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Evidence and sources

Every empirical claim in this section is tied to a named source. This is the full list of 46 trials, systematic reviews, guidelines and Australian regulatory documents, with the topic pages that rely on each one.

How these sources are used

Treatments are graded on randomised trial evidence for the outcome that matters: pain, function, behaviour or quality of life, weighed against harm. Trials in residential care are preferred. Many pain trials were done in people living at home who were younger than most residents, and that is stated, with the average age where it was reported.

Observational studies, quasi-experimental studies and studies outside residential care are labelled as such. Industry funding is noted where the source states it. Procedure trials are described on their results, including the negative ones; no procedure, clinic or practitioner is recommended.

Australian regulatory details, including the Quality Standards, TGA opioid changes and PBS arrangements, are correct as at the review date below and change. The TGA opioid changes are cited from a TGA article published by the RACGP, because the TGA page could not be fetched. Confirm current arrangements against the primary source before relying on them.

Last full evidence review: November 2026.

Sources

  1. 1

    Australian Government Department of Health, Disability and Ageing. Strengthened Aged Care Quality Standards (November 2025; implemented 1 November 2025). Outcome 5.5, Action 5.5.8; Outcome 5.7, Actions 5.7.3 and 5.7.4. View source

    Cited in: Assessing pain when a person cannot tell you Pain: a guide for facility leadership

  2. 2

    Cole CS, Carpenter JS, Chen CX, et al. Prevalence and factors associated with pain in nursing home residents: a systematic review of the literature. J Am Med Dir Assoc. 2022;23(12):1916–25. (Systematic review of 26 descriptive studies, 2010–2020.) View source

    Cited in: Pain in aged care: how common, and why it is missed Persistent musculoskeletal pain: osteoarthritis and back pain Pain: a guide for facility leadership

  3. 3

    Helvik AS, Bergh S, Tevik K. A systematic review of prevalence of pain in nursing home residents with dementia. BMC Geriatr. 2023;23:641. (Systematic review of 25 observational studies.) View source

    Cited in: Pain in aged care: how common, and why it is missed

  4. 4

    Dowd LA, Hamada S, Hattori Y, et al. A mixed-methods study on the pharmacological management of pain in Australian and Japanese nursing homes. Age Ageing. 2024;53(2):afae024. (Cross-sectional; 550 residents of 12 South Australian nursing homes, 2019.) View source

    Cited in: Pain in aged care: how common, and why it is missed

  5. 5

    Dowd LA, Pitkälä KH, Jadczak AD, et al. Analgesic and adjuvant co-prescribing in Australian and Finnish residential care homes. Australas J Ageing. 2025;44(3):e70062. (Cross-sectional secondary analysis.) View source

    Cited in: Paracetamol and anti-inflammatory medicines Nerve pain and the gabapentinoids Pain: a guide for facility leadership

  6. 6

    Lichtner V, Dowding D, Esterhuizen P, et al. Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BMC Geriatr. 2014;14:138. View source

    Cited in: Pain in aged care: how common, and why it is missed Assessing pain when a person cannot tell you

  7. 7

    Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9–15. (Instrument development study, 19 residents.) View source

    Cited in: Pain in aged care: how common, and why it is missed Assessing pain when a person cannot tell you

  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. (Validation study in Australian residential aged care.) View source

    Cited in: Pain in aged care: how common, and why it is missed Assessing pain when a person cannot tell you

  9. 9

    Morrison RS, Siu AL. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. J Pain Symptom Manage. 2000;19(4):240–8. (Prospective cohort, one US academic hospital; observational.) View source

    Cited in: Pain in aged care: how common, and why it is missed

  10. 10

    The Australian Pain Society. Pain in Residential Aged Care Facilities: Management Strategies, 2nd edition, and supporting resources (resource page, copyright 2019). View source

    Cited in: Assessing pain when a person cannot tell you Pain: a guide for facility leadership

  11. 11

    Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee: a Cochrane systematic review. Br J Sports Med. 2015;49(24):1554–7. View source

    Cited in: Non-drug treatments: exercise, physiotherapy, heat and other approaches

  12. 12

    Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9:CD009790. (249 trials; mean participant age 43.7 years.) View source

    Cited in: Non-drug treatments: exercise, physiotherapy, heat and other approaches

  13. 13

    Australian Commission on Safety and Quality in Health Care. Osteoarthritis of the Knee Clinical Care Standard. Sydney: ACSQHC; first released 2017, revised August 2024. (Scope: people aged 45 and over.) View source

