Psychology, Exercise, Medication and Interventions for Persistent Pain

Cognitive behavioral therapy shows small to medium effects on pain and function, usually over eight to twelve sessions, and online delivery shows promising results. ACT has small effects, while evidence for mindfulness is still limited. Alison recommends a psychologically informed practice and careful framing of psychology referrals. For function, exercise can improve descending modulation, especially cardiovascular exercise in widespread pain and fatigue. Stability-based exercise is no better than general exercise, and walking is probably as effective for low back pain. Graded exposure or pacing applies to all goals, starting as low as one minute and building up over months, with supervision where needed. Manual therapy has weak evidence and is best seen as a leg up toward active approaches. On medication, opioids are largely unhelpful and can cause hyperalgesia. Gabapentinoids and tricyclic antidepressants help neuropathic pain, with a number needed to treat of about three, and SNRIs such as duloxetine can help. NSAIDs and paracetamol are largely unhelpful. Nerve root injections, radiofrequency ablation and spinal cord stimulation succeed in about half of patients.