–14) 0–2 = no pain; 3–7 = mild; 8–13 = moderate; 14 = severe
CPOT (Critical-Care Pain Observation Tool) Intubated/sedated ICU patients Observer-rated: facial expression, body movements, muscle tension, compliance with ventilator (total 0–8) β‰₯ 3 suggests significant pain

Neuropathic Pain Screening

If the pain history suggests neuropathic features (burning, shooting, tingling, allodynia, dysaesthesia), apply a validated screening tool to quantify the likelihood of a neuropathic component.

Tool Items Threshold Use in Australia
DN4 10 items (interview + physical exam: brush, pinprick, numbness) β‰₯ 4/10 = neuropathic pain likely Most widely validated; recommended by ANZCA Faculty of Pain Medicine
painDETECT 9 items (self-report questionnaire) β‰₯ 19 = neuropathic likely; 13–18 = ambiguous; ≀ 12 = nociceptive likely Useful in primary care when formal sensory testing is impractical
LANSS 7 items (5 self-report + 2 clinical: pin-prick, dynamic allodynia) β‰₯ 12/24 = neuropathic pain likely Alternative when DN4 is unavailable

Additional History Components

  • Previous treatments: All analgesics tried (including OTC), doses, duration, efficacy, adverse effects, reasons for discontinuation.
  • Medication history: Current medications (including anticoagulants, antiplatelets, SSRIs/SNRIs β€” bleeding risk with NSAIDs; opioids β€” tolerance, dependence), allergies, ADRs.
  • Substance use: Alcohol, tobacco, cannabis, methamphetamine, and other illicit substances β€” relevant to analgesic safety and pain chronicity.
  • Comorbidities: Renal/hepatic impairment, respiratory disease (opioid risk), GI disease (NSAID risk), cardiac disease, endocrine conditions (diabetes β€” neuropathy).
  • Social history: Occupation, compensation/insurance claims, legal proceedings, housing stability, social supports, carer responsibilities.
  • Patient goals and expectations: What does the patient want from treatment? Return to work? Sleep through the night? Walk to the shops? Understanding patient-centred goals guides realistic treatment planning.
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Opioid risk screening: For any patient being considered for opioid therapy, document an assessment of risk factors for opioid use disorder: personal or family history of substance use disorder, mental health conditions (depression, anxiety, PTSD, personality disorder), younger age, social isolation, and concurrent benzodiazepine use. Use the Opioid Risk Tool (ORT) or the Victorian Opioid Management Clinical Indicator (VOMCI). Refer to the RACGP Prescribing drugs of dependence in general practice guide.

Physical Examination

Physical examination in pain assessment serves three purposes: (1) to confirm or localise the pain source, (2) to identify red flags requiring urgent investigation, and (3) to document functional findings that support the diagnosis. The examination should be targeted to the pain presentation rather than exhaustive.

General Principles

  • Observe the patient's posture, gait, facial expression and movement patterns before beginning formal examination.
  • Ask the patient to point to the area of maximal pain with one finger β€” start the examination away from the painful area and progress towards it.
  • Compare side-to-side (symmetry is a useful reference).
  • Document objective findings (range of motion in degrees, strength on MRC scale 0–5, reflexes 0–4+) separately from pain behaviour.
  • Use the VAS or NRS before and during provocative manoeuvres to document the effect of movement on pain severity.

Musculoskeletal Examination

  • Inspection: Swelling, erythema, deformity, muscle wasting, skin changes (colour, texture, hair loss β€” CRPS), surgical scars.
  • Palpation: Temperature (warmth = inflammation; cool = vascular), tenderness (localised vs diffuse), bony tenderness (point tenderness over bone = fracture until proven otherwise), muscle spasm, trigger points, peripheral pulses.
  • Range of motion: Active and passive; note limitation, pain arc, crepitus, end-feel (hard = bony block; soft = tissue approximation; empty = patient stops due to pain before mechanical end-point).
  • Special tests (region-specific):
Region Key Tests Positive Finding Suggests
Cervical spine Spurling test, cervical rotation, upper limb tension test (ULTT) Cervical radiculopathy, brachial plexus tension
Shoulder Neer, Hawkins-Kennedy, painful arc, Speed's, O'Brien's, drop arm Impingement, rotator cuff tear, labral pathology, biceps tendinopathy
Elbow Cozen's, Mills, resisted wrist extension/flexion Lateral epicondylitis, medial epicondylitis
Lumbar spine Straight leg raise (SLR), crossed SLR, slump test, femoral nerve stretch, Schober's test Lumbar radiculopathy (SLR), L3/L4 radiculopathy (femoral stretch), ankylosing spondylitis (Schober's)
Hip FABER (Patrick's), FADIR, Thomas test, Trendelenburg, log roll Hip osteoarthritis, femoroacetabular impingement, labral tear, gluteus medius weakness
Knee Anterior/posterior drawer, Lachman, McMurray, valgus/varus stress, patellar apprehension ACL/PCL tear, meniscal tear, collateral ligament injury, patellar instability
Ankle/foot Anterior drawer (ankle), squeeze test (syndesmosis), Thompson test, Morton's compression Lateral ligament sprain, syndesmotic injury, Achilles rupture, Morton's neuroma

