Physical Activity and Pacing

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

📋

Physical activity is a first-line non-pharmacological intervention for chronic non-cancer pain, supported by strong evidence from Australian and international guidelines (RACGP, ACSQHC, NICE).
Graded exercise therapy and pacing strategies can reduce pain intensity, improve physical function, and decrease pain-related disability when applied consistently over 8–12 weeks.
Pacing involves breaking activities into manageable segments with scheduled rest periods to avoid the "boom–bust" cycle of overactivity followed by prolonged recovery.
Activity scheduling uses structured, time-based plans to gradually increase functional capacity by 10–20% per week, reducing fear-avoidance behaviour.
Pool-based (hydrotherapy) exercise is particularly effective for musculoskeletal and arthritic pain, leveraging warm water (33–36°C) buoyancy and hydrostatic pressure to reduce joint loading.
Exercise should be individualised: start at 50–60% of the patient's current tolerance and progress incrementally to avoid flare-ups.
Multimodal approaches combining exercise with cognitive-behavioural therapy (CBT), education, and pharmacotherapy yield superior outcomes compared with any single modality.
Referral to an accredited exercise physiologist (AEP) or physiotherapist is recommended and supported by Medicare (MBS items 81110–81125 under Chronic Disease Management plans).
NSAIDs (e.g., ibuprofen, naproxen) and simple analgesics (paracetamol) may be used adjunctively to facilitate exercise participation; opioids should be avoided or deprescribed.
Aboriginal and Torres Strait Islander Australians experience chronic pain at 1.4× the general population rate; culturally safe, community-based activity programmes are essential.
Outcome measures include the Patient-Reported Outcomes Measurement Information System (PROMIS), Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and 6-Minute Walk Test (6MWT).
Flares are expected and should be managed with temporary load reduction (not complete rest), ice/heat, and short-term analgesic adjustment.

Introduction & Australian Epidemiology

Chronic pain affects an estimated 3.37 million Australians (16.1% of the population), making it one of the most costly and prevalent health conditions managed in primary care. The Australian Institute of Health and Welfare (AIHW) reports that chronic pain is the leading cause of disability-adjusted life years (DALYs) in Australians aged 25–64 years, and accounts for over 9 billion annually in direct healthcare costs, lost productivity, and informal care burden.

Physical activity — encompassing structured exercise, activity scheduling, and pacing — is now recognised as a cornerstone of chronic pain management. The Royal Australian College of General Practitioners (RACGP) and the Australian Commission on Safety and Quality in Health Care (ACSQHC) Clinical Care Standard for Osteoarthritis both recommend physical activity as a first-line intervention, prior to or concurrent with pharmacotherapy. Despite this, fewer than 30% of Australians with chronic pain receive exercise-based management, reflecting gaps in clinician confidence, access to allied health, and patient self-efficacy.

This article provides a comprehensive Australian guideline for integrating exercise, activity scheduling, pacing, and pool-based exercise into chronic pain management plans, with attention to special populations, PBS-listed adjunctive pharmacotherapy, and Aboriginal and Torres Strait Islander health considerations.

⚠️

Key principle: The goal of physical activity in chronic pain is functional restoration — not pain elimination. Patients should be counselled that some discomfort during graded exercise is expected and safe, and that "hurt does not equal harm."

Exercise

Exercise is the most extensively studied non-pharmacological intervention for chronic pain. A 2021 Cochrane review of 264 trials (over 19,000 participants) concluded that exercise reduces pain severity and improves physical function across multiple chronic pain conditions, including low back pain, osteoarthritis, fibromyalgia, and chronic widespread pain.

