Psychological Techniques for Pain

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

📋

Psychological techniques are first-line strategies for both acute and chronic pain management and should be offered alongside pharmacological therapy, not as an afterthought.
Active listening is the foundational communication skill that builds therapeutic alliance and directly influences pain outcomes; it requires structured empathic responses, not passive silence.
Reassurance is most effective when it is specific, evidence-based, and addresses the patient's individual fears — vague reassurance ("you'll be fine") can worsen anxiety and pain catastrophising.
Cognitive Behavioural Therapy (CBT) for pain has Level I evidence and is recommended by RACGP, ARA, and international guidelines as core management for chronic non-cancer pain.
Acceptance and Commitment Therapy (ACT) and mindfulness-based interventions are at least equivalent to CBT for chronic pain and may be superior for patients with high psychological inflexibility.
Psychological interventions reduce opioid consumption in acute pain settings by 20–30% and improve functional outcomes in chronic pain by 30–50%.
GPs can deliver brief psychological techniques in standard 15-minute consultations using structured frameworks (e.g., motivational interviewing, brief CBT).
Referral to a clinical psychologist for formal CBT or ACT is recommended when pain persists >3 months, when there is significant psychological comorbidity, or when self-management is insufficient.
Medicare provides up to 20 sessions per calendar year under a Mental Health Treatment Plan (MBS items 80110–80170) — these should be used for structured psychological pain interventions.
Pain catastrophising, kinesiophobia, and central sensitisation are key psychological targets that predict poor outcomes if unaddressed.
Digital delivery (telehealth, apps such as PainCHRONIC, MindSpot) is evidence-based and particularly valuable for rural and remote Australians.
Aboriginal and Torres Strait Islander Australians experience chronic pain at 1.4–2 times the rate of non-Indigenous Australians — culturally safe, trauma-informed psychological approaches are essential.

Introduction & Australian Epidemiology

Pain is a biopsychosocial phenomenon. The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." Psychological factors — including beliefs, expectations, attention, fear, catastrophising, and coping strategies — are among the strongest predictors of pain-related disability, often surpassing biomedical findings in explanatory power.

In Australia, chronic pain affects approximately 3.24 million people (AIHW, 2020), costs the economy over billion annually, and is the leading cause of early retirement. Despite this, psychological pain management is significantly underutilised: fewer than 15% of Australians with chronic non-cancer pain access evidence-based psychological therapy (Painaustralia, 2019).

Both basic psychological techniques — active listening, therapeutic reassurance — and formal interventions — CBT, ACT, mindfulness — are recommended as first-line management by the Royal Australian College of General Practitioners (RACGP), Therapeutic Guidelines (eTG), the Australian Rheumatology Association (ARA), and the Faculty of Pain Medicine (FPM) of the Australian and New Zealand College of Anaesthetists (ANZCA). These interventions are not adjuncts to "real" treatment; they are real treatment.

✅

Key principle: Psychological techniques should be initiated at the first presentation of pain — not reserved for patients who have "failed" pharmacotherapy. Early psychological intervention prevents chronification.

This article covers four foundational psychological approaches applicable across primary care, specialist, and hospital settings: active listening, reassurance, Cognitive Behavioural Therapy (CBT), and Acceptance and Commitment Therapy / Mindfulness (ACT/MBSR).

Active Listening

Active listening is the single most important communication skill in pain management. It is not passive silence — it is a structured, deliberate clinical technique that validates the patient's experience, gathers diagnostic information, and establishes the therapeutic alliance upon which all subsequent interventions depend.

Why Active Listening Matters in Pain

Patients with pain frequently report feeling dismissed, disbelieved, or patronised by clinicians. Perceived invalidation is independently associated with increased pain intensity, greater disability, higher opioid use, and treatment non-adherence. Conversely, patients who feel heard demonstrate improved self-efficacy, better adherence to self-management plans, and reduced pain catastrophising.

⚠️

Clinician trap: Premature reassurance or jumping to investigations before the patient has finished speaking signals to the patient that their experience is unimportant. This worsens pain perception through the nocebo effect and erodes trust.

