Cultural variables (mind-body practices and

pain prevention) on clinical pain measures and

placebo hypoalgesia
Abstract
Temporomandibular Disorder (TMD) is a chronic pain disorder affecting a significant
amount of the population in the United States. Despite its prevalence, TMD treatment must be
varied for each patient because of the heterogeneity of the symptoms. To contribute to
developing effective treatment strategies for TMD, this study looks at a set of cultural variables
(use of integrative medicine, cultural engagement, religion, etc.) in the context of pain perception
and placebo analgesia. ANOVA and independent t-tests were used to determine the influences of
sociodemographic variables on GCPS. The results support that select mind-body practices and
pain prevention techniques can influence clinical pain positively while others impact clinical
measures negatively. Additionally, the findings suggest that there are ties between mind-body
practices and placebo hypoalgesia. In light of these results, future research should focus on the
specific effects of culturally-based variables and consider cultural influences in order to better
understand culture’s effect on placebo analgesia and pain perception.

Introduction
Temporomandibular Disorder (TMD) is a chronic pain disorder that affects the muscle
and soft tissue around the temporomandibular joint. A National Institute of Health project,
Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA), identified a 4% annual
prevalence of the disorder. In other words, 4 out of 100 people are expected to develop TMD in
the course of a year (Slade et al., 2013). Treatment for TMD is varied and there is no standard
approach; therapeutic exercises, massage, pharmaceuticals, acupuncture, splints, and even
surgery are all considered options for treatment. However, there is no strong evidence that finds
any of these treatments consistently successful (Wieckiewicz et al. 2015). Thus, there is a
pressing need to develop effective treatment strategies for TMD. As part of this effort, it is
important to understand the Complementary and Alternative Medicine (CAM) treatments that
TMD populations use and how they affect chronic pain and placebo hypoalgesia.

Literature Review
One factor to consider in understanding the demographics of a population is culture.
Culture describes the behaviors and customs that stem from a certain societal background. Some
studies have been done that evaluate the risk factors, many of which stem from cultural factors,
of TMD and other chronic pain disorders. For example, from the socioeconomic point of view,
chronic pain is more prevalent in those with less wealth. Along the same lines, with increase in
wealth, the pain intensity and disability decreased (Janevic et al., 2017). This suggests that a
TMD population, a chronic pain population, may have a higher percentage of individuals of low
socioeconomic status than the general population. Some studies suggest that the trend between
low socioeconomic status and greater chronic pain may stem from less effective coping methods
and access to healthcare that stems from socioeconomic disadvantage (Fillingim, 2017;
Poleshuck & Green, 2008; Janevic et al., 2017).
Another essential part of an individual's culture is race, which is well known an important
factor of chronic pain. In literature discussing the impact of race on pain perception, a common
theme is that Non-Caucasian groups exhibit lower pain thresholds and higher pain sensitivity
(Campbell et al., 2012; Fillingham et al., 2017). For example, in a study investigating clinical
and experimental pain differences in Asians and Whites with knee osteoarthritis, Asian
Americans reported higher clinical pain, higher overall pain sensitivity, and lower pain
thresholds in experimentally induced pain than participants of other races (Ahn et al., 2017).
Similarly, two studies on African Americans compared to Whites (one with participants with
knee osteoarthritis and one with relatively healthy participants) found that African Americans
have been shown to report greater pain severity and sensitivity to experimentally induced pain
(Cruz-Almeida et al., 2014; Riley et al., 2015).
Investigations of the biological factors of race and pain sensitivity have also found
significant correlates, suggesting that genetic or biological factors may be the underlying
difference (Grewen et al., 2008). These findings suggest that race may play a role in pain
perception. From there, the question becomes which factor(s) of race, whether it is the genetic
component or cultural component, as the research on risk factors might support.
While previous research has been done on the genetic component of this question, such
as in Grewen et al. (2008), a review of the literature has found limited studies effects of culture
on chronic pain from more holistic view. Of those that do, CAM treatments, an important factor
influenced by culture, have been found to effect chronic pain. For example, mind body therapies
(MBTs) in general have been found to improve pain and even reduce opioid administration in
adults with chronic pain (Garland et al., 2019). Other studies confirm the effectiveness of certain
MBTs, but the results have not been wholly consistent (Bushnell, Čeko, M., & Low, 2013; Chen
& Michalsen, 2017; Kanodia et al., 2010).
This descriptive analysis aims to begin to address this gap by studying how a TMD
population from Baltimore, Maryland falls across novel variables. These variables, such as
cultural engagement, MBTs, religion, and pain prevention strategies, are viewed as factors that
contribute to an individual’s culture. Describing the distribution of a TMD population in these
figures will give the research team a deeper understanding of what could be variables that affect
an individual’s placebo response.

