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Self-Management and Goal Setting

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

📋
  • Functional improvement is the primary goal of chronic pain self-management; pain intensity reduction is secondary. Patients who set activity-based goals report better long-term outcomes than those focused solely on pain scores.
  • All goal setting should use the SMART framework — Specific, Measurable, Achievable, Relevant, Time-bound — to ensure clarity and accountability.
  • A written, individualised Pain Management Plan is recommended by the Royal Australian College of General Practitioners (RACGP) for all patients with chronic non-cancer pain lasting >3 months.
  • The "Function First" approach prioritises graded activity, pacing strategies, and meaningful life participation over passive treatments or numeric pain ratings.
  • Every patient should have a written flare management plan that distinguishes expected pain fluctuations from red-flag deterioration, and specifies pre-agreed strategies including medication adjustments.
  • Flare plans should include heat/cold therapy, modified activity (not bed rest), relaxation techniques, and short-term rescue analgesia with clear stop dates.
  • Sustained behaviour change requires understanding the transtheoretical model of change; motivational interviewing is first-line for patients in pre-contemplation or contemplation stages.
  • Shared decision-making between clinician and patient is central — patients who co-design their plan show higher adherence and satisfaction.
  • Self-management programs (e.g., Pain Management Network, PainAustralia resources, MindSpot Chronic Pain Course) are evidence-based, free, and accessible across Australia.
  • Patients on long-term opioids should incorporate functional goals into review agreements; failure to improve function is an indication for opioid tapering, not dose escalation.
  • Aboriginal and Torres Strait Islander Australians experience chronic pain at 1.4× the rate of non-Indigenous Australians, with significant barriers to specialist access in remote communities.
  • Regular goal review — typically every 4–6 weeks initially, then 3-monthly — is essential to maintain engagement and adjust targets to the patient's evolving capacity.

Introduction & Australian Epidemiology

Chronic pain — defined as pain persisting beyond normal tissue healing time, typically >3 months — affects approximately 3.24 million Australians (16.1% of the adult population), according to the 2020 National Health Survey. It is the leading cause of disability in Australia and accounts for more years lived with disability than cancer, diabetes, and cardiovascular disease combined (Australian Institute of Health and Welfare [AIHW], 2020).

Despite the burden, chronic pain management in Australia remains fragmented. Many patients receive pharmacotherapy without adequate self-management support. The RACGP Guideline for the Management of Knee and Hip Osteoarthritis (2018), National Strategic Action Plan for Pain Management (2019), and PainAustralia's National Pain Strategy all emphasise that first-line management should be non-pharmacological, centred on self-management, goal setting, and functional restoration.

Self-management is not self-treatment. It is a structured, clinician-supported process in which the patient develops knowledge, skills, and confidence to manage their condition day-to-day. Effective self-management has been shown to reduce healthcare utilisation by 20–30%, improve physical function, and decrease pain-related distress (Dear et al., 2015; Nicholas et al., 2019).

This article provides an Australian primary-care framework for self-management and goal setting in chronic non-cancer pain, covering SMART goals, the Function First approach, flare planning, and evidence-based behaviour change strategies.

⚠️
Key principle: The primary aim of any chronic pain management plan should be functional improvement — returning to meaningful activity, work, and social participation — not achieving a target pain score. Pain reduction, while desirable, is a secondary outcome.

SMART Goals

Goal setting is a cornerstone of self-management. Research consistently demonstrates that patients who set explicit goals achieve better functional outcomes than those who receive advice alone. The SMART framework is the most widely validated structure for clinical goal setting in chronic pain (Bovend'Eerdt et al., 2009).