    Cited in: Persistent musculoskeletal pain: osteoarthritis and back pain Non-drug treatments: exercise, physiotherapy, heat and other approaches Paracetamol and anti-inflammatory medicines Injections and other procedures: what the trials show

  14. 14

    Australian Commission on Safety and Quality in Health Care. Low Back Pain Clinical Care Standard. Sydney: ACSQHC; September 2022. (Scope: people aged 16 and over in primary care and emergency departments.) View source

    Cited in: Persistent musculoskeletal pain: osteoarthritis and back pain Non-drug treatments: exercise, physiotherapy, heat and other approaches Nerve pain and the gabapentinoids

  15. 15

    French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006;(1):CD004750. View source

    Cited in: Non-drug treatments: exercise, physiotherapy, heat and other approaches

  16. 16

    Rutjes AW, Nüesch E, Sterchi R, et al. Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database Syst Rev. 2009;(4):CD002823. View source

    Cited in: Non-drug treatments: exercise, physiotherapy, heat and other approaches

  17. 17

    Niknejad B, Bolier R, Henderson CR, et al. Association between psychological interventions and chronic pain outcomes in older adults: a systematic review and meta-analysis. JAMA Intern Med. 2018;178(6):830–9. (22 randomised trials; mean age 71.9 years.) View source

    Cited in: Non-drug treatments: exercise, physiotherapy, heat and other approaches

  18. 18

    Tse MM, Tang SK, Wan VT, et al. The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes. Pain Manag Nurs. 2014;15(4):778–88. (Described by its authors as quasi-experimental; 10 Hong Kong nursing homes.) View source

    Cited in: Non-drug treatments: exercise, physiotherapy, heat and other approaches

  19. 19

    Maltais M, Rolland Y, Vellas B, et al. Effect of exercise on behavioral symptoms and pain in patients with dementia living in nursing homes. Am J Alzheimers Dis Other Demen. 2019;34(2):89–94. View source

    Cited in: Non-drug treatments: exercise, physiotherapy, heat and other approaches

  20. 20

    Leopoldino AO, Machado GC, Ferreira PH, et al. Paracetamol versus placebo for knee and hip osteoarthritis. Cochrane Database Syst Rev. 2019;2:CD013273. View source

    Cited in: Paracetamol and anti-inflammatory medicines

  21. 21

    Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. Cochrane Database Syst Rev. 2016;(6):CD012230. View source

    Cited in: Paracetamol and anti-inflammatory medicines

  22. 22

    Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384:1586–96. (PACE trial, Sydney primary care; funded by the NHMRC and GlaxoSmithKline Australia.) View source

    Cited in: Paracetamol and anti-inflammatory medicines

  23. 23

    Derry S, Wiffen PJ, Kalso EA, et al. Topical analgesics for acute and chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;5:CD008609. View source

    Cited in: Paracetamol and anti-inflammatory medicines

  24. 24

    Coxib and traditional NSAID Trialists’ (CNT) Collaboration; Bhala N, Emberson J, Merhi A, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013;382:769–79. View source

    Cited in: Paracetamol and anti-inflammatory medicines

  25. 25

    Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319(9):872–82. (US veterans; mean age 58.3 years.) View source

    Cited in: Opioids in older people: benefits, harms and deprescribing

  26. 26

    Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: a systematic review and meta-analysis. JAMA. 2018;320(23):2448–60. (96 randomised trials; median age 58 years.) View source

    Cited in: Opioids in older people: benefits, harms and deprescribing

  27. 27

    Seppala LJ, van de Glind EMM, Daams JG, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: III. Others. J Am Med Dir Assoc. 2018;19(4):372.e1–8. (Observational studies.) View source

    Cited in: Opioids in older people: benefits, harms and deprescribing

  28. 28

    Erdal A, Flo E, Aarsland D, Ballard C, Slettebo DD, Husebo BS. Efficacy and safety of analgesic treatment for depression in people with advanced dementia: randomised, multicentre, double-blind, placebo-controlled trial (DEP.PAIN.DEM). Drugs Aging. 2018;35(6):545–58. (47 Norwegian nursing homes.) View source

    Cited in: Opioids in older people: benefits, harms and deprescribing Pain, dementia and changed behaviour

  29. 29

    Frank JW, Lovejoy TI, Becker WC, et al. Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. Ann Intern Med. 2017;167(3):181–91. (11 randomised and 56 observational studies; overall evidence very low quality.) View source