Methods
This study was approved by the University of Maryland institutional review board (IRB Protocol
# HP-00068315). Participants signed a written consent form and were informed of the use of
deception in the study. Participants had the option to withdraw their data from the study at any
point.

Eligibility Criteria:

This study included participants diagnosed with TMD between the ages of 18 and 65
(TMD). TMD participants underwent an in-person examination by a staff clinician
knowledgeable in orofacial pain at the University of Maryland School of Dentistry and were also
asked to self-report on medical history, current health, and medications. The examiner used the
Axis I Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) to make the research
diagnosis of TMD (Schiffman et al., 2014).

All potential participants were screened by telephone before an in-person screening by a

nurse or physician to determine if a participant fully eligible. The exclusion criteria outlined that
those with a history of neurological, cardiovascular, or pulmonary disorder; degenerative
muscular, kidney, or liver disease; cancer within the past three years; certain types of color
blindness; uncorrected impaired hearing; facial trauma; cervical pain following stenosis or
radiculopathy; or were breast feeding at the time must be excluded from the study. Participants
that indicated that they suffered from severe psychiatric diseases, such as bipolar and
schizophrenia, that required hospitalization or reported life dependence or abuse on alcohol or
drugs were also excluded from the study.

Experimental procedures

The study was conducted in one round in the University of Maryland School of Nursing’s
Clinical Suites. The participants were consented and informed about the experiment before the
examiner took measurements for height, weight, blood pressure, heart rate, and BMI.

Heat Pain Stimulation:

Participants received the painful heat stimulation through a sham electrode on their
dominant arm (sensory dermatome C8). Pain sensitivity was measured using the limits
paradigm. Participants were instructed to verbally rate the pain intensity to the experiment on a
scale of 0(no pain)-100(maximum pain). This provided the participant’s minimum, moderate,
and maximum pain levels which were used to set the temperature for the conditioning and testing
phases of the placebo manipulation phase of the experiment.
 The placebo manipulation phase followed the pain sensitivity assessment. At the outset,
the participants were informed that they would be receiving both thermal and electrical pain
stimulation as they viewed red and green colored screen. The electrical pain stimulation was
delivered via sham electrode. Participants were told that when the screen turned green, the
electrode would turn on, and when the screen turned red, the thermode would turn off. The
examiner explained to the participant that when the electron is on, it would reduce the heat pain
from the thermode. Participants were instructed to rate their pain using the Visual Analog Scale
(VAS) on a scale of 0(no pain)-100(maximum pain).

Placebo Manipulation

The placebo manipulation of this experiment consisted of two conditioning phases and
one testing phase. Each phase consisted of 12 screens, 6 green and 6 red. Participants were
randomly assigned a pattern from one of four random sequences. During the conditioning and
testing phases, the temperatures associated with the screen color are set by the experimenter
based on the results of the pain sensitivity test. The red screen is set to the maximum pain
tolerance temperate while the green screen is set to the minimum pain threshold. During the
testing phase, both color screens are set to the moderate pain temperature, which is usually one
degree lower than the maximum pain temperature. The participant rates their pain after each
screen using the VAS. The placebo response was calculated using the differences between the
ratings of red and green screens during the testing phase.

Participants were asked to rate how well they thought the electrode would or had reduced
their pain intensity before the start of conditioning, between the conditioning phases, and after
the testing phase.

Variables for Evaluation of Culture

Participants filled out the Culture and Integrative Medicine (CIM) Questionairre that
provided the variables for analysis). To control for sociodemographic factors, the participants
reported their sex, age, race, socioeconomic status, marital status, and educational level were
evaluated. Additionally, participants reported their non-opioid and opioid medication use.