The SMART Framework

S
Specific
Define exactly what the patient will do. Avoid vague goals like "get fitter." Instead: "Walk to the letterbox and back without stopping."
M
Measurable
Include a quantifiable metric: distance, duration, frequency, or number of repetitions. "Swim 4 laps of the local pool, 3 times per week."
A
Achievable
Realistic for the patient's current capacity. Use baseline assessment. A goal that is too ambitious increases frustration and dropout.
R
Relevant
Linked to what matters to the patient — their values, roles, and life priorities. "I want to play with my grandchildren" is more motivating than "improve my walking distance."
T
Time-bound
Set a review date. "By my next appointment in 4 weeks." This creates accountability and a natural checkpoint.

Practical Goal-Setting Process

  1. Explore values and priorities: "What activities matter most to you that pain has stopped or limited?"
  2. Establish a baseline: Ask the patient to rate their current level of activity (0–10 scale or specific count — e.g., "I can currently walk for 5 minutes").
  3. Set 1–3 short-term goals (2–4 weeks) and 1–2 long-term goals (3–6 months).
  4. Write goals down: Provide a printed or handwritten goal card. Patients who write goals are 42% more likely to achieve them (Matthews, 2015).
  5. Agree on review dates: Schedule specific follow-up to review progress and adjust goals.
✅
Example SMART goal: "I will walk my dog around the block (350 m) for 15 minutes, 4 mornings per week, for the next 3 weeks. I will record each walk in my diary and discuss progress at my GP appointment on 15 March."

Common Pitfalls in Goal Setting

Pitfall Why It Fails Better Approach
"Get rid of my pain" Not within patient control; sets up failure "Use my pacing strategy for all daily tasks"
"Do more exercise" Vague, unmeasurable "Attend hydrotherapy class every Tuesday for 4 weeks"
"Get off all medications" May not be safe or realistic; not function-focused "Reduce pregabalin by 25 mg each fortnight with GP review"
"Go back to full-time work" Too large a leap from baseline "Return to work 2 half-days per week for 4 weeks, then review"

Function First

The "Function First" principle is the central philosophy of modern chronic pain management. It reframes the clinical conversation from "How bad is your pain?" to "What do you want to be able to do?"

Decades of evidence demonstrate that pursuing pain elimination in chronic non-cancer pain leads to escalating medication use, iatrogenic harm, and worsening disability. Conversely, patients who prioritise functional goals — returning to work, recreation, family roles — show sustained improvements in both function and pain intensity over time (Vlaeyen et al., 2012; Williams et al., 2020).

Core Principles

  • Activity over rest: Prolonged rest and avoidance worsen deconditioning, kinesiophobia, and central sensitisation. Graded return to activity is the evidence-based standard.
  • Pacing, not boom-bust: Patients commonly alternate between over-activity on "good days" and enforced bed rest on "bad days." Pacing — breaking tasks into manageable segments with planned rest — interrupts this cycle.
  • Values-driven activity: Activities chosen should connect to the patient's personal values (family, work, spirituality, creativity) for sustained motivation.
  • Measure function, not just pain: Use validated functional outcome measures alongside pain scores (see Monitoring section).

Graded Activity Model

Week 1–2
Baseline assessment. Identify a meaningful activity. Set a comfortable starting time/distance (e.g., 50% of current capacity). Record in activity diary.
Week 3–4
Increase by 10–20% per week. Focus on consistency (number of sessions) before intensity. Normalise mild discomfort — "hurt ≠ harm."
Week 5–8
Continue gradual progression. Add a second valued activity. Review pacing strategies. Address flare response (see Flares Plan section).
Week 8–12
Consolidate gains. Begin maintenance phase. Set new longer-term goals. Transition from weekly to monthly self-monitoring.