Types of Exercise

Exercise Type	Examples	Evidence Level	Best Indication
Aerobic (low–moderate intensity)	Walking, cycling, swimming	Strong (Level I)	Chronic low back pain, fibromyalgia, general deconditioning
Resistance / strengthening	Theraband, bodyweight, free weights	Strong (Level I)	Osteoarthritis, post-surgical rehabilitation, sarcopenia
Flexibility / stretching	Yoga, Pilates, static stretching	Moderate (Level II)	Neck pain, hip/knee stiffness, global mobility
Neuromuscular / balance	Tai chi, balance boards, proprioceptive drills	Moderate (Level II)	Elderly patients, fall risk reduction, ankle/hip OA
Multicomponent	Combined aerobic + resistance + flexibility	Strong (Level I)	Most chronic pain presentations; recommended as default

Prescribing Exercise for Chronic Pain

Exercise should be prescribed using the FITT-VP framework (Frequency, Intensity, Time, Type, Volume, Progression):

Frequency: Begin with 2–3 sessions per week; progress to 5 days/week over 8–12 weeks.
Intensity: Low-to-moderate (40–60% heart rate reserve or RPE 3–5/10). Avoid high-intensity starting points.
Time: 20–30 minutes per session initially; build to 150 minutes/week (in line with Australian Physical Activity Guidelines).
Type: Patient preference-guided; enjoyable activities improve adherence by up to 60%.
Progression: Increase volume by no more than 10–20% per week. Use the "traffic light" system — green (comfortable), amber (mild discomfort, acceptable), red (sharp/increasing pain — stop and modify).

✅

Australian Physical Activity Guidelines (2021): Adults should accumulate 150–300 minutes of moderate-intensity or 75–150 minutes of vigorous-intensity physical activity per week, plus muscle-strengthening activities on ≥2 days. These targets apply to people with chronic pain, adapted to tolerance.

Barriers to Exercise in Chronic Pain

Fear-Avoidance

Patients fear that movement will worsen damage. Address with pain neuroscience education (PNE) — explaining that pain ≠ tissue damage in chronic states.

Deconditioning

Prolonged inactivity leads to cardiovascular deconditioning, reduced muscle mass, and heightened central sensitisation. Gradual reconditioning reverses these changes.

Access & Cost

Allied health access is limited in rural/remote areas. Telehealth-delivered exercise programmes (via EAPA-registered exercise physiologists) are increasingly available under MBS telehealth items.

Comorbid Depression/Anxiety

Up to 50% of chronic pain patients have comorbid mood disorders. Integrate psychological support and consider SSRIs/SNRIs (e.g., duloxetine) as adjuncts.

Activity Scheduling

Activity scheduling is a structured behavioural technique in which patients plan their daily activities in advance, balancing functional tasks with rest periods. It is a core component of cognitive-behavioural therapy (CBT) for chronic pain and is strongly recommended by the Australian Psychological Society and the 2020 RACGP guideline on managing chronic pain in primary care.

Principles of Activity Scheduling

Baseline assessment: The patient records their current daily activity levels for 1–2 weeks using an activity diary, noting pain levels (VAS 0–10), fatigue, and mood before and after each activity.
Set baseline: Identify the average daily activity level (in minutes of meaningful activity) and the "ceiling" — the point at which flare-up reliably occurs.
Establish initial target: Set the starting activity quota at 70–80% of the ceiling to create a sustainable foundation. For example, if flare-up occurs at 30 minutes of gardening, begin at 20–24 minutes.
Fixed-time quotas: Activities are prescribed by TIME, not by pain level. The patient stops when the timer ends — regardless of whether pain has increased or decreased.
Gradual escalation: Increase quotas by 10–20% per week. The patient is not permitted to exceed their quota, even on "good days."
Alternate activities: Alternate high-demand tasks (e.g., housework) with low-demand tasks (e.g., reading, gentle walking) throughout the day.

⚠️

Prevent the "boom–bust" cycle: Patients with chronic pain commonly overdo activity on good days (boom), triggering severe flare-ups that force prolonged rest (bust). Activity scheduling with fixed quotas is the primary strategy to break this cycle.

