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Pain Severity and Functional Scales

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

📋
  • Pain is a subjective experience; validated severity and functional scales are essential for objective documentation, treatment monitoring, and communication between clinicians.
  • The Numerical Rating Scale (NRS 0–10) is the most widely used pain intensity measure in Australian emergency departments, wards, and primary care; validated across adult populations.
  • The Faces Pain Scale–Revised (FPS-R) is the preferred self-report tool for children aged ≥ 4 years, older adults with cognitive impairment, and patients with limited English proficiency.
  • Pain scores must always be interpreted in clinical context — a score of 7/10 in one patient may require a different response than the same score in another, depending on diagnosis, functional impact, and goals of care.
  • The Functional Activity Scale assesses the real-world impact of pain on mobility, self-care, work, and social participation; essential for setting treatment goals beyond analgesia.
  • The PEG (Pain, Enjoyment, General Activity) 3-item scale and the Brief Pain Inventory (BPI) are the gold-standard brief and comprehensive tools for chronic pain assessment in Australian primary care.
  • A PEG score ≥ 5/10 on average warrants escalation to multidisciplinary chronic pain management pathways, including referral to a persistent pain service.
  • Routine pain assessment at every clinical encounter is mandated under the Australian Charter of Healthcare Rights and NSQHS Standards for safe pain management.
  • Functional outcomes — not pain intensity alone — should guide treatment decisions, particularly in chronic non-cancer pain where the goal is improved function rather than zero pain.
  • Special populations (paediatrics, elderly, cognitive impairment, non-English-speaking backgrounds, ATSI communities) require tailored scale selection and culturally appropriate assessment methods.
  • Behavioural pain assessment tools (e.g., Abbey Pain Scale, FLACC) are used when self-report is not feasible — particularly in dementia, delirium, and intubated patients.
  • Opioid risk screening (e.g., using the Opioid Risk Tool or SOAPP-R) should accompany chronic pain severity assessment before initiating long-term opioid therapy.

Introduction & Australian Epidemiology

Pain is the most common reason for healthcare presentation in Australia, with approximately 3.24 million Australians (1 in 5) living with chronic pain as of 2023. The Australian Institute of Health and Welfare (AIHW) estimates that chronic pain costs the Australian economy over billion annually when indirect costs (lost productivity, carer burden) are included. Despite this, pain remains undertreated in many settings, and standardised assessment remains inconsistent across Australian hospitals and general practices.

Validated pain severity and functional scales serve three critical roles in Australian clinical practice:

  1. Communication: Providing a shared language between patients, general practitioners, specialists, nurses, and allied health professionals.
  2. Treatment monitoring: Enabling objective tracking of analgesic efficacy over time and across care transitions.
  3. Safety and governance: Meeting National Safety and Quality Health Service (NSQHS) Standards for pain assessment documentation, particularly in postoperative and emergency settings.

Pain intensity alone is an incomplete measure. The biopsychosocial model of pain — endorsed by the International Association for the Study of Pain (IASP) and embedded in Australian persistent pain guidelines — requires that clinicians assess severity, functional impact, psychological distress, and social participation together. This article reviews the principal validated tools available in Australian clinical practice for measuring pain severity and function.

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Key principle: Pain scores should never be used as the sole trigger for opioid prescription. Clinical context, functional impact, diagnosis, and patient goals must guide treatment decisions. The Australian & New Zealand College of Anaesthetists (ANZCA) and Faculty of Pain Medicine recommend against treating to a numerical target alone.
Setting Recommended Primary Scale Population Standard
Emergency Department NRS 0–10 Adults ≥ 18 years NSQHS Clinical Care Standard
Paediatric ED / Ward FPS-R or FLACC (preverbal) Children 4–17 years RCH Melbourne Clinical Guideline
General Practice (acute) NRS 0–10 Adults RACGP Standards
General Practice (chronic) PEG or BPI Adults with persistent pain ≥ 3 months RACGP Persistent Pain Guide
Aged Care / Dementia Abbey Pain Scale Unable to self-report Aged Care Quality Standards
Postoperative (ward) NRS 0–10 Adults post-anaesthesia ANZCA PS09
Persistent Pain Service BPI + PEG + DN4 Referred chronic pain patients PainAustralia / FPM