Neurological Examination

Essential when neuropathic pain features are present or radiculopathy/plexopathy is suspected.

  • Sensory testing: Light touch (cotton wool), pinprick (neurotip), vibration (128 Hz tuning fork), temperature (cold metal), proprioception. Map dermatomal or peripheral nerve distribution.
  • Allodynia mapping: Use cotton wool (dynamic mechanical allodynia) and Von Frey filaments (punctate allodynia) to map the area of allodynia β€” document on a body diagram.
  • Hyperalgesia: Increased response to pinprick β€” test with a neurotip compared to a non-painful area.
  • Motor testing: MRC grading (0–5) of key myotomes β€” L2 (hip flexion), L3 (knee extension), L4 (ankle dorsiflexion), L5 (great toe extension), S1 (ankle plantarflexion), S2 (knee flexion). Upper limb myotomes C5–T1.
  • Reflexes: Biceps (C5/6), supinator (C5/6), triceps (C7), knee (L3/4), ankle (S1), plantar response (Babinski β€” upper motor neuron sign).
  • Gait assessment: Normal gait, antalgic gait (pain-limited), Trendelenburg, steppage (foot drop), wide-based (proprioceptive loss).

Red Flag Findings on Examination

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  • Cauda equina syndrome: Saddle anaesthesia, urinary retention or incontinence, bilateral leg weakness, reduced anal tone β†’ emergency MRI and urgent neurosurgical referral.
  • Spinal cord compression: Upper motor neuron signs (hyperreflexia, upgoing plantars, clonus) below a sensory level β†’ urgent MRI.
  • Compartment syndrome: Pain out of proportion, pain with passive stretch, tense compartment, paraesthesia, pallor, pulselessness (late) β†’ emergency compartment pressures and surgical review.
  • Septic joint / osteomyelitis: Joint warmth, erythema, effusion with fever, raised inflammatory markers β†’ urgent aspiration, blood cultures, orthopaedic review.
  • Vascular compromise: Cool, pale, pulseless limb with pain β†’ emergency vascular surgical review.

Functional Impact

Pain assessment is incomplete without documenting its impact on the patient's daily life. Functional impairment is a stronger predictor of healthcare utilisation and long-term disability than pain intensity alone. The Australian National Pain Strategy and the Faculty of Pain Medicine (ANZCA) recommend documenting functional impact at every pain assessment using validated patient-reported outcome measures (PROMs).

Domains of Functional Impact

Domain Assessment Questions Validated Tools
Physical function Can you dress, bathe, cook, walk, climb stairs, carry groceries? Oswestry Disability Index (ODI) for low back pain; DASH for upper limb; Lower Extremity Functional Scale (LEFS)
Sleep Does pain wake you? How many times? Difficulty falling asleep? Pittsburgh Sleep Quality Index (PSQI); Insomnia Severity Index (ISI)
Mood & mental health How has the pain affected your mood? Feeling depressed or anxious? PHQ-9 (depression); GAD-7 (anxiety); DASS-21 (depression, anxiety, stress)
Work / occupation Are you working? Modified duties? Days off due to pain? Work Ability Index; return-to-work self-efficacy scale
Social participation Have you stopped hobbies, sports, socialising? Impact on relationships? Patient-Reported Outcomes Measurement Information System (PROMIS) social function
Overall quality of life How would you rate your overall quality of life? EQ-5D-5L; SF-36 / SF-12; AQoL-8D (Australian Quality of Life instrument)

Brief Pain Inventory (BPI)

The BPI is the most widely used pain assessment tool globally and is recommended by the Faculty of Pain Medicine (ANZCA). It captures both pain severity (4 items: worst, least, average, current β€” NRS 0–10) and pain interference (7 items: general activity, mood, walking ability, work, relations with others, sleep, enjoyment of life β€” NRS 0–10). The BPI Short Form takes approximately 5 minutes to complete.