The NURSE Framework

The NURSE mnemonic provides a structured approach to active listening in pain consultations (adapted from Back et al., Memorial Sloan Kettering):

Name

Name the emotion you observe. "It sounds like you're feeling frustrated." Naming emotions reduces amygdala activation and helps patients feel understood.

Understand

Express understanding. "I can understand why that would be distressing." Avoid "I know how you feel" — instead validate their specific experience.

Respect

Acknowledge the patient's efforts. "You've been working hard to manage this." Recognise their coping strategies before suggesting changes.

Support

Express ongoing support. "I'm going to work with you on this." Commitment to continuity of care is itself analgesic — it reduces threat appraisal.

Explore

Explore further. "Tell me more about how this affects your daily life." Open-ended questions reveal the functional and emotional impact that determines management.

Practical Techniques

Open-ended questions first: "Can you tell me about your pain?" before "Where does it hurt?"
Reflective statements: Paraphrase the patient's words back to them to demonstrate comprehension and invite correction.
Non-verbal attentiveness: Maintain appropriate eye contact, face the patient, avoid computer screen gazing, lean slightly forward. These cues signal engagement.
Silence: Allow 5–10 seconds of silence after asking about pain experience. Resist the urge to fill pauses — patients often share the most important information after a deliberate pause.
Avoid minimising language: Replace "just" (as in "just a muscle strain") with neutral diagnostic language. Replace "normal" scan results with "reassuring" scan results.
Validate without reinforcing disability: "Your pain is real and significant" does not mean "and therefore you cannot function." Validation and functional encouragement are not mutually exclusive.

Time-Efficient Active Listening in Australian General Practice

The average Australian GP consultation is 15–18 minutes (MBS Level B/C). Active listening does not require lengthy sessions:

First 2 minutes: Uninterrupted open narrative ("Tell me what's been going on with your pain"). Studies show patients complete their opening narrative in under 2 minutes in >80% of consultations.
Minutes 2–5: NURSE-driven clarification, focused history.
Remaining time: Shared decision-making, management plan, safety-netting.

Reassurance

Reassurance is one of the most commonly used clinical interventions — and one of the most commonly performed poorly. Effective reassurance is a specific, evidence-based communication strategy; ineffective reassurance ("Don't worry, you'll be fine") can paradoxically increase anxiety and pain through the nocebo effect.

The Four Components of Effective Reassurance

Pincus et al. (2013) identified four components that distinguish effective from ineffective reassurance in musculoskeletal pain:

Component	Description	Example
1. Health promotion	Provide a clear, positive diagnosis or explanation that normalises the experience	"Your scan shows age-related changes — these are normal and present in most people your age, including those with no pain at all."
2. Affective validation	Acknowledge the patient's emotional response before providing information	"It makes complete sense that you're worried — pain in the back can feel very frightening."
3. Coping strategies	Offer actionable, specific self-management advice	"Gradual return to activity, even when it's uncomfortable, is the best evidence-based approach for this type of pain."
4. Diagnostic exclusions	Specifically name and exclude serious pathology when appropriate	"The examination and your test results do not show any signs of cancer, fracture, or infection."

Reassurance in Acute Pain

In acute pain (e.g., post-procedural, acute musculoskeletal, emergency department presentations), effective reassurance can reduce analgesic requirements by 15–20% through modulation of threat appraisal:

Explain the expected trajectory of pain: "This type of back pain typically improves significantly within 2–6 weeks."
Normalise pain as part of healing: "Some discomfort during recovery is expected and does not mean damage is occurring."
Provide explicit permission to return: "If you develop new symptoms — leg weakness, bladder changes, fever — come back immediately." This paradoxically reduces re-presentations by reducing uncertainty.