Pacing Strategy

✅ Do: Activity Pacing
  • Break tasks into 10–15 minute blocks
  • Alternate activity with planned rest periods
  • Stop at a pre-set time — not when pain peaks
  • Gradually increase task duration over weeks
  • Use a timer or activity tracker
❌ Avoid: Boom–Bust Pattern
  • Pushing through until pain is severe
  • Complete rest for days after a flare
  • Judging success by pain level alone
  • Catastrophising when pain increases with activity
  • Abandoning activity after one bad day

Validated Functional Outcome Measures for Australian Practice

Measure Domain Items Use in Primary Care
Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Global physical function 4–10 items (short forms) Free; computer-adaptive; excellent sensitivity
Brief Pain Inventory — Interference Scale (BPI-I) Pain interference with function 7 items Widely validated; used in PBS opioid reviews
Örebro Musculoskeletal Pain Screening Questionnaire Risk stratification for disability 10 items Predicts long-term work disability; useful in workers' comp
Patient-Specific Functional Scale (PSFS) Individualised functional goals 1–5 activities rated 0–10 Ideal for SMART goal tracking; minimal burden
Acceptance and Action Questionnaire (AAQ-II) Psychological flexibility 7 items Tracks ACT progress; sensitive to change

Flares Plan

Pain flares are expected, self-limiting exacerbations that occur in most chronic pain conditions. They are not treatment failure. A written flare plan — co-designed with the patient and documented in their pain management plan — reduces emergency presentations, prevents medication dose escalation, and maintains engagement with self-management strategies.

🚨
Red flags requiring urgent assessment — not a flare: new neurological deficit (e.g., foot drop, saddle anaesthesia, bladder/bowel dysfunction), unexplained weight loss, fever with back pain, pain at rest with progressive night waking unrelated to known condition, or sudden severe pain with haemodynamic instability. These require immediate clinical review and investigation.

Components of a Written Flare Plan

Step Action Details
1. Acknowledge Normalise the flare "Flares are expected. They do not mean new damage. They usually settle within 2–7 days."
2. Modify activity Reduce to baseline, not zero Drop to 50–70% of current activity level. Avoid complete bed rest. Maintain gentle movement.
3. Physical strategies Heat, cold, TENS, positioning Heat for muscle spasm/stiffness; cold for acute inflammatory flares. Trial TENS if previously effective.
4. Psychological strategies Breathing, relaxation, mindfulness Box breathing (4-4-4-4), progressive muscle relaxation, guided meditation (Smiling Mind app).
5. Rescue medication Pre-agreed, time-limited Short course of simple analgesia (see drug cards). Maximum 3–5 days. Document stop date.
6. Review and resume Restart graded activity Once flare settles, return to 70% of pre-flare activity and rebuild over 1–2 weeks.

Flare Management — Pharmacological Options

💊
Paracetamol
Panadol®, Panadol Osteo® · Analgesic
Adult dose 1 g PO every 4–6 hours (max 4 g/day); Panadol Osteo 665 mg MR 2 tabs TDS
Duration Flare use: 3–5 days; reassess if ongoing need
Renal adjustment eGFR 10–50: extend interval to every 6 h; eGFR <10: every 8 h, max 2 g/day
Hepatic adjustment Max 2 g/day in liver disease; avoid in severe hepatic impairment
PBS status ✔ PBS General Benefit
💊
Ibuprofen
Nurofen® · Brufen® · NSAID
Adult dose 200–400 mg PO every 6–8 hours (max 1.2 g/day OTC; 2.4 g/day Rx)
Duration Shortest effective course; typically 3–5 days for flares
Renal adjustment Avoid if eGFR <30; use with caution eGFR 30–60
Hepatic adjustment Avoid in severe hepatic impairment
PBS status ✔ PBS General Benefit
💊
Naproxen
Naprosyn® · Inza® · NSAID
Adult dose 250–500 mg PO BD (max 1 g/day)
Duration 3–5 days for flares; longer courses require review
Renal adjustment Avoid if eGFR <30
Hepatic adjustment Avoid in severe hepatic impairment
PBS status ✔ PBS General Benefit
💊
Diazepam
Diazemuls® · Antenex® · Benzodiazepine (muscle relaxant)
Adult dose 2–5 mg PO PRN (max 15 mg/day); short course only (≤5 days)
Duration Maximum 5 days; no repeat without specialist review
Renal adjustment No adjustment required
Hepatic adjustment Reduce dose; avoid in severe hepatic impairment
PBS status ✔ PBS General Benefit
⚠️
Opioids are not recommended as flare rescue medication in chronic non-cancer pain. Evidence shows no sustained benefit, and short-term opioid use during flares is associated with dose escalation, tolerance, and opioid-induced hyperalgesia (RACGP, 2022). If a patient is already on a stable opioid regimen, flares should be managed with non-opioid strategies; the regular opioid dose should not be increased.