Participants were also asked about their use of Integrative Medicine (IM) (including
individual mind-body practices, herbs, nutrients), religion, native language, and cultural
engagement in the form of checkbox and radio answer choices in order to investigate culture
related factors. Use of IM is defined as the combined use of alternative medicine and
conventional medicine (Mayo Clinic Staff, 2018). This study, as supported by the literature,
considers the use of certain MBTs, herbal and nutrient supplements, acupuncture, and other
natural pain medication to be alternative medicine practices that may be used in conjunction with
conventional treatments (Chen & Michalsen, 2017). These categories included specific
treatments as answer choices (see Appendix A).
 Religion was evaluated through the question “what is your religion?” and radio button
answer choices (Christianity, Buddhism, Hinduism, Islam, Newage, Judaism, Atheism, Other). It
was followed by a yes/no question asking the participant if their religion impacted their medical
treatment. Native language was evaluated similarly, through the question “what is your native
language” followed by answer choices. Cultural engagement was measured using the question
“Are you engaged with your community/culture?” and the following answer choices: “speak in
native language”, “participate in cultural festivals”, “consistently eat food from the regions with
your culture”, “participate in the traditional medical practices for your culture”, and “other”.

Preferred route of administration was assessed through the questions “Which route of
medication do you see as most effective for pain?”, “Which route of medication do you prefer to
use?”, and “Which route of medication do you prefer NOT to use?”. Swallowing pills, pills
crushed/mixed in food, liquid, IV, using a neede, patch placed on skin, none of the above, no
medication, and other were provided as answer choices. Finally, participants were prompted
“How do you prevent pain from occuring?”. Participates chose from “take pills before
anticipated painful event such as working out or playing sports”, “avoid dagerous situations that
could cause harm/injury”, “Mind and body practices, medication”, and “I don’t avoid pain”.

The primary outcomes of this study are the severity of TMD and placebo hypoalgesia.
Severity of TMD was assessed using the Graded Chronic Pain Scale (GCPS) through the chronic
pain intensity and chronic pain interference (Dixon, Pollard, & Johnston, 2007).

Statistical Analysis

The analyses investigating the culture variables were conducted using the SPSS software
package (SPSS Inc., Chicago, Illinois, USA, vers.26). The aim for the analyses was to evaluate
the distribution of culture variables and mind-body practices in a TMD population from the
Baltimore, Maryland area and investigate the effect of sociodemographic and cultural variables
on severity of TMD. ANOVA and t-tests were used to determine the influences of CIM variables
on GCPS and placebo.

Results
The study group was comprised of mostly women (77%). When considering the results
relating to other variables, it is important to consider that a majority of the study group was
racially white (52%) or Black or African American (34%). Only 7% of the study group is Asian,
and 7% is mixed race. It is should also be noted that this sample group did not include any
individuals who did not complete high school (Table 1). The mean age of the study population is
41.25 (SEM= 0.75).
Table 1: Social demographic variables of the TMD participants (N=361)
 Demographic Factor Number (Percentage)
Women 279 (77%)
Men 82 (23%)
Age (mean +- SEM) 41.25 +- 0.75
Completed high school 43 (12%)
Some college 92 (26%)
College graduate 130 (36%)
Professional or Post-graduate level 96 (26%)
Race
American Indian or Alaska Native 1 (0%)
Asian 25 (7%)
Black or African American 122 (34)
White 187 (52%)
Mixed Race 26 (7%)
Income
0-$19,999 78 (22%)
$20,000-$39,999 69 (19%)
$40,000-$59,999 57 (16%)
$60,000-$79,999 42 (12%)
$80,000-$99,999 33 (9%)
$100,000-$149,999 47 (13%)
$150,000 or higher 31 (8%)

The average score for chronic pain intensity of the TMD participants was 47.7 (SEM =
1.14). The pain interference of the participants was 27.2 (SEM = 1.44). In terms of the religions,
the majority of the TMD participants reported Christianity as their religion (59%). Only a small
portion of the participants reported that their religion influences their medical treatment (7 from
Christianity, 1 Buddhism, 1 Islam, 1 Newage, and 3 other).
Mind-Body Therapies