Reassurance in Chronic Pain

Reassurance in chronic pain is more complex because the standard reassurance model ("nothing is seriously wrong") often fails. Patients interpret this as dismissive. Effective reassurance in chronic pain requires:

Explain central sensitisation: "Your nervous system has become highly sensitised — this means the pain system is amplifying signals, even though the original tissues have healed. This is a real, biological process."
Reframe pain neuroscience: Use the metaphor of a "faulty alarm system" or "pain dial turned up too high" — these metaphors have RCT evidence for reducing pain catastrophising (Moseley & Butler, 2015).
Avoid binary reassurance: Do not say "There's nothing wrong." Instead: "We've ruled out dangerous causes. Now we need to work on calming the pain system and rebuilding your confidence in movement."
Validate without confirming the sick role: "Your pain is real and I take it seriously. And I believe we can improve your function and quality of life."

🚨

Avoid "diagnosis of exclusion" framing: Telling a patient "We can't find anything wrong" communicates failure and fuels health anxiety. Reframe: "We've completed a thorough assessment and excluded serious causes. Now I can tell you what's actually going on and how we'll treat it."

Reassurance and the Nocebo Effect

Clinicians must be mindful that negative expectations increase pain (nocebo effect). This has implications for how results are communicated:

Avoid alarmist language about imaging findings: "Degeneration," "tears," and "bulges" found incidentally on MRI can catastrophically worsen pain outcomes when communicated without context.
Use neutral or positive framing: "Your joint has age-appropriate wear" rather than "You have severe degenerative disease."
Correlate imaging with clinical findings explicitly: "The changes on your scan don't explain your symptoms — this means we can target the real source."

Cognitive Behavioural Therapy (CBT) for Pain

CBT is the most extensively studied psychological intervention for chronic pain, with Level I evidence from multiple Cochrane reviews and meta-analyses. It is recommended as core management (not adjunctive) by RACGP, ARA, FPM/ANZCA, NICE (UK), and the American College of Physicians (ACP).

Evidence Base

Chronic low back pain: CBT reduces pain intensity (SMD −0.31, 95% CI −0.46 to −0.16) and disability (SMD −0.38) with effects maintained at 12 months (Williams et al., Cochrane 2020).
Fibromyalgia: CBT improves pain, fatigue, and function with NNT of 5 for ≥30% pain reduction (Bernardy et al., 2018).
Osteoarthritis: CBT + exercise is superior to exercise alone for pain and function (Hurley et al., 2018).
Headache/migraine: CBT is first-line preventive therapy alongside pharmacotherapy, with evidence for paediatric and adult populations.
Acute postoperative pain: Brief CBT-based preoperative interventions reduce opioid consumption by 20–30% and length of stay (Powell et al., 2019).

Core CBT Techniques for Pain

Cognitive Restructuring

Identify and challenge maladaptive pain beliefs: "My back is damaged," "Pain means I'm harming myself," "I'll never get better." Replace with balanced, evidence-based alternatives: "Pain does not always equal damage," "Movement is medicine."

Activity Pacing

Break the boom-bust cycle. Patients over-activity on good days, crash on bad days. Pacing involves graded, consistent activity with pre-planned rest, irrespective of pain intensity. Goal: consistent baseline → gradual increase.

Graded Exposure

Systematic, stepwise return to feared activities. Identify kinesiophobic beliefs → hierarchy of feared movements → gradual exposure with cognitive challenge. More effective than graded activity alone for high fear-avoidance (Vlaeyen et al., 2012).

Behavioural Activation

Chronic pain is closely linked with depression and withdrawal. Scheduled, pleasurable and mastery-based activities counteract the avoidance-depression-pain cycle.

Relaxation Training

Progressive muscle relaxation (PMR), diaphragmatic breathing, and applied relaxation reduce sympathetic arousal and muscle tension. PMR has specific evidence for tension headache and chronic low back pain.

Sleep Hygiene CBT (CBT-I)

Insomnia and chronic pain are bidirectionally related. CBT-I (6–8 sessions) improves both sleep and pain outcomes with effect sizes exceeding pharmacotherapy. Refer to a psychologist trained in CBT-I or use the online programme at ThisWayUp.org.au.