Numerical Rating Scale (NRS 0–10)

The Numerical Rating Scale (NRS) is a unidimensional pain intensity measure in which the patient rates their pain from 0 (no pain) to 10 (worst imaginable pain). It is the most commonly used pain severity tool in Australian emergency departments, hospital wards, and general practice for adults who can communicate verbally. The NRS can be administered verbally (NRS-V) or in written/visual form (NRS-V).

Administration

  • Ask the patient: "On a scale of 0 to 10, where 0 is no pain and 10 is the worst pain you can imagine, what number best describes your pain right now?"
  • Record current pain, average pain (over 24 hours or past week), and worst pain as three separate values.
  • For non-English-speaking patients, use certified interpreter services and translated NRS cards (available through TIS National, 131 450).
  • Administer at presentation, 30–60 minutes post-analgesic, and at regular intervals per facility protocol.

Interpretation & Severity Bands

Mild
NRS 1–3
Pain present but tolerable; minimal functional limitation. Non-opioid analgesia appropriate (paracetamol, NSAIDs). Reassess in 1–2 hours if acute.
Setting: GP, ward, self-management
Moderate
NRS 4–6
Pain interferes with activity and concentration. Consider combination analgesia (paracetamol + weak opioid or adjuvant). Assess functional impact explicitly.
Setting: ED, ward, GP follow-up
Severe
NRS 7–10
Pain dominates the clinical picture; significant functional impairment. Strong opioid or regional anaesthesia may be required. Urgent assessment and multimodal analgesia strategy. Reassess frequently.
Setting: ED, acute ward, pain service consult
ℹ️
Clinical context matters: An NRS of 7/10 in a patient with a fractured neck of femur demands a different management response than 7/10 in a patient with chronic low back pain presenting to their GP for the fifth time. Always pair the NRS with a functional question — e.g., "How much is this pain stopping you from doing what you need to do?"

Psychometric Properties

  • Test–retest reliability: ICC 0.67–0.95 in acute pain; 0.76–0.89 in chronic pain.
  • Minimum clinically important difference (MCID): 1.5–2 points (acute pain); 2 points or 30% reduction (chronic pain).
  • Responsiveness: Good sensitivity to change post-analgesic intervention.
  • Limitations: Ceiling effects in severe chronic pain; poor validity in patients with cognitive impairment, delirium, or significant language barriers without interpreter support.

When to Consider Alternatives

  • Age < 6 years → use Faces Pain Scale–Revised or FLACC.
  • Cognitive impairment (MMSE < 20, dementia) → use Abbey Pain Scale or PAINAD.
  • Intubated / sedated → use Behavioural Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT).
  • Limited English → use translated NRS or FPS with interpreter.

Faces Pain Scale–Revised (FPS-R)

The Faces Pain Scale–Revised (FPS-R) is a self-report tool consisting of six faces arranged in a horizontal sequence, showing expressions from "no pain" (scored 0) to "very much pain" (scored 10, in increments of 2). It was developed by Hicks et al. (2001) as a revision of the original Bieri Faces Pain Scale, with neutral rather than smiling faces to reduce confusion.

Administration

  • Present the six faces and explain: "These faces show how much something can hurt. This face [point to far left] means no pain. This face [point to far right] means very much pain. Point to the face that shows how much you hurt right now."
  • Score each selected face: 0, 2, 4, 6, 8, or 10.
  • Suitable for children aged ≥ 4 years, older adults, and patients with limited literacy.
  • Do not use smiling or crying faces that may bias responses; the FPS-R uses neutral expression changes only.
✅
Recommended by the Royal Children's Hospital Melbourne: The FPS-R is endorsed as the primary self-report pain intensity tool for children aged ≥ 4 years in Australian paediatric settings, alongside the Wong-Baker FACES scale (which is considered less psychometrically robust due to its smiling anchor face).