  • Pain severity score: Mean of 4 severity items (0–10).
  • Pain interference score: Mean of 7 interference items (0–10).
  • Clinical interpretation: Interference scores β‰₯ 7 indicate severe functional impairment requiring multidisciplinary input.

Psychosocial Yellow Flags

Yellow flags are psychosocial factors that increase the risk of pain persisting and progressing to chronicity. Identifying yellow flags early is essential for appropriate referral to psychology and pain management programs. They are more predictive of poor outcomes than physical examination findings or imaging results.

Low Risk
Minimal Yellow Flags
Patient understands their condition, has realistic expectations, is engaged in recovery, has good social support, no significant mood disturbance.
Setting: Standard GP management, reassurance, active self-management
Medium Risk
Moderate Yellow Flags
Mild catastrophising, some fear-avoidance behaviour, low mood without major depression, believes pain means damage, reduced activity levels, some workplace issues.
Setting: Structured self-management education, consider GP Mental Health Treatment Plan, physiotherapy with active approach
High Risk
Multiple / Severe Yellow Flags
High catastrophising (PCS β‰₯ 30), significant fear-avoidance, clinical depression or anxiety, passive coping, disability claim / legal proceedings, social withdrawal, belief that pain is uncontrollable, previous failed treatments.
Setting: Multidisciplinary pain management program referral (public or private), psychology (CBT / ACT), consider pharmacotherapy for comorbid mood disorder

Useful Screening Tools for Yellow Flags

Tool Construct Threshold
STarT Back Prognostic screening for low back pain (physical + psychosocial) Low (0–3), Medium (4+ with low psychosocial subscale), High (4+ with high psychosocial subscale β‰₯ 4)
Γ–rebro Musculoskeletal Pain Screening Questionnaire Predicts long-term disability and work loss Score β‰₯ 105/210 = high risk of developing chronic disability
Pain Catastrophising Scale (PCS) Rumination, magnification, helplessness β‰₯ 30 = clinically significant catastrophising
Tampa Scale of Kinesiophobia (TSK) Fear of movement / re-injury β‰₯ 37/68 = elevated kinesiophobia

Investigations

Investigations in pain assessment are guided by the clinical presentation and the identification of red flags. Routine imaging for non-specific musculoskeletal pain (particularly low back pain) in the absence of red flags is not recommended β€” it does not improve outcomes and may cause harm through unnecessary procedures and patient anxiety (RACGP, NICE, Choosing Wisely Australia).

Principles of Investigation

  • Investigations should answer a specific clinical question β€” do not order "screening" panels.
  • Results must be interpreted in clinical context β€” incidental findings on imaging are common (e.g. disc bulges in asymptomatic adults aged > 40 years are present in up to 50%).
  • Normal investigations do not exclude pain β€” pain is a subjective experience and can exist without identifiable structural pathology (nociplastic pain).
  • Discuss the purpose, limitations and potential for incidental findings with the patient before ordering imaging.

Laboratory Investigations

Essential Full blood examination (FBE) MBS item 66512. If infection, malignancy or inflammatory disease suspected. Anaemia, leucocytosis, thrombocytosis may indicate underlying pathology.
Essential CRP / ESR MBS item 66554 (CRP), 65070 (ESR). Inflammatory markers β€” elevated in infection, malignancy, autoimmune/inflammatory conditions (polymyalgia rheumatica, GCA, rheumatoid arthritis, spondyloarthropathy).
Available Renal function tests (eGFR, creatinine, electrolytes) MBS item 66515. Baseline before NSAID or opioid prescribing; guide dosing adjustments.
Available Liver function tests (LFTs) MBS item 66516. Baseline before paracetamol combination preparations or if hepatic disease suspected.
Available HbA1c / fasting glucose MBS item 66841. If neuropathic pain β€” screen for diabetes mellitus as the most common cause of peripheral neuropathy in Australia.
Available Vitamin B12, folate, TSH MBS item 66836 (B12), 66555 (folate), 66708 (TSH). Exclude reversible causes of peripheral neuropathy and fatigue/malaise contributing to pain perception.
Available Serum protein electrophoresis, calcium, alkaline phosphatase MBS item 66573 (SPEP). If bone pain with red flags for malignancy (myeloma) or metabolic bone disease (osteoporotic fracture).
Available Uric acid MBS item 66536. If gout or crystal arthropathy suspected (acute monoarticular arthritis).
Referral Autoimmune serology (RF, anti-CCP, ANA, HLA-B27) MBS item 66590 (RF), 66591 (anti-CCP). If inflammatory arthritis, spondyloarthropathy or connective tissue disease suspected. Request guided by rheumatologist.
Specialist Nerve conduction studies / EMG MBS item 11000–11015. To confirm peripheral neuropathy, radiculopathy, or plexopathy when diagnosis is uncertain. Performed by neurologist or rehabilitation specialist.