Sample Weekly Activity Schedule

Day	Morning (AM)	Midday	Afternoon (PM)	Evening
Mon	Gentle walk 15 min	Seated stretches 10 min	Housework 20 min	Relaxation / heat pack
Tue	Resistance exercises 15 min	Rest / reading	Gardening 20 min	Gentle walk 10 min
Wed	Pool session 30 min	Rest	Social outing	Stretching 10 min
Thu	Gentle walk 20 min	Seated exercises 10 min	Rest / light activity	Relaxation techniques
Fri	Resistance exercises 15 min	Walking 15 min	Housework 20 min	Heat / TENS
Sat	Pool session 30 min	Social / recreational	Rest	Gentle stretching
Sun	Rest day — gentle mobility only	Pleasurable activity	Rest	Plan next week

Referral Pathways (Australian MBS)

Under the Medicare Chronic Disease Management (CDM) programme, GPs can refer patients for up to 5 allied health sessions per calendar year (MBS items 10950–10970). Patients with a GP Management Plan (GPMP, MBS item 721) and Team Care Arrangement (TCA, MBS item 723) are eligible. Additional sessions may be accessible through state-funded chronic pain programmes (e.g., NSW Agency for Clinical Innovation Pain Management Network).

Pacing

Pacing is a self-management strategy in which activities are divided into smaller segments with planned rest breaks, enabling the patient to remain active without triggering exacerbations. Unlike activity scheduling (which uses fixed quotas), pacing emphasises the BALANCE between activity and rest across the entire day.

Core Principles of Pacing

Plan activities in advance with clear start and stop times
Take rest breaks BEFORE pain escalates (pre-emptive rest)
Alternate between sitting, standing, and walking tasks
Use ergonomic aids and adaptive equipment
Gradually increase activity duration by 10–20% weekly
Keep a pacing diary to identify triggers and patterns

Avoid

Pushing through severe pain ("no pain, no gain" mindset)
Complete rest for more than 24–48 hours (increases deconditioning and central sensitisation)
Ignoring early warning signs (stiffness, fatigue, mood changes)
Comparing current capacity to pre-pain levels
Using pain as the sole guide for activity levels

The Traffic Light System

The traffic light system is a simple patient-facing tool recommended by Pain Australia and the Faculty of Pain Medicine (ANZCA) to guide activity decisions:

Green Zone

Comfortable Activity

Pain 0–3/10. Activity feels manageable. Safe to continue and gradually increase.

Action: Continue; slightly increase duration or intensity next session.

Amber Zone

Mild Discomfort

Pain 4–6/10. Activity is challenging but tolerable. Take a rest break within 5 minutes.

Action: Pause, rest, then resume at the same level. Do NOT increase load this session.

Red Zone

Severe Flare

Pain 7–10/10. Sharp, escalating, or new symptoms. Stop activity immediately.

Action: Cease activity. Apply ice/heat. Take PRN analgesic. Review plan with clinician.

Pacing vs Rest

🚨

Bed rest is harmful: Prolonged bed rest (>48 hours) for chronic pain is associated with increased pain sensitivity (central sensitisation), muscle wasting, venous thromboembolism risk, and depression. Australian guidelines (RACGP 2020) explicitly recommend AGAINST bed rest for chronic non-cancer pain. Pacing with continued movement is the evidence-based alternative.

Implementing a Pacing Plan

Assess Baseline

Patient keeps a 7-day activity diary recording each activity, duration, pain (VAS), and fatigue. Identify the "flare threshold" — the duration at which pain reliably increases by ≥2 points.

Set Initial Quotas

Set activity durations at 60–80% of the flare threshold. For example, if walking causes flare at 20 minutes, start at 12–16 minutes.

Schedule Rest Breaks

Insert rest breaks every 15–20 minutes during sustained tasks. Rest should be 5–10 minutes and include position change (sit if standing, stand if sitting).