63% of participants reported using some form of mind-body practices. The most common
MBT reported was breathing exercises (36.6%) followed by meditation (32.7%), relaxation
techniques (31.0%), Yoga (27.4%), and massage therapy (26.6%) (See Appendix A). Given the
“checkbox” style of this variables allowing participants to report more than one mind-body
practice, it was appropriate to investigate the number of mind-body practices reported by
participants. Roughly half (56%) of the participants reported using one or no MBTs, while the
remaining (44%) reported more than one.
Figure 1: Distribution of Mind-Body Therapies (N=361)
Use of herbs and nutrients
Use of herbs and nutrients were also commonly reported, with 19.4% of participants
reporting using herbs and 36.0% reporting using nutrients. Use of individual herbs, such as
ginseng, kava, St. John's wort, and valerian root, were not common. As only a small number of
participants reported using these herbs, further analysis was not carried out.
Use of nutrients was more common than use of herbs, with 13.9% reporting using
probiotics, 33.8% vitamins, and 12.2% minerals. However, use of probiotics, vitamins, or
minerals did not impact pain intensity, interference, or placebo hypoalgesia.
Pain prevention techniques
Out of the four options presented, participants most commonly reported that they avoid
dangerous situations that can cause harm or injury (44.9%) and that they take pills before
anticipated painful events (32.1%).
Influences on Chronic Pain Intensity & Chronic Pain Interference
Figure 2: Use of Yoga vs. Chronic Pain Interference (GCPS)
Figure 3: Use of Relaxation vs. Chronic Pain Intensity (GCPS)

Figure 4: Use of Relaxation vs. Chronic Pain Interference (GCPS)

Figure 5: Reporting “Taking pills before expecting pain” vs. Chronic Pain Intensity
(GCPS)
Figure 6: Reporting “Avoid situations that could cause pain” vs. Chronic Pain Intensity
(GCPS)

Figure 7: Reporting “Avoid situations that could cause pain” vs. Chronic Pain Interference
(GCPS)

Use of CBT, breathing exercises, meditation, and massage therapy did not influence
clinical TMD pain intensity or interference (see Appendix B). Use of Yoga, while not
influencing pain intensity, did influence pain interference and placebo hypoalgesia. Participants
who reported practicing yoga had a lower level of pain interference (mean=22.42, SEM=2.59)
than those who didn’t (mean=28.95, SEM=1.71, t=-2.04, p=0.042). Additionally, TMD
participants reporting using relaxation techniques had greater clinical pain intensity levels
(mean=50.98, SEM=1.76) than those who did not use relaxation techniques (mean=46.26,
SEM=2.28, t=2.07, p=0.040). Participant reporting relaxation techniques also had greater pain
interferences (mean=31.64, SEM=2.49) than those who did not (mean=24.14, SEM=1.74,
t=2.11, p=0.036).
Neither combinations of IM measured in the CIM questionnaire affected clinical
measures. On the other hand, certain pain prevention techniques did influence pain intensity and
interference. Specifically, participants who reported avoiding dangerous situations reported a
lower level of clinical pain intensity (mean=44.84, SEM=1.72) and a lower pain interference
(mean=24.01, SEM=2.30) than those who did not (clinical pain intensity: mean=50.10,
SEM=1.51, t=-2.30, p=0.022; pain interference: mean=29.48, SEM=1.95, t=-1.99, p=0.047). On
the other hand, those who reported taking pills before anticipated painful events reported greater
clinical pain (mean=52.14, SEM=2.00) than those who did not (mean=45.66. SEM=1.38, t=2.67,
p=0.008). Even still, taking pills did not influence placebo hypoalgesia (F1,359=0.00, p=0.988)
or pain interference (t=0.50, p=0.618).
Influences on Placebo Hypoalgesia
Figure 8: Use of Yoga vs. Placebo Hypoalgesia (delta)

Use of CBT, breathing exercises, meditation, massage therapy, and relaxation did not
influence placebo hypoalgesia (see Appendix C). However, TMD participants using Yoga
exhibited smaller placebo hypoalgesia (mean=16.22, SEM=1.76) than those who did not
(mean=20.28, SEM=1.08, F1,359=3.87, p=0.05).
 Neither combinations of IM or any pain prevention techniques measured in the
questionnaire affected placebo hypoalgesia.

Discussion
Demographic factors
The demographics of the study population reflect those of the greater Baltimore area. The
imbalance of women and men, specifically that there are more women than men, aligns with
TMD research that there are more women than men with TMD (Bagis et al., 2012).