Imaging

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Choosing Wisely Australia: Do not order imaging for non-specific low back pain unless red flags are present (RACGP recommendation). Plain radiographs of the lumbar spine have poor sensitivity for most causes of low back pain and expose the patient to radiation. MRI is the investigation of choice when red flags are present or when conservative management fails after 6 weeks.
Imaging Modality Indications MBS Notes
Plain radiographs Suspected fracture (trauma, osteoporosis, focal bony tenderness), joint effusion, alignment assessment, post-operative review MBS item 58100–58126 (regional). Bulk-billed at most practices. Low sensitivity for soft-tissue and early bony pathology.
Ultrasound Soft-tissue pathology (rotator cuff, tendinopathy, bursitis, effusion), guided injections, suspected DVT (D-dimer positive), Morton's neuroma MBS item 55800–55850 (regional). No radiation. Operator-dependent; best for superficial structures.
MRI Red-flag back pain (cauda equina, suspected malignancy, infection, cord compression), soft-tissue joint pathology, nerve entrapment, complex regional pain, failed conservative management MBS item 63001–63533 (regional). Most sensitive for soft tissue, marrow and neural pathology. Public waiting times 4–12 weeks; private 1–2 weeks (out-of-pocket 0–800 without concession).
CT Bony detail (fracture characterisation), CT-guided injection/biopsy, when MRI is contraindicated (pacemaker, cochlear implant, claustrophobia) MBS item 56001–56800. Higher radiation dose than plain films. Less sensitive than MRI for soft tissue and marrow oedema.
Bone scan (SPECT/CT) Occult fracture, stress fracture, metastatic bone disease, prosthetic joint infection MBS item 61301. Sensitive but low specificity; best combined with CT (SPECT/CT).
DEXA scan Bone pain with suspected osteoporosis, fragility fracture, age β‰₯ 70 with risk factors MBS item 12310. Bulk-billed for patients β‰₯ 70 years or with specific clinical indications (e.g. glucocorticoid use > 3 months).

Special Investigations

  • Diagnostic nerve blocks: Performed by a pain specialist or interventional radiologist to localise the pain source (e.g. medial branch block for facet joint pain, sacroiliac joint block, selective nerve root block).
  • Quantitative sensory testing (QST): Research and specialist tool to characterise sensory phenotypes (thermal thresholds, mechanical detection/pain thresholds). Available at major pain medicine departments (Royal North Shore, Austin Health, Sir Charles Gairdner).
  • Skin biopsy (intra-epidermal nerve fibre density): Gold standard for diagnosing small fibre neuropathy when NCS/EMG is normal. Available through dermatology or neurology referral at tertiary centres.
  • Thermography, functional MRI: Currently research tools in Australia; not funded by MBS and not part of routine clinical assessment.

Special Populations

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Pregnancy

Common pain presentations: Pelvic girdle pain (affects ~20% of pregnancies), low back pain, carpal tunnel syndrome, headache (consider pre-eclampsia if > 20 weeks).
Assessment considerations: Use NRS or VAS β€” safe in pregnancy. Avoid CT (radiation). Ultrasound is first-line for soft-tissue assessment. MRI without gadolinium is preferred if imaging beyond ultrasound is needed.
Red flags: Severe headache with visual disturbance or hypertension (pre-eclampsia/HELLP), abdominal pain with vaginal bleeding (placental abruption, ectopic), unilateral calf pain and swelling (DVT β€” increased risk in pregnancy).
Paracetamol: First-line analgesic in pregnancy. Safe at recommended doses (500 mg–1 g QDS, max 4 g/day). Advise minimum effective dose for shortest duration.
NSAIDs: Avoid, especially after 20 weeks (risk of premature ductus arteriosus closure and oligohydramnios). Contraindicated in third trimester.
Opioids: Use only when benefits outweigh risks; associated with neonatal withdrawal syndrome if used near term. Short-acting preferred.
Refer to ANZCA Faculty of Pain Medicine position statement on pain management in pregnancy. Pelvic girdle pain responds well to physiotherapy and a pelvic support belt.
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Paediatrics