Progress Gradually

Increase each activity quota by 10–20% per week. Patients must NOT exceed their quota on good days — this is the hardest but most important rule.

Review & Adjust

Fortnightly review with GP, AEP, or physiotherapist. Adjust quotas based on 2-week diary average. Reassess flare threshold every 4 weeks.

Pool-Based Exercise (Hydrotherapy)

Pool-based exercise, also known as aquatic exercise or hydrotherapy, is conducted in heated pools (typically 33–36°C) and is particularly beneficial for patients with chronic musculoskeletal pain, osteoarthritis, fibromyalgia, and chronic low back pain. The buoyancy of water reduces joint loading by 50–90% (depending on immersion depth), while the hydrostatic pressure provides gentle compression that reduces oedema and enhances proprioception.

Evidence for Pool-Based Exercise

A 2023 systematic review (Alcalde et al., British Journal of Sports Medicine) of 37 RCTs (n = 2,572) found that aquatic exercise produced clinically significant improvements in pain (mean reduction −1.3 on VAS 0–10) and function (standardised mean difference 0.45) compared with land-based exercise and no exercise controls. Benefits were sustained at 6-month follow-up, particularly in hip and knee osteoarthritis.

Pool Exercise Protocols

Component	Example Exercises	Duration	Intensity
Warm-up	Gentle walking in water, arm swings, shoulder rolls	5–10 min	Low (RPE 2–3)
Aerobic	Water walking, aqua jogging, flutter kicks	10–20 min	Low–moderate (RPE 3–5)
Resistance	Water resistance exercises, pool noodles, aquatic dumbbells	10–15 min	Low–moderate
Flexibility	Hip flexor stretch, hamstring stretch, calf stretch (supported by pool wall)	5–10 min	Low
Cool-down	Slow walking, floating, deep breathing	5 min	Very low

Australian Hydrotherapy Access

Hydrotherapy pools are available at most public hospitals and many community health centres across Australia.
Supervised group hydrotherapy sessions (6–10 patients) are often bulk-billed under MBS chronic disease management items when referred by a GP with a GPMP/TCA in place.
The Arthritis Australia community hydrotherapy programme offers subsidised sessions in capital cities and regional centres.
Patients should be screened for absolute contraindications: open wounds, uncontrolled epilepsy, active infection, severe cardiac failure, uncontrolled urinary/faecal incontinence.

ℹ️

Water temperature matters: Therapeutic pools should be heated to 33–36°C for chronic pain. Pools at ≥37°C are contraindicated for patients with cardiovascular disease, multiple sclerosis, or pregnancy due to hyperthermia risk.

Adjunctive Pharmacotherapy to Support Exercise Participation

Medications may be used short-term to facilitate engagement with physical activity. They should be considered adjuncts, not primary treatments.

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Paracetamol

Panadol® · Dymadon® · Analgesic

Adult dose 500–1000 mg PO every 4–6 hours (max 4 g/day)

Paediatric dose 15 mg/kg PO every 4–6 hours (max 60 mg/kg/day)

Route Oral (tablets, capsules, liquid)

Renal adjustment eGFR 10–50: extend interval to every 6 hours; eGFR <10: avoid or extend to every 8 hours

Hepatic adjustment Max 2 g/day in significant hepatic impairment; avoid in severe liver disease

PBS status ✔ PBS General Benefit

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Ibuprofen

Nurofen® · Brufen® · NSAID

Adult dose 200–400 mg PO every 6–8 hours (max 1200 mg/day OTC; 2400 mg/day Rx)

Paediatric dose 5–10 mg/kg PO every 6–8 hours (max 30 mg/kg/day)

Route Oral; take with food

Renal adjustment Avoid if eGFR <30; use with caution if eGFR 30–60

Hepatic adjustment Avoid in severe hepatic impairment

PBS status ✔ PBS General Benefit

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Naproxen

Naprosyn® · Inza® · NSAID

Adult dose 250–500 mg PO every 12 hours (max 1000 mg/day)