Interpretation

FPS-R Score Severity Clinical Action
0 No pain Routine monitoring
2 Very mild Non-pharmacological comfort measures; paracetamol PRN
4 Mild–moderate Scheduled non-opioid analgesia; distraction techniques
6 Moderate Multimodal analgesia; consider adjuvant (e.g., ibuprofen); reassess 30 min
8 Severe Strong analgesia (oral morphine or IV opioid in hospital); frequent reassessment
10 Very much pain Urgent multimodal analgesia ± regional technique; senior review

Psychometric Properties

  • Test–retest reliability: ICC 0.83–0.94 in paediatric populations.
  • Convergent validity: Strong correlation with NRS (r = 0.84–0.93) and VAS (r = 0.80–0.90).
  • MCID: 1 face change (equivalent to 2 NRS points).
  • Cross-cultural validation: Validated in Indigenous Australian children and adolescents, though culturally adapted pictorial scales may improve engagement in remote communities.

Comparison with Other Faces Scales

Scale Number of Faces Scoring Smiling Anchor? Australian Endorsement
FPS-R 6 0, 2, 4, 6, 8, 10 No (neutral) Preferred — RCH, ANZCA
Wong-Baker FACES 6 0, 2, 4, 6, 8, 10 Yes Widely used but less recommended
Bieri (original) 7 1–7 No Largely superseded by FPS-R

Functional Activity Scales

Functional activity scales measure the degree to which pain interferes with daily activities, mobility, work, and social participation. In Australian clinical practice, functional assessment is increasingly recognised as the primary treatment target in chronic pain — more so than pain intensity alone. The Australian and New Zealand College of Anaesthetists (ANZCA) Faculty of Pain Medicine (FPM) recommends that all chronic pain management plans include explicit functional goals.

Why Function Matters More Than Pain Score Alone

  • Studies show that functional improvement predicts long-term outcomes better than NRS reduction in persistent pain.
  • Patients who reduce opioid dose while improving function have better outcomes than those who achieve pain reduction without functional gains.
  • PainAustralia's National Strategic Action Plan for Pain Management (2019) explicitly identifies function as a core outcome measure.
  • NSQHS Clinical Care Standard for Acute Pain Management (ACSQHC, 2021) mandates functional assessment alongside pain severity.

Commonly Used Functional Scales in Australia

Scale Items Domain Population Setting
Oswestry Disability Index (ODI) 10 items Low back–specific disability Adults with chronic LBP Spinal clinics, pain services
Neck Disability Index (NDI) 10 items Cervical spine–specific disability Adults with neck pain Spinal clinics, physiotherapy
DASH (Disabilities of Arm, Shoulder, Hand) 30 items Upper limb function Adults with upper limb pain/conditions Orthopaedics, rheumatology
Lower Extremity Functional Scale (LEFS) 20 items Lower limb function Adults with lower limb musculoskeletal pain Physiotherapy, orthopaedics
Patient-Specific Functional Scale (PSFS) 3–5 patient-chosen activities Individualised functional goals Any population GP, physio, pain services
WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) 12 or 36 items Global disability (ICF-based) Any population Persistent pain services, research

Oswestry Disability Index (ODI) — Detailed

The ODI is the most widely used condition-specific functional measure for low back pain in Australian spinal and pain services. It comprises 10 sections covering pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and travelling. Each section is scored 0–5, yielding a percentage disability score.

ODI Score (%) Disability Level Clinical Interpretation
0–20% Minimal disability Able to cope with most activities; may need minor lifestyle modification
21–40% Moderate disability Experiencing more pain; difficulty with sitting, lifting, and standing; may require work modifications
41–60% Severe disability Pain is the primary problem; significant impact on daily living and work capacity; consider pain service referral
61–80% Crippling disability Bed-bound for significant periods; requires comprehensive multidisciplinary management
81–100% Bed-bound / exaggeration Exaggerated responses possible; consider psychological assessment and yellow flags screening

Patient-Specific Functional Scale (PSFS)

The PSFS is a patient-centred tool that asks the patient to nominate 3–5 activities that are difficult or impossible due to their pain, then rate their ability to perform each on an 0–10 scale. It is highly responsive to change and is recommended by Australian physiotherapy and persistent pain guidelines for individualised goal-setting.