Assessment tools by age: Pre-verbal/infant β†’ FLACC (2 months – 7 years), COMFORT-B (ICU); preschool β†’ Wong-Baker FACES (β‰₯ 3 years); school-age β†’ NRS or VAS (β‰₯ 8 years); adolescent β†’ NRS (β‰₯ 12 years, adult tools).
Behavioural observation: In young children, rely on behavioural cues β€” guarding, withdrawal, irritability, altered feeding, inconsolable crying, regression in developmental milestones.
Developmental considerations: Children may not localise pain or describe quality. Referred pain is common. Use body maps and age-appropriate language. Ask parents/carers for their observations separately.
Common pitfalls: Under-treatment of pain in children is documented in Australian paediatric settings. Pre-medication for procedures (e.g. EMLA for venepuncture, intranasal fentanyl for fracture reduction) is standard of care.
Chronic pain: Functional abdominal pain, headache and musculoskeletal pain are common in school-age children. Screen for school avoidance, bullying, anxiety, and family stress. Refer to paediatric pain services (e.g. Royal Children's Hospital Melbourne, Westmead Children's Hospital) for multidisciplinary management.
Weight-based paracetamol dosing: 15 mg/kg/dose QDS (max 60 mg/kg/day). Ibuprofen: 5–10 mg/kg TDS. Always confirm weight on the day β€” do not estimate.
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Older Adults (β‰₯ 65 years)

Prevalence: Chronic pain affects ~50% of community-dwelling older Australians and up to 80% of aged care residents.
Assessment barriers: Cognitive impairment (use Abbey Pain Scale for moderate-severe dementia), hearing/vision loss (use written NRS), stoicism/pain as "normal ageing" belief, polypharmacy limiting analgesic options.
Atypical presentations: Older adults may present with functional decline, confusion, agitation, withdrawal, or falls rather than verbal pain complaints. Maintain a high index of suspicion for pain in unexplained behavioural change.
Pharmacological considerations: Reduced renal clearance (dose-adjust paracetamol to max 2 g/day if eGFR < 30); increased sensitivity to opioids (start low, go slow β€” 50% dose reduction); NSAIDs carry higher GI bleed, renal and cardiovascular risk β€” avoid where possible; gabapentinoids require dose reduction for renal function and carry fall risk.
Pain in residential aged care: Use the Abbey Pain Scale or PAINAD for residents with dementia. Pain is significantly under-recognised and under-treated in Australian aged care facilities β€” the Royal Commission into Aged Care Quality and Safety (2021) identified this as a priority area.
Regular analgesic review is essential. Consider non-pharmacological strategies: gentle exercise, heat/cold, TENS, social engagement, music therapy.
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Renal Impairment

Key principle: Many analgesics are renally cleared and accumulate in renal impairment, increasing toxicity risk.
Paracetamol: Safe at standard doses (up to 4 g/day) for eGFR > 10; reduce to max 2 g/day in severe CKD or dialysis. No dose adjustment for mild-moderate impairment.
NSAIDs: Avoid in CKD (eGFR < 30) β€” risk of acute kidney injury, fluid retention, hyperkalaemia. Use with extreme caution and short duration only if eGFR 30–60 with regular monitoring.
Opioids: Avoid morphine and codeine (active renally-cleared metabolites β€” M6G accumulation causes prolonged sedation and respiratory depression). Prefer fentanyl, hydromorphone, buprenorphine or methadone. Dose-reduce all opioids in CKD.
Gabapentinoids: Gabapentin requires dose reduction (100 mg after dialysis if eGFR < 15); pregabalin (25–75 mg OD if eGFR < 15).
Dialysis patients: Paracetamol is safe. Avoid codeine and morphine. Fentanyl and hydromorphone preferred. NSAIDs absolutely contraindicated. Gabapentinoids dose-reduced.
Always check eGFR before prescribing any analgesic. Use the Australian Medicines Handbook (AMH) renal dosing guide.
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Hepatic Impairment