Paediatric dose 5–7 mg/kg PO every 12 hours (juvenile idiopathic arthritis)

Route Oral; take with food

Renal adjustment Avoid if eGFR <30

Hepatic adjustment Reduce dose in hepatic impairment; avoid if severe

PBS status ✔ PBS General Benefit

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Duloxetine

Cymbalta® · SNRI — for neuropathic/musculoskeletal pain

Adult dose 30 mg PO daily for 1 week, then 60 mg PO daily

Paediatric dose Not recommended <18 years for pain indication

Route Oral (enteric-coated capsule)

Renal adjustment Avoid if eGFR <30

Hepatic adjustment Contraindicated in hepatic impairment

PBS status ⚠️ PBS Authority Required

Outcome Measures & Investigations

Physical activity interventions for chronic pain are assessed primarily through patient-reported outcome measures (PROMs) and functional performance tests. No imaging or laboratory investigations are required to initiate exercise-based management, but baseline investigations may be needed to exclude red flags.

Patient-Reported Outcome Measures

Essential Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS) 0–10 Baseline and fortnightly. Clinically meaningful change = ≥2-point reduction.

Essential Patient-Reported Outcomes Measurement Information System (PROMIS) — Pain Interference Validated Australian version available. Assesses impact of pain on daily function.

Available Oswestry Disability Index (ODI) — for low back pain 10-item questionnaire. Clinically meaningful change = ≥10% improvement.

Available WOMAC — for hip/knee osteoarthritis Australian-validated version. Assesses pain, stiffness, and physical function.

Available Fear-Avoidance Beliefs Questionnaire (FABQ) Assesses fear-avoidance beliefs about physical activity. Guides PNE interventions.

Available Tampa Scale of Kinesiophobia (TSK) 17-item scale measuring fear of movement. Decrease of ≥4 points indicates improvement.

Functional Performance Tests

Essential 6-Minute Walk Test (6MWT) Standardised corridor walk. Minimum clinically important difference (MCID) = 30–50 metres. Normative Australian data available.

Available Timed Up and Go (TUG) Test Assesses mobility and fall risk. Normal <12 seconds; high fall risk >14 seconds.

Available 30-Second Sit-to-Stand Test Lower limb strength and endurance. Normative values by age/sex in Australian populations.

Special Populations

🤰 Pregnancy

Pelvic girdle pain and lumbar pain affect 45–70% of pregnant Australians. Exercise is safe and recommended (RANZCOG).

Preferred: Swimming, prenatal Pilates, walking, stationary cycling.

Avoid: Contact sports, supine exercise after 28 weeks, high-altitude exercise, hot pools (>37°C).

Paracetamol: first-line analgesic in pregnancy. NSAIDs: contraindicated after 30 weeks (risk of premature ductus arteriosus closure). Avoid codeine (neonatal respiratory depression).

Hydrotherapy in pools at 33–36°C is safe throughout pregnancy and particularly effective for pelvic girdle pain.

👶 Paediatrics

Chronic pain affects 25–40% of Australian school-aged children. Functional disability is the primary target — not pain score reduction.

Preferred: School-based physical activity, sport participation, active play, family-based exercise.

Pacing: Use age-appropriate tools (traffic light cards, sticker charts for activity tracking).

Paracetamol 15 mg/kg every 4–6 hours; ibuprofen 5–10 mg/kg every 6–8 hours. Avoid opioids in paediatric chronic pain.

Paediatric chronic pain programmes: refer to paediatric pain services at tertiary children's hospitals (e.g., RCH Melbourne, Children's Health Queensland).

👴 Elderly (≥65 years)

Chronic pain prevalence is 50–60% in community-dwelling older Australians. Falls risk is a critical concern.

Preferred: Tai chi (strong evidence for falls prevention), balance training, resistance exercise, walking programmes.