Brief CBT in General Practice

GPs can deliver brief CBT-informed interventions in standard consultations:

Pain neuroscience education (PNE): 10–15 minute explanation of central sensitisation, the pain-fear-avoidance cycle, and the role of the brain in pain perception. Has standalone evidence (Louw et al., 2011).
Thought challenging: "What goes through your mind when the pain increases?" → Identify catastrophic thought → Challenge with evidence → Reframe. Single-session thought challenging can reduce catastrophising scores (Sullivan & Stanish, 2003).
Activity goal-setting: Collaborative, specific, measurable, achievable, relevant, time-bound (SMART) functional goals rather than pain-intensity goals. "Walk to the letterbox daily" rather than "Reduce my pain."

Referral for Formal CBT

ℹ️

Medicare Mental Health Treatment Plan: GPs can initiate a Mental Health Treatment Plan (MBS item 80110) allowing up to 20 sessions per calendar year with a clinical psychologist (item 80135) or registered psychologist (item 80140). For chronic pain, specify CBT for pain management. The patient gap fee averages –120 per session in metropolitan areas; bulk-billing is available at some community health centres and Aboriginal Community Controlled Health Organisations (ACCHOs).

Consider formal psychology referral when:

Pain persists >3 months despite primary care management
Significant depression, anxiety, PTSD, or substance use disorder co-exists
High scores on the Pain Catastrophising Scale (PCS ≥30) or Tampa Scale of Kinesiophobia (TSK ≥37)
Patient requests psychological support
WorkCover / TAC / NDIS cases where psychological assessment is required

Digital CBT for Pain (Available in Australia)

Programme	Type	Access	Cost
MindSpot Pain Course	Clinician-guided online CBT	mindspot.org.au	Free (funded by Australian Government)
This Way Up — Pain Programme	Clinician-supervised online CBT	thiswayup.org.au	Free with GP referral; otherwise
PainTRAINER	Self-guided online CBT	paintrainer.com.au	Free
ManagePain (ACI NSW)	Self-management app	App Store / Google Play	Free

Acceptance and Commitment Therapy (ACT) & Mindfulness

Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Stress Reduction (MBSR) represent a "third wave" of psychological interventions for pain. Unlike CBT, which primarily targets the content of thoughts, ACT targets the relationship with thoughts — emphasising psychological flexibility, acceptance, and values-driven behaviour change.

Evidence Base

A 2020 Cochrane review (Hughes et al.) found ACT produced moderate improvements in pain acceptance, function, and quality of life in chronic pain, with effects sustained at 12 months.
Head-to-head trials suggest ACT and CBT are broadly equivalent, with some evidence that ACT is superior for patients with high psychological inflexibility and avoidance (Veehof et al., 2016).
MBSR (8-week programme) reduces pain intensity (SMD −0.32), improves physical function, and reduces depression in chronic pain (Hilton et al., 2017).
ACT has specific evidence for fibromyalgia, chronic low back pain, headache, and cancer-related pain.
Brief ACT interventions (even 1–4 sessions) show clinically meaningful improvements, making them feasible in primary care settings.

Core ACT Processes (the "Hexaflex")

ACT targets six core processes that together build psychological flexibility — the ability to be present, open to experience, and act in line with values:

Process	Description	Pain Application
Acceptance	Willingness to experience pain, thoughts, and emotions without avoidance or struggle	"Can you make room for the pain rather than fighting it?" Resistance amplifies suffering.
Cognitive defusion	Stepping back from thoughts; observing them as mental events, not truths	"I notice I'm having the thought that I'm broken" vs. "I am broken."
Present-moment awareness	Attending to the here-and-now rather than ruminating about the past or catastrophising about the future	Mindful breathing, body scan — redirect attention from anticipated future pain to current sensory experience.
Self-as-context	Identity is larger than pain; the self is the observer, not the pain	"I am a person who experiences chronic pain" is more flexible than "I am a chronic pain patient."
Values	Clarifying what truly matters — relationships, roles, purposes	"What do you want your life to be about, even with pain?" Values provide motivation for action.
Committed action	Taking values-consistent steps, even in the presence of pain	Graded activity driven by values (e.g., "be a present grandparent") rather than by pain level.