Key principle: Most analgesics are hepatically metabolised. Impaired liver function increases drug half-life and toxicity risk.
Paracetamol: Use with caution in chronic liver disease (reduced glutathione stores). Maximum 2 g/day in severe hepatic impairment or active hepatitis. Avoid in acute liver failure.
NSAIDs: Avoid in cirrhosis β€” increased risk of GI bleeding (portal hypertensive gastropathy + coagulopathy), fluid retention and hepatorenal syndrome.
Opioids: Reduce dose by 50% and extend interval. Morphine clearance is reduced; consider fentanyl or hydromorphone as alternatives. Avoid tramadol (seizure risk, serotonin syndrome in liver disease).
Adjuvants: TCAs (amitriptyline, nortriptyline) require caution β€” hepatic metabolism; start at very low dose. Gabapentin is renally cleared and may be safer. Pregabalin is also mainly renal.
Assess hepatic function with Child-Pugh score to guide analgesic choice and dosing. Seek hepatology or pain medicine advice for complex cases.
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Immunocompromised

Causes in Australia: HIV/AIDS, chemotherapy, solid organ or bone marrow transplant, biologic therapies (TNF inhibitors, rituximab), high-dose corticosteroids, primary immunodeficiency.
Assessment priority: New or changing pain in an immunocompromised patient is infection or malignancy until proven otherwise. Lower threshold for investigation (FBE, CRP, blood cultures, imaging).
Specific concerns: Septic arthritis (may present atypically β€” no fever, normal WCC), vertebral osteomyelitis, discitis, multifocal bone pain (metastases vs disseminated infection), post-herpetic neuralgia (VZV reactivation).
Drug interactions: Many analgesics interact with immunosuppressants β€” tramadol with tacrolimus (CYP3A4), NSAIDs with calcineurin inhibitors (additive nephrotoxicity). Always check interactions before prescribing.
Pain from treatments: Chemotherapy-induced peripheral neuropathy (CIPN), mucositis, post-surgical pain β€” assess and manage proactively, not reactively.
Refer to infectious disease and/or oncology early for new-onset pain in immunocompromised patients. Do not attribute pain to "the treatment" without excluding serious pathology.
Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience chronic pain at approximately twice the rate of non-Indigenous Australians, with onset at a younger age, greater severity, and more significant functional impact. Despite this burden, access to pain assessment and management services is significantly lower, particularly in regional and remote communities. Pain assessment must be culturally safe, flexible, and delivered in partnership with patients, families and Aboriginal and Torres Strait Islander health workers.