    Cited in: Opioids in older people: benefits, harms and deprescribing

  30. 30

    Skerritt J (Therapeutic Goods Administration). What the TGA’s recent opioid changes mean for GPs. newsGP, Royal Australian College of General Practitioners; 9 November 2020. (Describes the 2020 opioid regulatory changes and the PBS changes of 1 June 2020; regulatory details change.) View source

    Cited in: Opioids in older people: benefits, harms and deprescribing

  31. 31

    Soliman N, Moisset X, Ferraro MC, et al. Pharmacotherapy and non-invasive neuromodulation for neuropathic pain: a systematic review and meta-analysis. Lancet Neurol. 2025;24(5):413–28. (313 randomised trials; NeuPSIG recommendations.) View source

    Cited in: Nerve pain and the gabapentinoids

  32. 32

    Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Engl J Med. 2017;376(12):1111–20. (PRECISE trial; funded by the NHMRC.) View source

    Cited in: Nerve pain and the gabapentinoids

  33. 33

    Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W. Gabapentin, opioids, and the risk of opioid-related death: a population-based nested case–control study. PLoS Med. 2017;14(10):e1002396. (Observational; Ontario, Canada.) View source

    Cited in: Nerve pain and the gabapentinoids

  34. 34

    Jüni P, Hari R, Rutjes AW, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015;(10):CD005328. View source

    Cited in: Injections and other procedures: what the trials show

  35. 35

    McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017;317(19):1967–75. (Single US centre; mean age 58 years.) View source

    Cited in: Injections and other procedures: what the trials show

  36. 36

    Rutjes AW, Jüni P, da Costa BR, et al. Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis. Ann Intern Med. 2012;157(3):180–91. View source

    Cited in: Injections and other procedures: what the trials show

  37. 37

    Bennell KL, Paterson KL, Metcalf BR, et al. Effect of intra-articular platelet-rich plasma vs placebo injection on pain and medial tibial cartilage volume in patients with knee osteoarthritis: the RESTORE randomized clinical trial. JAMA. 2021;326(20):2021–30. (Community participants in Sydney and Melbourne; mean age 61.9 years.) View source

    Cited in: Injections and other procedures: what the trials show

  38. 38

    Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371(1):11–21. (LESS trial.) View source

    Cited in: Injections and other procedures: what the trials show

  39. 39

    Buchbinder R, Johnston RV, Rischin KJ, et al. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev. 2018;11:CD006349. View source

    Cited in: Injections and other procedures: what the trials show

  40. 40

    Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361(6):557–68. View source

    Cited in: Persistent musculoskeletal pain: osteoarthritis and back pain Injections and other procedures: what the trials show

  41. 41

    Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the Mint randomized clinical trials. JAMA. 2017;318(1):68–81. (16 Dutch pain clinics; not blinded; mean age 52.2 years.) View source

    Cited in: Injections and other procedures: what the trials show

  42. 42

    Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003;(1):CD004016. View source

    Cited in: Injections and other procedures: what the trials show

  43. 43

    Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ. 2011;343:d4065. View source

    Cited in: Pain, dementia and changed behaviour Pain: a guide for facility leadership

  44. 44

    Manietta C, Labonté V, Thiesemann R, et al. Algorithm-based pain management for people with dementia in nursing homes. Cochrane Database Syst Rev. 2022;4:CD013339. View source

    Cited in: Assessing pain when a person cannot tell you Pain, dementia and changed behaviour Pain: a guide for facility leadership

  45. 45

    Austen S, Kamps I, Boonen AERCH, Schols JMGA, van Onna MGB. Prevalence of rheumatic and musculoskeletal diseases (RMDs) in nursing home residents: a systematic literature review. Eur Geriatr Med. 2024;15(5):1245–58. View source

    Cited in: Persistent musculoskeletal pain: osteoarthritis and back pain

  46. 46

    Sant AM, Portelli S, Ballard C, Bezzina-Xuereb M, Scerri C, Sultana J. Prevalence of opioid use in nursing homes over the last decade: a systematic literature review. J Pharm Technol. 2024;40(3):123–33. (17 studies reporting annual prevalence, published 2011–2021.) View source

    Cited in: Opioids in older people: benefits, harms and deprescribing

Listing a source is not an endorsement of every conclusion its authors draw, and summarising a trial in one sentence necessarily loses detail. Where a finding matters to a decision, read the original.

Written by Dr Josh Hatch, FRACGP. This page is general information reflecting his reading of these sources, not individual medical advice.

This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.

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