A practical guide to recognize, assess, treat and evaluate (RATE) primary care patients with chronic pain

Figures & data

Figure 1. Classification of pain types by putative mechanisms.

Table 1. Diagnosis of pain type from patient’s description of symptoms.

Patient’s description of pain at exam	Likely pathophysiological mechanism
Throbbing, sore, aching, sharp or dull. Pain made worse with activity. Pain that is limited to an area of injury or inflammation.	Nociceptive pain
Hot, burning, stabbing, shooting, cold, localized, numbness, tingling sensation or extreme sensitivity to touch.	Neuropathic pain
Widespread pain, hypersensitivity, or fatigue	Nociplastic pain or sensory hypersensitivity

Table 2. Examples of tools for the diagnosis of pain type.

Diagnostic tool	Administration	Composition	Usage	Output
ID Pain [18]	Self- administered	6-item survey	Distinguishes between nociceptive and neuropathic pain	Scores between – 1 and 5 suggest a greater component of neuropathic pain
painDETECT [19]	Self-administered	9-item survey	Determines the contribution of neuropathic pain	Scores 0–12 indicate neuropathic pain is unlikely Scores 13–18 are ambiguous, however, neuropathic pain can be present Scores 0–12 indicate neuropathic pain is likely
Fibromyalgia Symptom Scale [20]	Self-administered	14-item survey	Useful for the identification of nociplastic pain	A total score >13 indicates potential fibromyalgia
Neuropathic Pain Diagnostic Questionnaire [21]	Clinician-administered	7-item interview and 3-item examination	Distinguishes between nociceptive and neuropathic pain	A score >4 indicates neuropathic pain is likely
Short-form McGill Pain Questionnaire-2 [22]	Self-administered	24-item survey comprising 4 scales of pain descriptors	Assesses both neuropathic and non-neuropathic pain	Total pain score is calculated from averaged ratings of all questions Individual scales can be used to determine the type of pain
Leeds Assessment of Neuropathic Symptoms and Signs [23]	Clinician-administered	5-item interview and 2-item examination	Determines the contribution of neuropathic pain	Score <12 indicates neuropathic pain is unlikely Score ≥12 indicates neuropathic pain is likely

Table 3. Examples of tools to assess physical functioning, emotional functioning, patients’ beliefs and coping, and multidimensional measures.