Brief ACT Techniques for Primary Care

GPs can integrate ACT-informed language and exercises into routine consultations:

Passengers on the bus metaphor: "Imagine you're driving a bus. Pain, fear, and self-doubt are passengers shouting directions. You don't have to obey them — you can keep driving toward what matters to you." (Useful for the first consultation.)
Tug-of-war with a monster: "If you're in a tug-of-war with pain, the harder you pull, the harder it pulls back. What if you dropped the rope?" This introduces the concept of acceptance without requiring formal therapy.
Values card sort: Simple card-sort exercises (available free at actmindfully.com.au) help patients identify core values in 5 minutes.
3-minute breathing space: A brief mindfulness exercise: (1) Notice what you're experiencing now, (2) Narrow attention to the breath, (3) Expand attention to the whole body. Can be taught in 2 minutes and practised anywhere.
Willingness scale: "On a scale of 0–10, how willing are you to have this pain in order to do what matters to you?" Tracks acceptance over time.

Mindfulness-Based Stress Reduction (MBSR)

MBSR is a structured 8-week programme developed by Jon Kabat-Zinn, originally for chronic pain. Standard delivery includes:

8 weekly group sessions (2–2.5 hours each)
Daily home practice (45 minutes guided meditation)
One full-day silent retreat
Core practices: body scan, sitting meditation, mindful yoga, walking meditation

In Australia, MBSR programmes are available through hospital pain clinics, community health centres, and private practitioners. Medicare rebates apply when delivered by a psychologist. Online MBSR is available through Mindful.org and Palouse Mindfulness (free).

💡

ACT vs CBT — which to recommend? Both are effective. CBT may be preferable when the patient has clear cognitive distortions amenable to restructuring. ACT may be preferable when the patient has high avoidance, low acceptance, or when previous CBT has been attempted without success. Many psychologists now integrate both. Refer based on local availability and patient preference.

Assessment & Screening Tools

Validated screening instruments help identify patients who would benefit most from psychological pain interventions and can track progress over time:

Essential

Pain Catastrophising Scale (PCS)

13-item self-report. Score ≥30 indicates clinical catastrophising. Strong predictor of poor outcomes. Free for clinical use.

Essential

Tampa Scale of Kinesiophobia (TSK)

17-item measure of fear of movement/re-injury. Score ≥37 indicates high kinesiophobia. Guides need for graded exposure.

Available

Patient Health Questionnaire-9 (PHQ-9)

9-item depression screen. Standard in chronic pain assessment. Score ≥10 warrants further evaluation. MBS item 705/707 for GP mental health assessment.

Available

Generalised Anxiety Disorder-7 (GAD-7)

7-item anxiety screen. Anxiety amplifies pain perception. Score ≥10 indicates moderate anxiety.

Available

Brief Pain Inventory (BPI)

Measures pain intensity and functional interference. Widely used in Australian pain clinics and research. 15 items.

Available

Pain Self-Efficacy Questionnaire (PSEQ)

10-item measure of confidence in performing activities despite pain. Score <30 indicates low self-efficacy — target for CBT/ACT.

Specialist

Avoidance-Endurance Questionnaire (AEQ)

Identifies maladaptive response patterns: fear-avoidant, eustress-endurance, distress-endurance. Used in pain psychology assessment.

Specialist

Chronic Pain Acceptance Questionnaire (CPAQ)

20-item measure of pain acceptance. Core outcome measure in ACT research. Tracks psychological flexibility in relation to pain.

Special Populations

🤰

Pregnancy

Psychological techniques are first-line in pregnancy — preferred over pharmacotherapy for pain management where possible.

CBT and mindfulness are safe and effective for pelvic girdle pain, low back pain, and labour pain preparation.

Antenatal education incorporating CBT principles reduces epidural requests and labour pain catastrophising.

MBSR programmes adapted for pregnancy ("Mindful Motherhood") are available through some Australian maternity services.

👶

Paediatrics

CBT is first-line for paediatric functional abdominal pain, headache, and chronic musculoskeletal pain (RCH Melbourne guidelines).

Age-adapted techniques: "Pain thermometer," distraction, guided imagery ("magic glove" for hand pain), and therapeutic storytelling for children <8 years.

