The underlying biological factors that contribute to arthritis pain and individuals’ abilities to cope are complex and can be difficult to treat. Chronic inflammation and degeneration of bone and cartilage can cause damage to joints, tendons, and ligaments. This swelling, stiffness, and joint deterioration result in immobility, discomfort, and persistent pain. The biomedical model is most commonly used to understand and treat arthritis pain symptoms (Keefe, Abernethy, & Campbell, 2005; Turk & Melzack, 2011). With a focus on pain and methods of pain relief, the biomedical model aims to manage pain symptoms by modifying biological mechanisms that contribute to pain (Keefe et al., 2005; Turk & Melzack, 2011).

From a biomedical perspective, blood tests (e.g., hematocrit and hemoglobin counts, white blood cell and platelet counts), X-rays, and magnetic resonance imaging (MRI) are often used in combination to diagnose and define arthritic conditions. Based on disease progression and symptom severity, results inform treatment decision-making and can also provide information on how well a patient may be responding to treatment.

Traditional biomedical treatments emphasize the use of pharmacologic and surgical interventions (Keefe et al., 2005; Turk & Melzack, 2011). Due to advances in its effectiveness, medication has become the mainstay of arthritis pain management as it reduces disease activity, eases pain, and increases mobility. Analgesic therapies, including acetaminophen and opioids, are the most common forms of medication prescribed to arthritis patients with persistent pain. Nonsteroidal anti-inflammatory drugs are also used to reduce swelling and stiffness and provide pain relief. Additional medication treatments include steroidal injections and topical pain relievers. Although a traditional method of pain management, these medications have side effects that can be burdensome and difficult for patients to tolerate, which increases arthritis patients’ overall coping burden (Keefe et al., 2005; Turk & Melzack, 2011; van Laar et al., 2012). Biologic agents, such as Enbrel and Humira, are a new class of drugs that are genetically engineered to copy the effects of substances naturally made by the body’s immune system. Given by injection under the skin or by intravenous infusion, biologics are designed to slow disease progression in patients with inflammatory arthritis conditions (Curtis & Singh, 2011). Although they work quickly to relieve symptoms and improve physical function, biologic agents are also associated with immunosuppressive effects creating risk for infections and other health problems (Curtis & Singh, 2011; Scheinfeld, 2005; Schiff et al., 2006). Surgical treatments for arthritis pain include joint replacement or stabilization to target pain and increase use and mobility. Similar to medication regimens, surgical treatments are not without risk. When deciding whether surgical treatment is an appropriate avenue, patients are encouraged to consider factors such as anesthesia, surgical risks, hospitalization, and the recovery phase, including the potential for physical therapy and rehabilitation (Keefe et al., 2005; Turk & Melzack, 2011).

Biological factors that influence pain coping include the disease process, physiological stress associated with chronic illness, and side effects of treatment (Gatchel et al., 2007; Keefe et al., 2002; Somers et al., 2009). Biological factors associated with the disease process include inflammation marked by CRP, cartilage damage, and joint degeneration (Keefe et al., 2002). CRP is a biological marker of arthritis disease activity—elevated levels of CRP reflect inflammation and pain flare up (Shadick et al., 2006). Higher levels of CRP have also been found to be associated with increased risk for psychological distress and depression (Wium-Andersen et al., 2013). Increases in tissue damage and joint inflammation lead to increased stiffness and discomfort, and decreased range of motion. These biological changes significantly interfere with one’s ability to maintain an active lifestyle and engage in meaningful activities, ultimately leading to functional and social limitations. Due to the level of suffering and disability caused by the disease process, patients learn to adopt a more sedentary lifestyle in an attempt to minimize or avoid pain (Gatchel et al., 2007; Somers et al., 2009). Inactivity is a maladaptive coping strategy that is related to poor health outcomes and perpetuates difficulty coping; low levels of physical activity lead to weight gain and decreased muscle strength, two factors known to increase arthritis pain (Somers et al., 2009). Furthermore, the deconditioning (a biological response) that results from low levels of physical activity can exacerbate pain, muscle weakness, and difficulty tolerating activity (Keefe et al., 2002).

Treatment side effects are other biological factors that influence an individual’s pain coping experience. For traditional analgesic treatments, common side effects can be difficult to tolerate, and prolonged use can have adverse effects, including gastrointestinal problems and weight gain, further impacting an individual’s pain coping experience (Somers et al., 2009; van Laar et al., 2012). Issues with medication compliance may arise as a result of adverse side effects and have the potential to produce biological changes, which, in turn, influence pain symptoms (Keefe et al., 2002). Each of these biological and physical factors represents a stressor that challenges a person’s ability to cope with pain, has the potential to lead to poor coping, and ultimately impacts social and psychological well-being, and overall quality of life (Irwin et al., 2012; Katz, 1998).