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Practical tip for Australian GPs: Use the PSFS during the initial chronic pain consultation to establish 3 functional goals. Reassess at 4-weekly intervals. A change of ≥ 2 points on any nominated activity is considered clinically meaningful. This approach aligns with the RACGP's guidance on goal-oriented chronic pain management.

PEG Scale & Brief Pain Inventory (BPI)

The PEG and Brief Pain Inventory (BPI) are the two most validated composite tools for chronic pain assessment in Australian primary care and persistent pain services. The PEG is a 3-item ultra-brief screener; the BPI is a comprehensive 15-item instrument that assesses both severity and interference.

PEG Scale (Pain, Enjoyment, General Activity)

The PEG is a 3-item derivative of the BPI, developed by Krebs et al. (2009) for efficient screening in primary care. It is increasingly recommended in Australian GP persistent pain guidelines as the minimum chronic pain assessment tool.

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Three PEG questions:
P — What number best describes your pain on average in the past week? (0–10)
E — What number best describes how, in the past week, pain has interfered with your enjoyment of life? (0–10)
G — What number best describes how, in the past week, pain has interfered with your general activity? (0–10)

PEG score = mean of the three items (range 0–10)
PEG Score Severity Category Recommended Action
< 3 Mild chronic pain Self-management education; exercise prescription; continue current plan
3–4.9 Mild–moderate Structured self-management; review analgesia; consider physiotherapy / psychology
5–6.9 Moderate–severe Multidisciplinary referral; consider persistent pain service; optimise non-pharmacological strategies; review opioid appropriateness
≥ 7 Severe Urgent persistent pain service referral; comprehensive biopsychosocial assessment; yellow flags screening; review all analgesia

Brief Pain Inventory (BPI)

The Brief Pain Inventory, developed by Cleeland (1991), is the gold-standard comprehensive pain assessment tool. The short form (BPI-SF) consists of 15 items across two domains:

  • Pain Severity (4 items): Worst pain, least pain, average pain, and current pain — all scored 0–10.
  • Pain Interference (7 items): General activity, mood, walking ability, normal work, relations with other people, sleep, enjoyment of life — all scored 0–10.
BPI Interference Score Interpretation
< 3/10 Minimal interference — pain is present but not significantly limiting function
3–5/10 Mild interference — some limitations in work or recreation
5–7/10 Moderate interference — significant impact on multiple domains
> 7/10 Severe interference — profound impact on quality of life; pain service referral indicated

When to Use PEG vs BPI

Use the PEG when:
  • Time-poor consultation (< 2 minutes to complete)
  • Initial screening of chronic pain in primary care
  • Monitoring response to treatment over time
  • Quality improvement audit (e.g., GP chronic pain register)
Use the BPI when:
  • Comprehensive assessment at a persistent pain service intake
  • Research and clinical trials
  • Workers' compensation or medicolegal assessment
  • Need for domain-specific interference data (e.g., sleep vs mood vs work)

Additional Composite Tools

  • DN4 (Douleur Neuropathique 4): 7-item questionnaire + 2 physical examination items. Sensitivity 83%, specificity 90% for neuropathic pain. Used in Australian persistent pain services for screening. A score ≥ 4/10 suggests neuropathic pain and warrants adjuvant therapy (amitriptyline, duloxetine, gabapentin, or pregabalin).
  • PainDETECT: Self-report 9-item screening for neuropathic pain. Useful when physical examination is not feasible. Score ≥ 19 suggests predominantly neuropathic pain.
  • STarT Back Screening Tool: 9-item tool for stratifying low back pain patients by prognosis. Endorsed by NICE and increasingly used in Australian physiotherapy and GP settings.
🚨
Do not use pain scores alone to initiate long-term opioid therapy. The Royal Australian College of General Practitioners (RACGP) and ANZCA FPM recommend that a PEG ≥ 7 or BPI interference ≥ 7 should trigger a comprehensive biopsychosocial assessment — not automatic opioid dose escalation. Opioid prescribing for chronic non-cancer pain requires explicit functional goals, informed consent, an exit strategy, and regular review per the Pharmaceutical Benefits Scheme (PBS) authority requirements for sustained-release opioids.