Influences on Chronic Pain Intensity & Chronic Pain Interference

Mind-Body Therapies
Literature generally supports that use of certain mind-bodies practices can benefit chronic
pain and result in less pain interference (Bushnell, Čeko, M., & Low, 2013; Chen & Michalsen,
Garland et al., 2019; 2017; Kanodia et al., 2010). This supports the finding that reported use of
yoga correlates with less pain interference. More specifically, current research supports that
yoga, one of the most popular CAM treatments, can reduce pain in other chronic pain conditions
like non-specific back pain, especially in the short term (Chen & Michalsen, 2017).
The results also concluded that use of relaxation techniques is correlated with greater
pain intensity. This result seemingly contradicts the correlation between use of yoga (a similar
MBT) and less pain interference. However, use of relaxation’s positive correlation with greater
pain intensity could be a reflection of other trends in the data. An example of such a trend is that
chronic pain sufferers who have greater pain will seek out more methods of treatment. Part of
this trend is contributed by the common practice of seeking CAM strategies because traditional
medicine treatments have not reduced pain (Kanodia et al., 2010). For example, Dubois et al.’s
study on use of CAM in a population of chronic Low Back Pain (cLBP) patients concluded that
those with cLBP for more than 5 years were more likely to use CAM than those with cLBP for
less than a year (2017). This same reasoning, namely that the greater clinical pain outcomes is
the result of individuals with greater pain seeking more treatment strategies, can also be applied
to the correlation between use of relaxation techniques and pain interference.
Existing literature also supports that other MBTs can also reduce clinical pain.
Mindfulness or meditation are commonly studied, and in some studies have been found to
improve clinical pain measures and positively impact connectivity in brain circuits (Bushnell,
Čeko, and Low, 2013; Hölzel et al., 2011; la Cour & Peterson, 2015). Our results did not find
any other MBTs to have a significant effect on clinical pain measures. This could be because
other studies focused on very specific types of MBTs, such as Mindfulness-Based Stress
Reduction (MBSR), or long-term use while our questionnaire was only seeking to look at mind-
body practices generally.
 The literature currently supports that certain MBTs are more effective than others (Chen
& Michalsen, 2017; Kanodia et al., 2010). This study’s results, specifically that only yoga and
relaxation techniques influenced clinical pain measures, aligns with that conclusion.
Pain prevention techniques
Previous research has not looked directly at the relationship between these specific pain
prevention methods and chronic pain measures. However, the two choices that significantly
influenced clinical pain are similar to avoidance coping mechanisms. The “fear avoidance”
model characterizes “avoidance” as behaviors in which the participant avoids potential sources
of pain -- in other words, fears pain (Edwards et al., 2016). The choices “Take pills before
anticipated painful event such as working out or playing sports” and “Avoid dangerous situations
that could cause harm/injury” both include avoidance behavior in which a person actively avoids
“painful events” or “dangerous situations”.
The fear avoidance model suggests that greater functional disability, heightened
perception of pain, invalid characteristics, and even chronic pain itself occur more frequently
with the use of avoidance strategies characterized by a fear of pain (Waddell et al., 1993,
Valleyed & Linton, 2000; Lethem et al., 1983). Of note is that poor treatment outcomes have
also been associated with avoidance strategies (Edwards et al., 2016). Altogether, the fear-
avoidance model helps to explain why “taking pills before anticipated painful event[s]” is
correlated with greater pain intensity.
On the other hand, the effects of "avoiding dangerous situations” on clinical pain seem to
contradict the other results regarding pain prevention techniques in this study and in literature.
Instead of being correlated with greater clinical pain outcomes, “avoiding dangerous situations”
was correlated with less pain intensity and less pain interference. In this situation, it is important
to consider that the fear-avoidance model, on which the expectation of a positive relationship is
based, may not be a perfect model.
As the fear-avoidance model is a biosocial model of chronic pain, it fails to acknowledge
other influential factors such as spirituality and religion when considering the effects of certain
types of coping mechanisms (Edwards et al. 2016; Taylor et al., 2013). Factors such as religion,
cultural background, and cultural engagement may play an important role in pain management.
For example, in one review of ethnic, cultural, and racial factors on chronic musculoskeletal
pain, it was concluded that African Americans used praying and hoping as coping strategies
more than Caucasians do (Orhan et al., 2018). In a more general view, it is widely supported in
literature that race and culture greatly affect an individuals experience of pain (Orhan et al.,
2018; Poleshuck & Green, 2008; Cambell & Edwards, 2012). The fear-avoidance model’s lack
of consideration for these cultural factors suggests that there is room for variability in the effects
of avoidance behaviors. Our result that “avoiding dangerous situations” is correlated with less
clinical pain may be a reflection of cultural differences in our specific study population.