Pacing: May need longer rest periods and slower progression (5–10% per week). Account for fatigue and multimorbidity.

Paracetamol: first-line (max 3 g/day in frail elderly). NSAIDs: use with extreme caution — GI bleeding risk. Consider topical NSAIDs (diclofenac gel) as safer alternative.

Refer to Falls Prevention programmes (available through state health departments) and Exercise Physiology for individually tailored programmes.

🫘 Renal Impairment

Exercise is safe and beneficial in CKD stages 1–4. Haemodialysis patients benefit from intradialytic exercise programmes.

Preferred: Low-intensity aerobic exercise, resistance exercise, flexibility. Pool-based exercise if no open dialysis access sites.

Paracetamol: preferred analgesic (adjust interval if eGFR <10). NSAIDs: contraindicated if eGFR <30. Avoid codeine (accumulation of active metabolite morphine-6-glucuronide). Tramadol: reduce dose by 50% if eGFR <30.

Coordinate with renal team. Monitor electrolytes if starting a new exercise programme in CKD stage 4–5.

🫁 Hepatic Impairment

Exercise is generally safe and may improve hepatic steatosis. Adjust exercise intensity to patient tolerance.

Paracetamol: max 2 g/day in significant liver disease. NSAIDs: avoid in severe hepatic impairment (coagulopathy, varices). Duloxetine: contraindicated. Amitriptyline: use with caution.

Avoid supine exercise in patients with tense ascites. Pool exercise may be limited if the patient has a peritoneal drain or open wounds.

🛡️ Immunocompromised

Exercise is beneficial and does not increase infection risk in immunocompromised patients (cancer, transplant, biologics). However, pool-based exercise may be contraindicated during neutropenic periods (ANC <0.5 × 10⁹/L) due to waterborne infection risk.

Preferred: Home-based exercise programmes, walking, resistance exercise with clean equipment.

Coordinate with treating specialist. Consider telehealth-supervised exercise if immunosuppressed and unable to attend group sessions.

Monitoring & Follow-Up

Regular monitoring is essential to sustain engagement, adjust pacing plans, and identify early signs of deconditioning or mood deterioration.

Week 1–2

Baseline assessment: activity diary, VAS/NRS, PROMIS, FABQ/TSK. Establish initial pacing quotas. Commence low-intensity exercise. Provide pain neuroscience education.

Week 3–4

First review: assess adherence, flare frequency, and functional change. Adjust quotas (10–20% increase if tolerated). Address barriers and fear-avoidance.

Week 6–8

Mid-programme review: repeat VAS/NRS, 6MWT. Add resistance component if aerobic base established. Consider group hydrotherapy or community exercise programme. Reassess pharmacotherapy needs.

Week 10–12

Programme completion: full reassessment with PROMs (PROMIS, ODI/WOMAC, FABQ). Transition to self-directed maintenance programme. Referral for ongoing community exercise if needed.

3–6 months

Maintenance phase: GP review every 4–8 weeks. Repeat functional testing (6MWT, TUG). Reinforce pacing strategies. Address relapse or new barriers.

ℹ️

Flare management plan: Every patient should have a written flare plan: (1) reduce activity to 50% of current quota for 48 hours, (2) apply heat/ice, (3) take PRN paracetamol or NSAID, (4) resume gradual increase after 48–72 hours. If flare persists >1 week, schedule clinician review.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Prevalence

Chronic pain affects Aboriginal and Torres Strait Islander Australians at 1.4 times the rate of non-Indigenous Australians, with musculoskeletal conditions the leading cause of disability burden. The AIHW reports that 28.4% of Aboriginal and Torres Strait Islander adults report chronic pain compared with 19.2% of non-Indigenous adults.