Behavioural Pain Assessment Tools

When self-report is not possible — due to cognitive impairment, delirium, intubation, sedation, or developmental age — behavioural observation tools must be used. Australian aged care and critical care guidelines mandate the use of validated behavioural scales for patients unable to self-report.

Abbey Pain Scale (Aged Care — Australia)

The Abbey Pain Scale was developed in Australia specifically for use in residential aged care facilities for people with dementia who cannot verbalise their pain. It is endorsed under the Aged Care Quality Standards and is the recommended tool by Dementia Training Australia.

  • Six domains: Vocalisation, facial expression, change in body language, behavioural change, physiological change, and physical changes.
  • Scoring: Each domain scored 0–3; total range 0–18.
  • Interpretation: 0–2 = no pain; 3–7 = mild; 8–13 = moderate; 14–18 = severe pain.
  • Administration: Observe the patient for 5 minutes; compare to their baseline behaviour; score only deviations from their usual presentation.

Other Behavioural Tools

Tool Population Domains Score Range
FLACC (Face, Legs, Activity, Cry, Consolability) Children 2 months – 7 years; cognitively impaired adults 5 behavioural categories 0–10
PAINAD (Pain Assessment in Advanced Dementia) Advanced dementia Breathing, negative vocalisation, facial expression, body language, consolability 0–10
BPS (Behavioural Pain Scale) ICU — intubated, sedated adults Facial expression, upper limb movement, compliance with ventilator 3–12
CPOT (Critical-Care Pain Observation Tool) ICU — intubated and non-intubated adults Facial expression, body movements, muscle tension, compliance with ventilator/vocalisation 0–8
rFLACC (Revised FLACC) Children with cognitive impairment Modified FLACC with individualised behavioural descriptors 0–10
⚠️
Aged Care Quality Standard 3: Residential aged care facilities must demonstrate that residents who cannot self-report pain have their pain assessed using a validated behavioural tool at each shift and after any change in condition. Failure to document pain assessment is a reportable quality indicator under the Aged Care Quality and Safety Commission.

Special Populations

👶

Paediatrics

Neonates (0–3 months): Use Neonatal Pain, Agitation and Sedation Scale (N-PASS) or Premature Infant Pain Profile–Revised (PIPP-R). Cannot self-report.
Infants (3–12 months): Use FLACC. Behavioural observation only.
Toddlers (1–3 years): FLACC (preferred). Toddler Pre-Schooler Postoperative Pain Scale (TPPPS) for postoperative settings.
Preschool (4–6 years): FPS-R (self-report) supplemented by FLACC (observer). Wong-Baker FACES may be used but FPS-R preferred.
School age (7–11 years): FPS-R or NRS 0–10. Child can reliably self-report.
Adolescents (12–17 years): NRS 0–10 (preferred). BPI-SF and PEG valid from age 12+.
👴

Older Adults

Cognitively intact: NRS 0–10 or FPS-R. Both validated in older adults. Visual impairment may favour verbal NRS.
Mild–moderate cognitive impairment: FPS-R or PAINAD. Check with carer for baseline pain behaviours.
Severe dementia: Abbey Pain Scale (Australian standard) or PAINAD. Observe for non-verbal indicators: grimacing, guarding, agitation, reduced appetite, disrupted sleep.
Note: Elderly patients frequently under-report pain due to stoicism, fear of implications, or belief that pain is a normal part of ageing. Regular proactive assessment is essential.
🫘