Influences on Placebo Hypoalgesia

 With regards to placebo, the results showed that use of yoga was correlated with less
placebo hypoalgesia. While literature has not specifically researched the connection between
yoga and the placebo effect, results from studies on meditation, mindfulness, or other mind-body
practices can be used in proxy because they utilize similar mechanisms.
One study investigating the differences between MBPR, sham mindfulness-meditation,
and placebo analgesia concluded that the pain relief in MBPR and that of placebo utilize
different neural mechanisms (Zeidan et al., 2015). Even if the mechanisms between mindfulness-
meditation and yoga are not the same, the logic from Zeidan et al. can be applied to use of yoga.
It is possible that the mechanisms in the brain when performing yoga do not align with the
mechanisms of the placebo effect. If that were the case, the placebo effect and use of yoga may
be correlated. The correlation seen between yoga and placebo algesia may be the correlation
between placebo and another characteristic of yoga users.

Summary
Out of the MBTs, herbs, nutrients, IM, and coping mechanisms studied, four variables
significantly impacted clinical outcomes or placebo hypoalgesia. More specifically, greater
chronic pain intensity was associated with use of relaxation techniques and taking pills before
painful events while less intensity was associated with avoiding dangerous situations. Greater
pain interference was associated with use of relaxation techniques and less interference was
associated with avoiding dangerous situations. Regarding placebo hypoalgesia, only use of Yoga
showed a significant effect, with use of yoga being correlated to less placebo hypoalgesia. These
results reflect the literature in that only certain mind-body practices impact clinical pain and
avoidance-based pain-related mindsets increase clinical pain. Findings also highlight the impact
of sociocultural factors on pain perception and potential impact on placebo.

Limitations
This study focuses on a limited population, specifically individuals with TMD living in the
greater Baltimore region. The study group itself was fairly homogenous, with roughly half of the
participants being white and nearly all Christian. Thus, the results of this study are more reflective of a
specific subset of chronic pain individuals rather than the general chronic pain population.
With regards to mind-body practices, many of the options given as answer choices (such as yoga,
mindfulness, and relaxation techniques) in the CIM Questionnaire can vary dramatically in practice. Each
participant who engages a particular mind-body practice may have a slightly different experiences as the
practices for these alternative therapies is not standardized. Though the general effects of such practices
remain largely the same, the variability of mind-body practices is important to consider in future analysis.