Arthritis pain can influence and be influenced by an individual’s social context (Keefe et al., 2010). Social and environmental factors, such as stressful life circumstances (e.g., work, family responsibilities), sleep patterns, exercise, diet, alcohol, toxins, and hormonal fluctuations, are multidimensional and interact to shape a person’s pain coping experience (Turk & Melzack, 2011). Individuals with arthritis may experience changes in social role functioning, including difficulty fulfilling responsibilities as a parent or spouse (Aggarwal, Chandran, & Misra, 2006; Doeglas et al., 1994; Katz, Morris, & Yelin, 2006; Keefe, Somers, & Martire, 2008; Somers et al., 2009). Job-related problems may arise as a result of missed work due to frequent medical appointments, difficulty managing symptoms, and impaired physical functioning (Katz, 1998). Cultural (e.g., race and ethnicity) and socioeconomic factors also influence pain coping. Low socioeconomic status has been linked to poor health outcomes and low levels of coping self-efficacy among individuals with RA (Brekke et al., 1999; Somers et al., 2009). This may be attributed to social, economic, and cultural factors, such as low literacy, minority status, environmental stress, unemployment, low access to quality healthcare, cultural beliefs about illness, and poor health behaviors (Somers et al., 2009). Social context factors interact with biological and psychological factors; for example, someone who is unable to continue working may become depressed and adopt an overly sedentary lifestyle that contributes to physical deconditioning, increasing pain, and disability. Viewing arthritis pain through a biopsychosocial lens is critical to understanding the unique and complex issues associated with an individual’s pain coping experience.

Social support, including perceived support, is closely related to an individual’s ability to adjust to persistent pain and often serves as a buffer against depression and other psychosocial problems (Penninx et al., 1997). Evidence suggests that RA patients who receive higher levels of daily emotional support are less likely to be depressed and more likely to report high levels of psychological functioning (Doeglas et al., 1994). In a study of RA patients, researchers found that social network characteristics were associated with patients’ self-reported functional status (Evers et al., 1998). Study results showed that RA patients with smaller social networks are at risk of decline in functional mobility within the first year of the disease (Evers et al., 1998). Results also showed better functional status (i.e., mobility and self-care) among RA patients who perceived a greater availability of support (Evers et al., 1998).

Patients with arthritis are likely to benefit from various forms of support, including social and familial, emotional, informational, behavioral, and tangible sources of support (Reese et al., 2010). Familial support and pain-related communication have received considerable attention in the arthritis pain coping literature because disease-related pain is not only a burden for the patient but can also impact one’s partner. Partners may have difficulty judging and/or understanding the patient’s pain experience and consequently struggle to provide adequate or appropriate support (Martire et al., 2006; Reese et al., 2010). When a partner misjudges the patient’s pain experience, communication about pain can be strained or ineffective, which can lead to increased patient and caregiver burden and poor coping (Martire et al., 2006; Reese et al., 2010). For example, if the patient and/or partner intentionally hold back (also known as protective buffering, holding back is a hesitancy to fully communicate) with regard to discussing pain-related concerns, the patient may be more likely to respond to pain in a negative way. As a result, couples-, caregiver-, and group-based psychosocial interventions have been developed to target social context variables such as familial and social support and pain-related communication. Enhancing patients’ social contexts by providing increased support can improve patients’ coping experience, interpersonal functioning, and overall quality of life.

Cognitive behavioral therapy (CBT) for pain management is one of the most commonly developed, applied, and tested approaches for psychosocial pain interventions. CBT for pain management protocols systematically teach patients cognitive and behavioral strategies for managing psychological and social factors that negatively impact their pain. The main tenet of CBT for pain management is that learning skills to cope with pain is possible and that skills can be applied by patients in everyday life. CBT pain management interventions are generally taught with a series of in-person individual or groups sessions that last about 1 h each. Protocols have included as few as a single session to many sessions over several months; common protocols are 4–10 sessions in length. CBT protocols provide an educational rationale for why learning ways to enhance one’s pain coping skills can be beneficial, including the premise that pain can be impacted by thoughts, feelings, and behaviors. Patients are then taught a series of coping skills such as relaxation, imagery, activity pacing, pleasant activity planning, cognitive restructuring, goal setting, and problem solving. Generally, therapists provide a rationale for each skill, teach each skill, model the skill, and then ask the participant to practice the skill in session and during the time in between sessions. Home practice of skills is an integral part of CBT for pain management. Most CBT-based pain management protocols conclude with the development of a pain coping skills maintenance plan that outlines the patient’s goals for ongoing practice and pain management after the intervention period. An important overall goal of CBT for pain management is to increase patients’ self-confidence (i.e., self-efficacy) in their ability to cope with their pain in a way that minimizes the negative impact of pain on their functioning and quality of life.

An early study examining the efficacy of CBT for pain management was conducted by Bradley et al. and examined a 15-session protocol applied to patients with RA (N = 53) (Bradley et al., 1987). The CBT protocol included training in relaxation, biofeedback, goal setting, and self-rewards and was compared to a control condition that included 15 sessions of structured social support. This study found that the CBT protocol produced significant reductions in pain behavior, disease activity, and trait anxiety compared to the control condition. Other work has also examined CBT in patients having OA knee pain; Keefe et al. examined the efficacy of a 10-week group-based CBT protocol in 99 patients with OA (Keefe et al., 1996). In this study, the CBT protocol was compared to a 10-week group-based arthritis education condition and a standard care control condition. The findings were robust for the CBT condition, showing significant improvements in pain, psychological disability, and physical disability compared to the education and control conditions. Impressively, a 6-month follow-up study found that when compared to participants in the arthritis education group, participants in the CBT group maintained their improvements in psychological disability and showed a strong trend toward improvements in physical disability.