Parental involvement is essential: Parental catastrophising independently predicts child pain outcomes. Address parental beliefs alongside child treatment.

Digital programmes: Think Pain Australia and Solution Focused Brief Therapy for adolescents with chronic pain.

Referral to a paediatric pain service (e.g., RCH Melbourne, Westmead Children's, Perth Children's) for severe cases.

👴

Older Adults

Chronic pain affects >50% of Australians aged ≥65 living in the community and >80% in residential aged care.

CBT and mindfulness are effective but require adaptation: shorter sessions, larger print materials, hearing-accommodated delivery, and simpler language.

Cognitive impairment: Behavioural strategies (activity scheduling, pleasant events, environmental modification) are preferred over cognitive restructuring in moderate-severe dementia.

Pain in dementia is frequently under-recognised — use observational tools (e.g., ABBEY Pain Scale, PAINAD) and consider that behavioural changes may be pain expressions.

Medicare-funded psychology sessions are accessible and underutilised in this group — proactive referral is recommended.

🛡️

Immunocompromised

Patients with cancer, HIV, transplant recipients, and autoimmune disease on immunosuppression frequently experience complex chronic pain with strong psychological components.

Cancer pain: ACT has specific evidence for improving function and quality of life alongside standard analgesia (Cancer Council Australia guidelines).

CBT is effective for pain-related distress in cancer survivors — address fear of recurrence, treatment-related trauma, and body image alongside pain management.

Multidisciplinary pain programmes incorporating psychological therapy are recommended for complex cancer pain (refer to state-based cancer pain services).

🫘

Renal Impairment

Chronic pain is present in 37–50% of haemodialysis patients and is associated with depression, reduced quality of life, and increased mortality.

Pharmacological options are limited (opioids accumulate in renal failure); psychological interventions are particularly valuable as non-pharmacological analgesia.

Brief mindfulness during dialysis sessions has been shown to reduce pain and anxiety scores.

Consider renal psychology referral at major centres (e.g., Royal Melbourne, Princess Alexandra Hospital) for patients with CKD-related pain distress.

🫁

Hepatic Impairment

Patients with chronic liver disease often have pain and significant psychological distress. Paracetamol and most opioids require caution or dose reduction.

Psychological pain management is safe at all stages of liver disease and should be actively promoted.

Alcohol-related liver disease patients benefit from integrated CBT addressing both pain and substance use patterns.

Integrating Psychological Techniques into Pain Management

The Stepped Care Model

Psychological pain management should follow a stepped care approach, matching intensity to need:

Step 1

Universal Psychological Strategies

Active listening, effective reassurance, pain neuroscience education, basic activity advice. Delivered by any clinician in any setting.

Setting: All primary care and acute care consultations

Step 2

Guided Self-Management

Brief CBT/ACT techniques delivered by GP, self-guided digital programmes (MindSpot, This WayUp), community pain management groups.

Setting: General practice with GP Mental Health Treatment Plan

Step 3

Specialist Psychological Pain Management

Formal CBT / ACT / MBSR with a clinical psychologist; multidisciplinary pain management programme; pain management hospital admission.

Setting: Pain clinic, specialist psychology, inpatient multidisciplinary programme

Quick Reference: Psychological Techniques by Pain Duration

Acute pain (<3 months)

Active listening + specific reassurance + pain education

Every consultation

Prevents chronification; reduces opioid demand

Subacute pain (3–6 months)

Brief CBT (activity pacing, thought challenging) + digital programme

2–6 sessions (GP or psychology)

Screen for catastrophising (PCS) and kinesiophobia (TSK)

Chronic pain (>6 months)

Formal CBT or ACT + mindfulness programme

8–12 sessions + ongoing self-practice

Psychology referral via MHTP; values-based goal setting

Complex chronic pain with comorbidity

Multidisciplinary pain programme (psychology + physio + OT + medicine)

4–8 week programme

Refer to public hospital pain clinic; consider inpatient if severe

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience chronic pain at 1.4 to 2.0 times the rate of non-Indigenous Australians (AIHW, 2020). Pain is the most common presenting complaint in many Aboriginal Community Controlled Health Organisations (ACCHOs). Despite this, access to psychological pain services is significantly lower, with major barriers at every level.