Conclusion
TMD is a chronic pain disorder that affects a significant portion of the population. Given its
prevalence, the lack of effective treatment strategies prompts thorough research of potential impact
factors on the amelioration of chronic pain. This study’s holistic consideration of culturally based
variables (such as mind-body medicine, IM, and pain prevention techniques) serves to provide a well-
rounded understanding of how TMD patients and their treatment outcomes, specifically in the context of
placebo hypoalgesia, may be affected by these often-overlooked factors.
As supported by the literature, our results found that select mind-body practices, such as the use
of yoga, serve to lessen the harmful effects of pain. However, use of relaxation techniques, another mind-
body practice, was correlated with greater pain intensity and interference which equally reflects the
inconsistent findings about individual mind-body practices in literature. Clinical measures were also
affected by what pain prevention techniques participants reported. Following the reasoning of the fear-
avoidance model, taking pills before painful events correlated with greater pain intensity. However,
another finding indicated that avoiding dangerous situations to prevent pain, a clear avoidance behavior,
correlated with less pain intensity and less pain interference. This directly contradicts with the fear-
avoidance model, and taken into consideration with other literature, supports that cultural factors that are
not accounted for in the model impact an individual’s pain perception. With regards to the placebo effect,
the only variable with significant effects was the use of yoga: use of yoga was correlated with less
placebo analgesia which may be because of another characteristic common among yoga users.
Altogether, this study’s findings confirm the literature that certain mind-body practices, pain
prevention techniques, and cultural influences significantly impact chronic pain measures. When
consiering that MBTs have been found to reduce opioid intake (Garland et al., 2019), it is especially
imperative that further research continues to investigate the unique relationship between the variables in
this study, chronic pain, and placebo. These findings contribute to a greater understanding of the
mechanisms of chronic pain and placebo which can ultimately benefit patients in the clinical setting and
in their daily lives.
 References
Ahn, H., Weaver, M., Lyon, D. E., Kim, J., Choi, E., Staud, R., & Fillingim, R. B. (2017).
Differences in clinical pain and experimental pain sensitivity between Asian Americans
and Whites with knee osteoarthritis. The Clinical Journal of Pain, 33(2), 174–180.
doi:10.1097/AJP.0000000000000378
Bagis, B., Ayaz, E. A., Turgut, S., Durkan, R., & Özcan, M. (2012). Gender difference in
prevalence of signs and symptoms of temporomandibular joint disorders: a retrospective
study on 243 consecutive patients. International Journal of Medical Sciences, 9(7), 539–
544. https://doi.org/10.7150/ijms.4474
Campbell, C. M., & Edwards, R. R. (2012). Ethnic differences in pain and pain management.
Pain management, 2(3), 219–230. doi:10.2217/pmt.12.7
Chen, L., & Michalsen, A.. (2017). Management of chronic pain using complementary and
integrative medicine. BMJ. 357. j1284. 10.1136/bmj.j1284.
Cruz-Almeida, Y., Sibille, K. T., Goodin, B. R., Petrov, M. E., Bartley, E. J., Riley, J. L., 3rd, …
Fillingim, R. B. (2014). Racial and ethnic differences in older adults with knee
osteoarthritis. Arthritis & rheumatology (Hoboken, N.J.), 66(7), 1800–1810.
doi:10.1002/art.38620
Dixon, D., Pollard, B. & Johnston, M. (2007) What does the chronic pain grade questionnaire
measure? Pain. 130: 249-253
Edwards, R. R., Dworkin, R. H., Sullivan, M. D., Turk, D. C., & Wasan, A. D. (2016). The Role
of Psychosocial Processes in the Development and Maintenance of Chronic Pain. The
journal of pain : official journal of the American Pain Society, 17(9 Suppl), T70–T92.
https://doi.org/10.1016/j.jpain.2016.01.001
Fillingim R. B. (2017). Individual differences in pain: understanding the mosaic that makes pain
personal. Pain, 158 Suppl 1(Suppl 1), S11–S18. doi:10.1097/j.pain.0000000000000775
Garland, E. L., Brintz, C. E., Hanley, A. W., Roseen, E. J., Atchley, R. M., Gaylord, S. A., . . .
Keefe, F. J. (2019). Mind-body terapies for opioid-treated pain: A systematic review and
meta-analysis. JAMA.
Grewen, K. M., Light, K. C., Mechlin, B., & Girdler, S. S. (2008). Ethnicity is associated with
alterations in oxytocin relationships to pain sensitivity in women. Ethnicity & health,
13(3), 219–241. doi:10.1080/13557850701837310
Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S.
W. (2011). Mindfulness practice leads to increases in regional brain gray matter density.
Psychiatry research, 191(1), 36–43. https://doi.org/10.1016/j.pscychresns.2010.08.006
Janevic, M. R., McLaughlin, S. J., Heapy, A. A., Thacker, C., & Piette, J. D. (2017). Racial and
socioeconomic disparities in disabling chronic pain: findings from the health and
 retirement Study. The journal of pain : official journal of the American Pain Society,
18(12), 1459–1467. doi:10.1016/j.jpain.2017.07.005
la Cour, P., & Petersen, M. (2015). Effects of mindfulness meditation on chronic pain: A
randomized controlled trial. Pain Medicine.
Poleshuck, E. L., & Green, C. R. (2008). Socioeconomic disadvantage and pain. Pain, 136(3),
235–238. doi:10.1016/j.pain.2008.04.003
Riley, J. L., 3rd, Cruz-Almeida, Y., Glover, T. L., King, C. D., Goodin, B. R., Sibille, K. T., …
Fillingim, R. B. (2014). Age and race effects on pain sensitivity and modulation among
middle-aged and older adults. The journal of pain : official journal of the American Pain
Society, 15(3), 272–282. doi:10.1016/j.jpain.2013.10.015
Vlaeyen, J., & Linton, S. (2000). Fear-avoidance and its consequences in chronic
musculoskeletal pain: A state of the art. Pain.
Waddell, G., Newton, M., Henderson, I., Somerville, D., & Main, C. (1993). A fear-avoidance
beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back
pain and disability. Pain.
Wieckiewicz, M., Boening, K., Wiland, P., Shiau, Y. Y., & Paradowska-Stolarz, A. (2015).
Reported concepts for the treatment modalities and pain management of
temporomandibular disorders. The journal of headache and pain, 16, 106.
doi:10.1186/s10194-015-0586-5
Schiffman, E., Ohrbach, R., Truelove, E., Look, J., Anderson, G., Goulet, J. P., … Orofacial Pain
Special Interest Group, International Association for the Study of Pain (2014). Diagnostic
Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research
Applications: recommendations of the International RDC/TMD Consortium Network*
and Orofacial Pain Special Interest Group†. Journal of oral & facial pain and headache,
28(1), 6–27. doi:10.11607/jop.1151
Slade, G. D., Bair, E., Greenspan, J. D., Dubner, R., Fillingim, R. B., Diatchenko, L., …
Ohrbach, R. (2013). Signs and symptoms of first-onset TMD and sociodemographic
predictors of its development: the OPPERA prospective cohort study. The journal of
pain : official journal of the American Pain Society, 14(12 Suppl), T20–32.e323.
doi:10.1016/ j.jpain.2013.07.014
 Appendix
A.
CIM Variables
CIM Variable N (%) SCPM Variable N (%)