There is growing interest in translating CBT for pain management protocols to Internet interventions and to mobile health technologies (Rini et al., 2014). While CBT for pain management in arthritis has shown efficacy in several trials, many individuals with arthritis pain do not have access to such interventions—particularly when they are in-person and delivered at a major medical center. Internet interventions are likely to improve access to interventions for arthritis patients that may benefit from CBT for pain management. In a recent study by Rini et al. (2015), the investigators used a randomized controlled trial to examine the efficacy of an automated, Internet-based CBT intervention for OA pain (Rini et al., 2014, 2015). This group of investigators developed the automated, Internet program, paying particular attention to retaining critical in-person therapeutic elements of a CBT pain management program. The Internet-based program (PainCOACH) included eight modules completed in a self-directed manner (i.e., without therapist contact) at the rate of one module per week. Each module took 35–45 min to complete and provided interactive training in a cognitive-behavioral pain coping skill (e.g., progressive muscle relaxation, problem solving). As with in-person protocols, participants were encouraged to practice their new skills after learning them.

Participants in this study were 113 men and women with hip or knee OA pain. They were randomized to either PainCOACH or an assessment-only control group. Investigators were interested in the feasibility of this program as well as the effects of the program on the outcomes of pain, pain-related interference, pain-related anxiety, self-efficacy for pain management, and positive and negative affect. PainCOACH was found to be feasible with 91 % of participants completing the protocol in 8–10 weeks. Women were particularly likely to benefit from participating in the program; women who participated in PainCOACH had significantly lower postintervention levels of pain compared to women in the control group. Both men and women who participated in PainCOACH demonstrated increases in their self-efficacy from baseline to postintervention. The investigators also reported that smaller beneficial effects of PainCOACH were found for pain anxiety, pain-related interference with functioning, negative affect, and positive affect. This study is one of the first, if not the first, to report feasibility and initial efficacy of an automated, Internet-based CBT intervention to focus specifically on OA pain. The methods used in the development and testing will be valuable as work in Internet and technology-based interventions continues to advance.

Mindfulness for pain management is emerging as a viable intervention for enhancing pain coping and is receiving increasing empirical support for use in arthritis (Day et al., 2014; Fjorback et al., 2011). Mindfulness for pain management, explained simply, is encouraging an individual with chronic pain to cope with their pain by attending to it with curiosity and without judgment instead of ruminating about how bad the pain is and ways to eliminate the pain. An important part of mindfulness for pain management is to accept the pain. This means learning to let go of goals and expectancies about pain and to instead work on doing the best one can with the pain just as it is. Jon Kabat-Zinn, the founder of an empirically supported program titled Mindfulness-Based Stress Reduction (MBSR) , encourages individuals who use mindfulness for pain management to accept that nothing needs to be fixed, forced to stop, changed, or to go away (Kabat-Zinn, 2005).

The practice of mindfulness for pain management includes several exercises that are taught to an individual and then are recommended for regular, most often daily, practice. In the most traditional way, training in mindfulness for pain management would include a 1-day intensive practice and then 8 weeks of 2–2.5 h sessions to learn the exercises. Typically, the first exercise taught is a body scan. A body scan teaches an individual with pain to be aware of each part of the body, bring attention to that part of the body, and just experience the sensations with curiosity, even if the sensation is pain. During a body scan, one might be encouraged to really explore the pain—for example, the patient might be encouraged to notice which part of the back (e.g., lower or upper back) has the most sensation and which parts do not. A body scan meditation should be done in a quiet place and practice can last from 20 to 45 min. Another common exercise in mindfulness meditation for pain management is sitting meditation with a focus on the breath. These two exercises can be followed by a series of other exercises such as mindful movement, walking meditation, and/or meditation with yoga positions. Individuals who learn mindfulness for pain management are encouraged to bring mindfulness into their everyday lives and tasks.

In a study of 133 patients with arthritis and other persistent pain conditions, investigators examined the impact of an 8-week MBSR protocol on changes in bodily pain, health-related quality of life, and psychological symptoms (Rosenzweig et al., 2010). This study aimed to compare the intervention effects on subgroups of patients with different persistent pain conditions. Techniques used in this mindfulness intervention included body scan, awareness of breathing, awareness of emotions, mindful yoga and walking, mindful eating, and mindful listening. Participants were instructed to practice 20–25 min a day, 6 days each week. Participants with arthritis and other persistent pain conditions experienced significant pre- to postintervention changes in pain intensity and functional limitations due to pain. Interestingly, when compared to participants with headaches or fibromyalgia, participants with arthritis demonstrated the largest intervention effects for health-related quality of life and psychological distress. This finding is significant because it indicates that mindfulness-based meditation is a particularly viable intervention strategy for improving coping in patients with arthritis pain.