When to Escalate Beyond Self-Management

  • Flare lasting >7–10 days despite plan adherence
  • New symptoms or pain characteristics
  • Significant functional deterioration (unable to perform ADLs)
  • Psychological crisis (suicidal ideation, severe anxiety/panic)
  • Suspected medication adverse effect or interaction

Behaviour Change

Sustainable self-management requires behaviour change — shifting from passive treatment-seeking to active, autonomous pain management. This is a clinical skill that can be systematically supported using established psychological frameworks. Every clinician involved in chronic pain care should be familiar with basic behaviour change principles, even if formal psychological therapy is delivered by a psychologist.

Transtheoretical Model of Change (Prochaska & DiClemente)

Patients present at different stages of readiness. Matching your approach to their stage improves engagement:

Stage Patient Mindset Clinician Strategy
Pre-contemplation "I don't have a problem" or "Nothing works for me" Express empathy; provide information without pressure; plant seeds for future consideration
Contemplation "Maybe I should try something different" Explore ambivalence; use decisional balance (pros/cons of current approach vs. change)
Preparation "I'm ready to start making changes" Set SMART goals; develop action plan; identify barriers and solutions
Action "I'm doing it" Reinforce progress; troubleshoot barriers; regular follow-up
Maintenance "This is my new normal" Relapse prevention; long-term goal review; graduated discharge

Motivational Interviewing (MI) — Core Skills for GPs

  • OARS technique:
    • Open-ended questions: "What changes have you considered trying?"
    • Affirmations: "It takes real courage to keep trying after everything you've been through."
    • Reflective listening: "It sounds like you feel stuck between wanting to move more and being afraid of making things worse."
    • Summaries: "So the things that matter most to you are getting back to your garden and being able to sit through church. Let's think about how we can work towards those."
  • Elicit change talk: Listen for "change talk" language ("I want to…", "I could try…", "It would be better if…") and amplify it.
  • Avoid the "righting reflex": Resisting the urge to tell patients what to do increases their autonomy and intrinsic motivation.

Acceptance and Commitment Therapy (ACT) Principles

ACT is the most evidence-based psychological framework for chronic pain in primary care. Core components applicable to GP consultations include:

  • Cognitive defusion: Helping patients observe their pain thoughts without being controlled by them ("I notice I'm having the thought that this will never get better").
  • Acceptance: Willingness to experience pain without futile attempts at elimination — freeing energy for valued living.
  • Values clarification: Identifying what truly matters (family, work, spirituality, community) as the foundation for goal setting.
  • Committed action: Taking concrete steps towards values-driven goals, even in the presence of pain.
💡
Australian resource: The Pain Management Network (painmanagementnetwork.com.au) provides free, evidence-based ACT-based self-management modules for patients. The MindSpot Chronic Pain Course (mindspot.org.au) offers free, clinician-guided online ACT therapy for Australians with chronic pain. Both are available in all states and territories.