Cultural Safety

Exercise programmes must be culturally safe, community-controlled, and delivered by culturally competent practitioners. Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) and Aboriginal Health Workers (AHWs) is essential for programme design and delivery. Recognise that pain may be understood differently within cultural frameworks — avoid imposing biomedical-only models.

Remote Access

Allied health services (exercise physiology, physiotherapy, hydrotherapy) are extremely limited in remote and very remote communities. Telehealth-delivered exercise programmes under MBS telehealth items (e.g., 91790, 91800) can improve access. Fly-in-fly-out (FIFO) allied health models are used but have limited continuity. Community-based walking groups and Indigenous sports programmes offer scalable alternatives.

Multimorbidity

Aboriginal and Torres Strait Islander Australians with chronic pain frequently have concurrent diabetes, cardiovascular disease, renal disease, and mental health conditions. Exercise prescriptions must account for these comorbidities. Integrated, whole-of-person care through ACCHOs (e.g., the Central Australian Aboriginal Congress, Tharawal Aboriginal Corporation) is the preferred model.

Community Programmes

Successful Australian programmes include the "Deadly Moves" programme (Indigenous-specific exercise referral), the Indigenous Marathon Foundation (IMF) "Deadly Running" clubs, and community-controlled hydrotherapy programmes. These programmes emphasise social connection, cultural pride, and self-determination alongside physical activity.

Pharmacology Considerations

Access to PBS-listed medications may be limited in remote communities despite Closing the Gap PBS co-payment measures. Ensure patients are aware of CTG scripts (no co-payment for PBS medicines). Avoid opioids where possible — opioid-related harm is disproportionately high in Aboriginal and Torres Strait Islander communities. Support non-pharmacological strategies as primary management.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Chronic pain in Australia. Cat. no. PHE 324. Canberra: AIHW; 2023.
2. Royal Australian College of General Practitioners (RACGP). Guideline for the management of chronic non-cancer pain in primary care. 2nd ed. Melbourne: RACGP; 2020.
3. Australian Commission on Safety and Quality in Health Care (ACSQHC). Osteoarthritis of the Knee Clinical Care Standard. Sydney: ACSQHC; 2017.
4. Geneen LJ, Moore RA, Clarke C, et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4(4):CD011279.
5. Alcalde GE, Bovend'Eerdt TJH, De Kunder SL, et al. Aquatic exercise for chronic musculoskeletal pain: systematic review and meta-analysis. Br J Sports Med. 2023;57(12):720–728.
6. Department of Health (Australia). Australian 24-Hour Movement Guidelines for Adults (18–64 years). Canberra: Australian Government; 2021.
7. Pain Australia. National Pain Strategy: Pain Management for All Australians. Sydney: Pain Australia; 2019.
8. Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists (FPM ANZCA). Recommended clinical competencies for pain medicine in Australia and New Zealand. Melbourne: ANZCA; 2020.
9. Australian Institute of Health and Welfare (AIHW). The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples: 2023. Cat. no. IHW 234. Canberra: AIHW; 2023.
10. Steffens D, Maher CG, Pereira LS, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199–208.
11. National Health and Medical Research Council (NHMRC). Guidelines for the treatment of acute and chronic musculoskeletal pain. Canberra: NHMRC; 2022.
12. Arthritis Australia. Time to Move: Osteoarthritis. National Action Plan. Sydney: Arthritis Australia; 2022.
13. Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85(3):317–332.
14. O'Keeffe M, O'Sullivan P, Purtill H, et al. Cognitive functional therapy compared with a group-based exercise and education intervention for chronic low back pain: a multicentre randomised controlled trial (IMPACT trial). Lancet Rheumatol. 2023;5(6):e343–e354.
15. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Exercise during pregnancy: clinical practice guideline. Melbourne: RANZCOG; 2020.

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. 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. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
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. 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. 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. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
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. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
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. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
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. 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. 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. 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. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
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. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
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. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
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. 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. 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

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
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. 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. 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. 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. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
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. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
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. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
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. 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. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).