Service access

Psychologists are scarce in rural and remote areas. The ratio is approximately 1 psychologist per 100,000 people in remote areas vs. 1 per 15,000 in metropolitan areas. Telehealth psychology (Medicare items 91170–91185) can partially bridge this gap but requires reliable internet and private space.

Cultural safety

Mainstream CBT/ACT frameworks were developed in Western, individualistic contexts. Effective delivery requires cultural adaptation — incorporating yarning, story-telling, connection to Country, and family/community involvement. Aboriginal and Torres Strait Islander health practitioners and liaison officers should be involved in care planning.

Pain conceptualisation

Pain may be understood through holistic frameworks encompassing social, emotional, cultural, and spiritual dimensions — not just physical/biomedical. Pain education and psychological interventions must be delivered in ways that honour these perspectives rather than override them.

Intergenerational trauma

Chronic pain prevalence is amplified by intergenerational trauma, systemic racism, and socioeconomic disadvantage. Trauma-informed care principles are essential. Psychological pain interventions should be delivered alongside (not instead of) broader social and cultural determinants of health support.

Communication

Active listening and reassurance must account for communication styles that may include longer pauses, indirect communication, and the role of family members as advocates. Avoid rushing. Use plain English; avoid medical jargon. Interpreter services should be offered when English is a second, third, or fourth language.

Strengths-based approach

Aboriginal and Torres Strait Islander communities have strong existing coping resources — connection to family, Country, culture, and community. Psychological interventions should build on these strengths, not replace them. The "Social and Emotional Wellbeing" framework (developed by the Healing Foundation and Gayaa Dhuwi) provides a culturally grounded alternative to Western mental health models.

ℹ️

Resources: The Aboriginal and Torres Strait Islander Healing Foundation (healingfoundation.org.au) provides trauma-informed resources. Beyond Blue offers Aboriginal and Torres Strait Islander-specific mental health support (1300 22 4636). The RACGP National Guide (nationalguide.racgp.org.au) includes culturally adapted clinical recommendations for chronic disease management including pain.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Chronic pain in Australia. Cat. no. PHE 267. Canberra: AIHW; 2020.
2. Painaustralia. The cost of pain in Australia. Deakin, ACT: Painaustralia; 2019.
3. Williams AC de C, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020;(8):CD007407.
4. Hughes LS, Clark J, Colclough JA, Dale E, McMillan D. Acceptance and commitment therapy (ACT) for chronic pain: a systematic review and meta-analyses. Clin J Pain. 2017;33(6):552–568.
5. Veehof MM, Trompetter HR, Bohlmeijer ET, Schreurs KMG. Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cogn Behav Ther. 2016;45(1):5–31.
6. Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: systematic review and meta-analysis. Ann Behav Med. 2017;51(2):199–213.
7. Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. J Pain. 2015;16(9):807–813.
8. Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041–2056.
9. Vlaeyen JW, Morley S, Linton SJ, Boersma K, de Jong J. Pain-related fear: exposure-based treatment for chronic pain. IASP Press; 2012.
10. Pincus T, Holt N, Vogel S, et al. Cognitive and affective reassurance and patient outcomes in primary care low back pain. Pain. 2013;154(11):2483–2491.
11. Royal Australian College of General Practitioners (RACGP). Guideline for the management of knee and hip osteoarthritis. 2nd edn. East Melbourne: RACGP; 2018.
12. National Institute for Health and Care Excellence (NICE). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NG193. London: NICE; 2021.
13. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–530.
14. Bernardy K, Klose P, Busch AJ, Choy EH, Häuser W. Cognitive behavioural therapies for fibromyalgia. Cochrane Database Syst Rev. 2013;(9):CD009796.
15. The Healing Foundation. Social and emotional wellbeing framework. Canberra: Healing Foundation; 2021. Available at: healingfoundation.org.au.

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).