Addressing Common Barriers to Change

Barrier Clinical Response
"Movement will cause more damage" Explain pain neuroscience: hurt ≠ harm. Chronic pain reflects sensitisation, not tissue damage. Graded exposure is safe.
"I've tried everything" Validate frustration. Explore what was tried, how it was done, and whether it was sustained long enough (most strategies need 6–8 weeks).
"I just need stronger medication" Empathise with the desire for relief. Discuss evidence: opioids show minimal functional benefit at ≥3 months. Explore what medication represents (hope, validation, control).
"I don't have time for all this" Integrate strategies into existing routines. 5 minutes of breathing in the car. Walking during lunch break. Micro-goals.
Low health literacy Use teach-back method. Provide pictorial flare plans. Use interpreter services. Avoid jargon. Link to community health workers.

Role of Multidisciplinary Pain Programs

For patients who do not respond to GP-led self-management within 8–12 weeks, referral to a multidisciplinary pain management program is recommended. These programs combine physiotherapy, psychology (ACT/CBT), occupational therapy, and medical review. Publicly funded programs are available in all Australian states through hospital outpatient departments and Persistent Pain Services. Wait times vary (typically 3–12 months in metropolitan areas, longer in regional/remote settings).

Private pain management programs (e.g., Pain Management Australia, Hunter Pain Clinic) may be accessible via private health insurance or Medicare Chronic Disease Management plans (up to 5 allied health sessions per calendar year, item numbers 10950–10970).

Monitoring & Review

Regular structured review is essential to sustain self-management engagement, adjust goals, and identify patients who require escalation to specialist care. Monitoring should focus on functional outcomes, not pain scores alone.

Recommended Review Schedule

Week 0
Initial assessment: establish baseline function (PSFS or BPI-I), identify values, set SMART goals, provide written flare plan.
Week 2 (phone/telehealth)
Early check-in: troubleshoot barriers, reinforce progress, adjust goals if too ambitious or conservative.
Week 4
Face-to-face review: reassess functional measures, review flare plan use, update goals. Consider referral if no progress.
Week 8–12
Formal outcome assessment. Compare baseline vs. current function. Decision point: continue self-management, adjust, or refer to multidisciplinary pain service.
3-monthly (ongoing)
Maintenance reviews. Update goals. Monitor for new psychosocial stressors. Annual comprehensive pain plan review.

What to Monitor

Domain Tool / Measure Frequency
Functional status PSFS, BPI-I, PROMIS Physical Function Every review
Goal progress SMART goal tracking sheet Every review
Pain intensity NRS 0–10 (secondary measure only) Every review
Mood / distress PHQ-9, GAD-7, DASS-21 4–12 weekly
Sleep Insomnia Severity Index (ISI) If sleep concern
Medication use Review opioid dose (OMEDD), PRN use, adherence Every review
Self-efficacy Pain Self-Efficacy Questionnaire (PSEQ) Baseline + 3-monthly
Adverse effects Clinical assessment Every review

