Contextual aspects of pain: why does the patient hurt?

The context in which osteoarthritis (OA) pain is experienced moderates and, to an extent, mediates its severity and impact. Context is both internal to the patient (e.g. genes, gender, age, comorbidities, psychological distress, and catastrophizing), and a consequence of external factors (e.g. social, healthcare, and work environment). Context influences how people report their pain, and also how the nervous system processes nociceptive information. Treatment contexts moderate and mediate therapeutic effectiveness, dependent on treatment expectations, beliefs, and risk evaluation. Uptake of treatments, both in primary and secondary care, is further influenced by the contexts in which they are offered. Understanding the nature and consequences of context helps explain heterogeneity between different people with OA pain, and opens avenues for potentially powerful interventions that could improve their quality of life. Context can be adjusted through the clinician–patient relationship and by targeting risk factors for poor outcome. Concurrent weight reduction, and psychological and physiotherapeutic interventions illustrate the use of combination therapy to address multiple contextual aspects of OA pain.