Renal Impairment

Pain scales used are unchanged, but interpretation must consider that uraemic symptoms (restlessness, nausea) may confound behavioural scores.
In haemodialysis patients, the PEG has been validated for chronic pain assessment and is recommended by Kidney Health Australia.
🛡️

Immunocompromised / ICU

Sedated/ventilated patients: BPS (Behavioural Pain Scale) or CPOT are mandatory in Australian ICUs per ANZCA PS09.
Pain assessment should be conducted before, during, and after all procedures including turning, suctioning, and wound care.
Sedation level must be assessed concurrently using the Richmond Agitation–Sedation Scale (RASS) to avoid confounding pain and sedation scores.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience disproportionately higher rates of chronic pain compared to non-Indigenous Australians. The AIHW reports that Indigenous Australians are 1.6 times more likely to report chronic pain, with higher prevalence in remote and very remote communities. Pain assessment in these communities requires cultural safety, awareness of language barriers, and recognition that Western pain scales may not capture culturally specific expressions of suffering.

Key Considerations for Pain Assessment

  • Language: Over 250 distinct language groups exist among Aboriginal and Torres Strait Islander peoples. Translated pain scales are limited; visual tools (FPS-R, visual analogue charts) are generally preferred in communities where English is not the first language.
  • Cultural expression of pain: Some Indigenous Australians may under-report pain or express pain through silence, withdrawal, or stoicism rather than verbalisation. Clinicians should observe non-verbal cues and use open-ended questioning: "Tell me about that pain — what does it stop you from doing?"
  • Sorry Business and cultural obligations: Pain and functional limitation may be under-reported if patients perceive that acknowledging pain will interfere with cultural obligations (ceremony, family duties, community events). Understanding the patient's social context is essential for functional assessment.
  • Aboriginal Health Workers and Practitioners (AHW/Ps): Pain assessment should involve AHW/Ps wherever possible, as they can facilitate culturally safe communication, act as interpreters, and provide context about the patient's functional status within their community.
  • Chronic pain and comorbidity: High rates of diabetes, renal disease, musculoskeletal conditions, and mental health comorbidities in Indigenous communities mean that pain assessment must be holistic. The PEG scale is practical for primary care use but should be supplemented with yarning-based functional assessment.

Recommended Approaches

Scale selection
FPS-R with community-specific face illustrations where available. NRS-V with interpreter support for verbal administration. Avoid reliance on written questionnaires in communities with low English literacy.
Functional assessment
Use culturally appropriate functional questions — e.g., "Can you still go out on country?" "Are you able to do your usual work or activities in community?" The Patient-Specific Functional Scale (PSFS) is ideal because it allows the patient to define their own meaningful activities.
Remote and very remote settings
Royal Flying Doctor Service (RFDS) and remote area nurses use adapted visual pain scales. Telehealth pain assessments (MBS item 99201) are increasingly used for specialist persistent pain consultations to remote communities, overcoming geographic barriers to care.
Access to pain services
Only 4% of persistent pain services are in areas with high Indigenous population density. Aboriginal Community Controlled Health Organisations (ACCHOs) are expanding pain management programs, incorporating culturally safe group-based pain education (e.g., modified Explain Pain programs).
Avoiding diagnostic overshadowing
Pain in Indigenous patients may be attributed to comorbidities or lifestyle factors without thorough assessment. Each pain presentation should be evaluated on its own merits with the same clinical rigour applied to non-Indigenous patients, as mandated by the RACGP and NHMRC ethical guidelines.

Implementing Pain Assessment in Clinical Practice

Effective pain assessment requires systematic integration into clinical workflows. The following stepwise approach aligns with NSQHS Clinical Care Standards and Australian best-practice guidelines.