Special Populations

🤰
Pregnancy
Chronic pain in pregnancy is common (up to 30%); self-management strategies are preferred over pharmacotherapy.
Paracetamol is considered safe in pregnancy; NSAIDs are contraindicated from 30 weeks gestation (risk of premature closure of ductus arteriosus).
Pacing, graded activity, hydrotherapy, and mindfulness-based approaches are safe and effective.
Paracetamol is the preferred flare rescue analgesia. Category A (TGA).
Refer to physiotherapy with experience in antenatal care. Pelvic girdle pain and low back pain respond well to targeted exercise programs.
Monitor for antenatal depression and anxiety, which commonly co-occur with chronic pain in pregnancy. Screen with Edinburgh Postnatal Depression Scale (EPDS).
👶
Paediatrics
Chronic pain affects 15–25% of Australian children and adolescents. Common presentations include recurrent abdominal pain, headache, and musculoskeletal pain.
Goal setting should be age-appropriate and family-centred. Use visual scales, stickers, and activity charts for younger children.
School attendance is a critical functional goal. Avoid extended medical certificates that reinforce avoidance.
Cognitive-behavioural approaches (including ACT) have strong evidence in paediatric chronic pain. The Chronic Pain Australia website has parent resources.
Pharmacotherapy has a limited role. Paracetamol 15 mg/kg PO every 4–6 h (max 60 mg/kg/day, 4 g/day) for flares. Avoid long-term NSAID use.
Referral to a paediatric pain service (e.g., Royal Children's Hospital Melbourne, Children's Hospital Westmead) for refractory cases.
👴
Elderly (≥65 years)
Chronic pain prevalence exceeds 50% in Australians over 65 years. Common comorbidities (falls risk, cognitive impairment, polypharmacy) complicate management.
Goals should focus on maintaining independence: dressing, toileting, cooking, social participation, and preventing falls.
Avoid NSAIDs if possible (GI bleeding, renal impairment, cardiovascular risk). Paracetamol is first-line. Panadol Osteo (665 mg MR) offers convenient dosing.
Start low, go slow with any dose adjustments. Use Webster-pak or dosette boxes for adherence support.
Screen for cognitive impairment (MoCA/MMSE) before initiating complex self-management plans. Simplify written materials. Involve carers.
Exercise programs (Tai Chi, hydrotherapy, strength and balance) have strong evidence for chronic pain in older adults and reduce falls risk simultaneously.
🫘
Renal Impairment
Chronic pain is highly prevalent in CKD (up to 50%) and dialysis populations. Renal clearance affects many analgesics.
Paracetamol is first-line; adjust dose to 2 g/day if eGFR <10 mL/min.
Avoid NSAIDs if eGFR <30. Avoid codeine (active metabolite accumulates). Avoid tramadol (reduce dose 50% if eGFR <30; avoid if eGFR <15).
Self-management strategies should be adapted for dialysis schedules and fatigue. Coordinate goals with renal team.
Refer to nephrology pain management pathway. Many renal units now have embedded chronic pain assessment services.
🫁
Hepatic Impairment
Patients with chronic liver disease have altered drug metabolism. Non-pharmacological strategies are strongly preferred.
Paracetamol max 2 g/day in chronic liver disease. Avoid in acute liver failure.
Avoid NSAIDs (risk of variceal bleeding, renal impairment, fluid retention). Avoid codeine (impaired metabolism to morphine).
Mindfulness-based stress reduction and graded exercise have demonstrated benefit without hepatic risk.
Coordinate with hepatology; review all medications for hepatotoxicity.
🛡️
Immunocompromised
Chronic pain is common in immunocompromised patients (HIV, transplant recipients, biologic therapy). Consider pain aetiologies specific to immunosuppression (e.g., antiretroviral neuropathy, post-transplant bone pain).
Self-management goals should account for infection risk: avoid public hydrotherapy pools during severe immunosuppression. Home exercise programs may be preferred.
Drug interactions are common. Review analgesic compatibility with antiretrovirals, immunosuppressants, and transplant medications before prescribing.
Psychological support is critical — the burden of chronic pain plus chronic disease management increases depression and anxiety risk significantly.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Australians experience chronic pain at 1.4 times the rate of non-Indigenous Australians, with higher prevalence in regional and remote communities. Chronic pain in Indigenous Australians is associated with higher rates of disability, psychological distress, and reduced access to specialist pain services (AIHW, 2022; King et al., 2021).

Cultural safety, yarning-based communication, and community-led approaches are essential to effective self-management support for Aboriginal and Torres Strait Islander patients.