Key Considerations

Cultural expression of pain
Pain expression varies across Aboriginal and Torres Strait Islander communities. Some patients may minimise or under-report pain due to cultural norms of stoicism; others may express pain more openly. Avoid assumptions β€” ask directly and use visual tools (Wong-Baker FACES, body maps). Some languages do not have a direct word for "pain" β€” use locally understood terms with the help of an interpreter or health worker.
Language and health literacy
English may be a second, third or fourth language for many patients, particularly in remote Northern Territory, Western Australia and Queensland communities. Use plain language, visual aids, and Aboriginal and Torres Strait Islander health practitioners or interpreters (contact the Aboriginal Interpreter Service in NT, or local Aboriginal Community Controlled Health Organisation [ACCHO]). Do not rely on family members for interpretation of complex medical information.
Historical and intergenerational trauma
The legacy of colonisation, the Stolen Generations, systemic racism and historical mistreatment in healthcare settings creates distrust of mainstream health services. Acknowledge this openly, build rapport, and allow extra consultation time. Recognise that somatic presentations of grief, trauma and distress may manifest as chronic pain.
Remote access barriers
Specialist pain services, imaging and allied health (physiotherapy, psychology) are concentrated in major cities. Remote communities rely on fly-in/fly-out (FIFO) specialists, Aboriginal health workers, and telehealth. The Royal Flying Doctor Service (RFDS) provides pain-related retrievals and consultations. MBS-funded telehealth items (e.g. 91822, 91823) support video consultations with pain specialists.
Higher burden of painful conditions
Aboriginal and Torres Strait Islander Australians have higher rates of musculoskeletal injury, rheumatic heart disease, chronic kidney disease (painful neuropathy, renal colic), diabetes (neuropathic pain), otitis media, dental pain, and injury-related pain. Pain assessment must account for multiple comorbidities and the cumulative burden of disease.
Opioid-related harm
Aboriginal and Torres Strait Islander Australians are disproportionately affected by opioid-related harm, including higher rates of opioid dispensing, opioid use disorder and opioid-related mortality. Pain assessment should include routine opioid risk screening. Non-opioid analgesics and non-pharmacological strategies should be prioritised where appropriate. Engagement with local ACCHOs and the Nunkuwarrin Yunti or equivalent Aboriginal opioid substitution programs where relevant.
Family and community-centred care
Health decisions are often made collectively in Aboriginal and Torres Strait Islander communities. Encourage family involvement in pain assessment discussions (with patient consent). Recognise the role of sorry business (mourning), cultural obligations and community disruption as contributors to pain presentation and management adherence.
ACCHOs and Aboriginal health workers
Aboriginal Community Controlled Health Organisations (ACCHOs) deliver culturally safe, holistic primary care. Collaborate with local ACCHOs for chronic pain management. Aboriginal Health Workers and Aboriginal Health Practitioners (AHW/AHP) can administer validated pain assessment tools, provide health education, and support culturally appropriate self-management strategies. Funded under the Indigenous Australians Health Programme (IAHP).
βœ…
Cultural safety tip: Begin every consultation with an Acknowledgement of Country. Ask the patient how they would like to be addressed, who they would like present during the consultation, and whether they require an interpreter. Use the AHPRA Aboriginal and Torres Strait Islander Health Practice Board standards and the RACGP National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People (3rd edition, 2018) as frameworks for culturally safe practice.

πŸ“š References

  1. 1. Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976–1982.
  2. 2. Pain Australia. National Strategic Action Plan for Pain Management. Canberra: Pain Australia; 2019.
  3. 3. Australian and New Zealand College of Anaesthetists (ANZCA), Faculty of Pain Medicine. Recommended procedures for the management of acute and chronic pain. Melbourne: ANZCA; 2023.
  4. 4. Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice, Part B: Opioids. Melbourne: RACGP; 2022.
  5. 5. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice (Red Book), 9th edition. Melbourne: RACGP; 2018.
  6. 6. Australian Institute of Health and Welfare (AIHW). Chronic pain in Australia. Cat. no. PHE 298. Canberra: AIHW; 2023.
  7. 7. Deloitte Access Economics. The cost of pain in Australia. Prepared for Pain Australia. Sydney: Deloitte; 2019.
  8. 8. NPS MedicineWise / Choosing Wisely Australia. Recommendations for imaging in low back pain. Sydney: NPS MedicineWise; 2023.
  9. 9. Bouhassira D, Attal N, Alchaar H, et al. Comparison of pain syndromes associated with nervous or somatosensory lesions: validation of an easy-to-use tool for neuropathic pain screening (DN4). Pain. 2005;114(1–2):29–36.
  10. 10. Freynhagen R, Baron R, Gockel U, TΓΆlle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006;22(10):1911–1920.
  11. 11. Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59(5):632–641. (STarT Back)
  12. 12. Linton SJ, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Γ–rebro Musculoskeletal Pain Questionnaire. Clin J Pain. 2003;19(2):80–86.
  13. 13. Royal Commission into Aged Care Quality and Safety. Final Report: Care, Dignity and Respect. Canberra: Commonwealth of Australia; 2021.
  14. 14. National Aboriginal Community Controlled Health Organisation (NACCHO). National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People, 3rd edition. Melbourne: RACGP/NACCHO; 2018.
  15. 15. Australian Medicines Handbook (AMH). AMH Aged Care Companion. Adelaide: AMH; 2024.
  16. 16. Nicholas MK, Asghari A, Blyth FM, et al. Self-management intervention for chronic pain in older adults: a randomised controlled trial. Pain. 2013;154(6):824–835.
  17. 17. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019. Lancet. 2020;396(10258):1204–1222.
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 Β± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; Β± 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 Β± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

πŸ“š 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.

πŸ“š 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, LandewΓ© 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 β€” 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 TNFΞ± 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.

πŸ“š 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, LandewΓ© 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 β€” 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 TNFΞ± 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).