A. Physical functioning
Diagnostic tool	Abbreviation	Usage and interpretation
Western Ontario and McMaster Universities Osteoarthritis Index Physical Function Subscale [29]	WOMAC Physical Function	Designed specifically for patients with osteoarthritis of the hip or knee Measures the ability to perform daily functions Higher scores indicate greater functional impairments
Roland Morris Disability Questionnaire [30]	RMDQ	Disability scale specifically for low back pain Assesses the impact of pain on daily tasks Higher scores indicate greater levels of pain-related disability
Oswestry Disability Index [31]	ODI	Disability scale specifically for low back pain Assesses pain intensity and relief from medication Measures the impact of pain on daily function Scores above 40% require detailed investigation. Scores above 60% require positive intervention
Fibromyalgia Impact Questionnaire [32]	FIQ	Assesses the impact of fibromyalgia on the domains of function, symptoms, and overall impact Higher scores indicate greater impairments
Neck Disability Index [33]	NDI	Specific tool to assess neck pain and impact on daily function Scores 30–48% indicate moderate disability, 50–64% indicate severe disability and over 70% indicate complete disability
Patient-Reported Outcomes Measurement Information System – Physical Function Item Bank [34]	PROMIS – Physical Function	General physical function measure covering daily tasks and upper, central and lower extremity functions Lower standardized scores indicate greater impairments
B. Emotional functioning
Diagnostic tool	Abbreviation	Usage and interpretation
Patient Health Questionnaire-9 [35]	PHQ-9	Screening tool that can be used to monitor the severity of depression and the response to treatment Scores 10–14 indicate moderate depression requiring a treatment plan, scores 15–19 indicate moderately severe depression requiring active treatment and scores 20–27 indicate severe depression requiring pharmacotherapy and referral to a mental health specialist
Generalized Anxiety Disorder 7-item Scale [36]	GAD-7	Self-report screening tool for the diagnosis of anxiety disorder and its severity Scores of 5, 10 and 15 are the cut off points for mild, moderate, and severe anxiety
Pain Anxiety Symptom Scale (short version) [37]	PASS-20	Evaluates pain-related anxiety and fear Higher scores indicate higher levels of pain related anxiety, with scores 35–67 classed as moderate and 68–100 classed as severe
Pain Catastrophizing Scale [47]	PCS	Assesses the patient’s feelings regarding their pain A total score above 30 indicates a clinically relevant level of catastrophizing
C. Patient beliefs and coping
Diagnostic tool	Abbreviation	Usage and interpretation
Chronic Pain Coping Inventory-42 [39]	CPCI-42	Assesses the strategies used by patients to cope with pain Scores are classified into clinical, subclinical, and adaptive ranges. Patients with clinical or subclinical scores for specific scales within the CPCI-42 may benefit from targeted interventions
Survey of Pain Attitudes [40]	SOPA	Assesses patient attitudes and beliefs about pain Scores are classified into clinical, subclinical, and adaptive ranges. Patients with clinical or subclinical scores for specific scales within the SOPA may benefit from targeted interventions
Tampa Scale for Kinesiophobia-11 [41]	TSK-11	Evaluates the fear of movement and physical activity in patients with chronic pain Higher scores indicate a greater fear of pain, movement, and injury
D. Multidimensional measures
Diagnostic tool	Abbreviation	Usage and interpretation
Brief Pain Inventory [42]	BPI	General tool to assess the perception of pain and its impact on common functions Higher ratings indicate a greater level of pain and its interference on daily functions
Brief Psychosocial Screening: Activities, Coping, Thinking, Upset and People responses [21]	Brief Psychosocial Screening: ACT-UP	Assesses the patient’s perception of their condition and how it affects their daily activities, mood, and interaction with others The results from initial screening questions can indicate the need for more in-depth assessments
Pain Self-Efficacy Questionnaire [43]	PSEQ	General tool to assess the impact of pain on daily tasks Can be used to measure the patient’s belief in the treatment plan Low scores may identify patients lacking confidence in dealing with their pain
Pain, Enjoyment of Life and General Activity Scale [44]	PEG	Determines the average pain experienced in the last week and how it interfered with the enjoyment of life and general activity The mean score can be used to track response to therapy over time
Patient-Reported Outcomes Measurement Information System-29 [45]	PROMIS-29	Assess the patient’s physical, mental, and social health and wellbeing Lower standardized scores indicate greater impairments
EQ-5D questionnaire [46]	EQ-5D	Measures mobility, self-care, ability to perform usual activities, pain, and anxiety Each dimension is assigned a level from 1 (no problems)–5 (extreme problems) to define a unique heath state

Table 4. Pharmacological treatments based on pain classification.

Pain classification	First line	Second line	Third line
Nociceptive pain	NSAIDs or acetaminophen Possibly in combination with corticosteroids and biologics	Serotonin-norepinephrine reuptake inhibitors (e.g. duloxetine) Tramadol	Opioids (e.g. oxycodone or morphine)
Neuropathic pain	Antiepileptic drugs (e.g. pregabalin or gabapentin) Serotonin-norepinephrine reuptake inhibitors (e.g. duloxetine) Tricyclic antidepressants (e.g. amitriptyline)	Topical lidocaine Topical capsaicin Tramadol	Botulinum toxin A Opioids (e.g. oxycodone and morphine)
Nociplastic pain or sensory hypersensitivity	Antiepileptic drugs (e.g. pregabalin or gabapentin) Serotonin-norepinephrine reuptake inhibitors (e.g. duloxetine) Tricyclic antidepressants (e.g. amitriptyline)	Cyclobenzaprine Tramadol
Mixed pain states	Dependent on the relative contribution of pain type NSAIDs for common conditions such as OA and CLBP	Duloxetine Tramadol	Opioids (e.g. oxycodone or morphine)

CLBP, chronic low back pain; NSAIDs, nonsteroidal anti-inflammatory drugs; OA, osteoarthritis.

Figure 2. RATE, a general strategy for the treatment of patients with chronic pain.

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