Access barriers
Specialist pain services are concentrated in major cities. Average wait time for a public pain clinic in remote NT exceeds 12 months. Telehealth (MBS items 91790, 91800, 91801) has improved access but requires reliable internet, which is unavailable in many remote communities. Aboriginal Community Controlled Health Organisations (ACCHOs) are the backbone of chronic disease management in remote areas.
Cultural considerations
Pain expression and coping are shaped by cultural context. "Strong" cultural norms may lead to under-reporting of pain. Conversely, communication of pain through narrative ("yarning") rather than numeric scales may be more appropriate. Use culturally validated tools where available (e.g., the adapted Faces Pain Scale). Always ask about Sorry Business and cultural obligations that may affect attendance and engagement.
Yarning-based goal setting
Adapt SMART goals to a yarning framework: explore the patient's story, identify what matters within their cultural and community context, and co-design goals that are meaningful to their mob. Goals related to community participation, cultural activities (e.g., hunting, ceremony, family gatherings), and Country are often more motivating than individualised Western functional goals.
ACCHO integration
Collaborate with local Aboriginal health practitioners and liaison officers (AHPs/AHLOs) for care coordination. Many ACCHOs offer chronic disease self-management programs (e.g., "Yarning About Pain" programs). Medicare-funded Team Care Arrangements (TCAs) and GP Management Plans (GPMPs) — item numbers 721 and 723 — support structured chronic pain management within ACCHOs.
Social and emotional wellbeing
Chronic pain in Indigenous Australians intersects with social determinants of health: housing, employment, education, incarceration, intergenerational trauma. Self-management plans must address these broader contexts. The social and emotional wellbeing (SEWB) framework — encompassing connection to body, mind, family, community, culture, Country, and spirit — should inform goal setting. Refer to Aboriginal and Torres Strait Islander mental health services and SEWB counsellors where available.
Medication considerations
Ensure medications are available through Remote Area Aboriginal Health Services (RAAHS) and Remote Area Pharmacies. PBS Section 100 (s100) provisions apply to many remote communities. Check that flare plan medications are stocked at the local health service. Avoid complex medication regimens that require refrigeration or frequent dispensing if the patient is mobile between communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Chronic pain in Australia. Cat. no. PHE 267. Canberra: AIHW; 2020.
  2. 2. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Measures of pain and body mass. Canberra: AIHW; 2022.
  3. 3. Bovend'Eerdt TJ, Botell RE, Wade DT. Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide. Clin Rehabil. 2009;23(4):352–361.
  4. 4. Dear BF, Titov N, Perry KN, et al. The Pain Course: a randomised controlled trial of a clinician-guided internet-delivered cognitive behaviour therapy program for managing chronic pain and emotional wellbeing. Pain. 2015;156(6):942–950.
  5. 5. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. 2nd ed. New York: Guilford Press; 2012.
  6. 6. King T, Gall A, Fitts M, et al. Chronic pain experiences and management strategies among Aboriginal and Torres Strait Islander peoples: a systematic review. Aust N Z J Public Health. 2021;45(6):635–642.
  7. 7. Matthews G. Goal Research Summary. Paper presented at the 14th Annual Industrial and Organisational Psychology Conference, British Psychological Society; 2015.
  8. 8. Nicholas MK, Asghari A, Sharpe L, et al. Cognitive exposure versus avoidance in patients with chronic pain: adherence matters. Eur J Pain. 2019;23(2):375–388.
  9. 9. PainAustralia. National Pain Strategy: Pain Management for All Australians. Sydney: PainAustralia; 2019.
  10. 10. Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research & Practice. 1982;19(3):276–288.
  11. 11. Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice: Part C2 — The role of opioids in pain management. Melbourne: RACGP; 2022.
  12. 12. Royal Australian College of General Practitioners (RACGP). Guideline for the management of knee and hip osteoarthritis. 2nd ed. Melbourne: RACGP; 2018.
  13. 13. Vlaeyen JW, Morley S, Linton SJ, et al. Pain-Related Fear: Exposure and Reduction of Fear in Chronic Pain — A Cognitive-Behavioural Approach. Seattle: IASP Press; 2012.
  14. 14. Williams ACC, Fisher E, Hearn L, et al. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020;8(8):CD007407.
  15. 15. Department of Health (Australian Government). National Strategic Action Plan for Pain Management. Canberra: Commonwealth of Australia; 2019.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

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

📚 References

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

📚 References

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

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).