1
Screen
Assess pain severity at every clinical encounter using an appropriate self-report scale (NRS, FPS-R) or behavioural tool (Abbey, FLACC) if self-report is not possible. Document in the patient's medical record.
2
Assess Function
Pair the severity score with a functional question or validated functional instrument. For chronic pain, use the PEG (minimum) or BPI (comprehensive). For acute pain, ask: "What is this pain stopping you from doing?"
3
Classify & Risk-Stratify
Determine pain type (nociceptive, neuropathic, nociplastic, mixed), acuity (acute, acute-on-chronic, chronic), and risk factors for persistent pain (yellow flags). Use the STarT Back tool for LBP; DN4 for neuropathic screening.
4
Set Functional Goals
Collaborate with the patient to set 2–3 specific, measurable functional goals using the PSFS or agreed activities. Goals should be meaningful to the patient — not just "reduce pain score."
5
Reassess
Repeat pain severity and functional assessment at defined intervals: 30–60 min post-analgesic in acute settings; 2–4 weekly in chronic pain management. Adjust treatment based on both severity and functional response.
📋
Documentation standard: The ACSQHC Acute Pain Clinical Care Standard (2021) requires that pain assessment be documented at triage, within 30 minutes of analgesia administration, and at discharge. For chronic pain, the RACGP recommends documenting pain severity and function at every consultation where pain is discussed, using a consistent validated tool to enable longitudinal tracking.

Quick Reference — Scale Selection Guide

Adult — able to self-report — acute pain
NRS 0–10
Every 1–2 h (post-analgesic); every 4 h (ward)
Most widely validated
Child ≥ 4 years — able to self-report
FPS-R
Every 1–2 h (acute); every shift (ward)
No smiling anchor; neutral faces
Child < 4 years / non-verbal child
FLACC or rFLACC
Continuous observation; every 1–2 h documented
rFLACC for cognitively impaired children
Adult — chronic pain — primary care screening
PEG (3-item)
Every consultation; minimum 4-weekly
Mean of 3 items; ≥ 5 warrants escalation
Adult — chronic pain — comprehensive assessment
BPI-SF + DN4
Intake and 3-monthly
Add DN4 for neuropathic screening
Dementia — self-report not possible
Abbey Pain Scale
Every shift; post-change in condition
Australian-developed; Aged Care QSC
ICU — intubated/sedated
BPS or CPOT
Before, during, and after all procedures
Pair with RASS for sedation assessment

📚 References

  1. 1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Clinical Care Standard: Acute Pain Management. Sydney: ACSQHC; 2021.
  2. 2. Royal Australian College of General Practitioners (RACGP). Persistent pain: a guide for general practitioners — supporting patients with persistent pain in general practice. East Melbourne: RACGP; 2023.
  3. 3. Australian and New Zealand College of Anaesthetists (ANZCA), Faculty of Pain Medicine (FPM). PS09: Recommendations on Pain Management in Acute and Chronic Settings. Melbourne: ANZCA; 2023.
  4. 4. PainAustralia. National Strategic Action Plan for Pain Management. Canberra: PainAustralia; 2019.
  5. 5. Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med. 2009;24(6):733–738.
  6. 6. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singap. 1994;23(2):129–138.
  7. 7. Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale–Revised: toward a common metric in pediatric pain measurement. Pain. 2001;93(2):173–183.
  8. 8. Abbey J, Piller N, De Bellis A, et al. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. 2004;10(1):6–13.
  9. 9. Australian Institute of Health and Welfare (AIHW). Chronic pain in Australia. Cat. no. PHE 267. Canberra: AIHW; 2020.
  10. 10. Bouhassira D, Attal N, Alchaar H, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005;114(1–2):29–36.
  11. 11. Royal Children's Hospital Melbourne. Clinical Practice Guideline: Pain Assessment and Management. Melbourne: RCH; 2023. Available at: rch.org.au/clinicalguide.
  12. 12. Hjermstad MJ, Fayers PM, Haugen DF, et al. Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011;41(6):1073–1093.
  13. 13. Dementia Training Australia. Pain Assessment in Residential Aged Care: A Practical Guide. Melbourne: DTA; 2022.
  14. 14. Kidney Health Australia. Chronic Kidney Disease Management in Primary Care. 4th ed. Melbourne: KHA; 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. 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).