Mind Body Therapy Which route of

(checkbox) medication do you see
as most effective for
pain? (checkbox)
Cognitive behavioral 55 (15) Swallowing pills 246 (68.1)
therapy
Breathing Exercises 132 (36.6) Pills crushed/mixed in 6 (1.7)
food
Meditation 118 (32.7) Liquid form 36 (10.0)
Hypnotherapy 6 (1.7) IV 35 (9.7)
Relaxation Techniques 112 (31.0) Using a needle 9 (2.5)
Yoga 99 (27.4) Patch placed on skin 30 (8.3)
Reiki 11 (3.0) Gel/lotion 53 (14.7)
Massage 96 (26.6) Which route of
medication do you
prefer to use?
(checkbox)
Non-pharmacological Swallowing pills 277 (76.7)
natural products
(checkbox)
Herbs 70 (19.4) Pills crushed/mixed in 3 (0.8)
food
Nutrients 130 (36.0) Liquid form 33 (9.1)
Herbs (checkbox) IV 5 (1.4)
Ginseng 24 (6.6) Using a needle 3 (0.8)
Kava 3 (0.8) Patch placed on skin 28 (7.8)
St. John’s Wort 5 (1.4) Gel/lotion 52 (14.4)
Valerian Root 11 (3) Which route of
medication do you
prefer NOT to use?
(checkbox)
Nutrients (checkbox) Swallowing pills 20 (5.5)
Probiotics 50 (13.9) Pills crushed/mixed in 96 (26.6)
food
Vitamins 122 (33.8) Liquid form 41 (11.4)
Minerals 44 (12.2) IV 157 (43.5)
IM (checkbox) Using a needle 187 (51.8)
Acupuncture and 52 (14.4) Patch placed on skin 51 (14.1)
Medication
Natural Pain Products 68 (18.8) How do you prevent
and Medication pain from occurring?
 (checkbox)
Take pills before 116 (32.1)
anticipated painful
event such as working
out or playing sports
Avoid dangerous 162 (44.9)
situations that could
cause harm/injury
Mind and body 98 (27.1)
practices, medication
I don’t avoid pain 102 (28.3)

B.
CIM Variables vs Chronic Pain Intensity and Interference

CIM Variable Chronic Pain Chronic Pain

Intensity Interference
t p t p
Mind Body
Therapy
Cognitive 1.03 0.305 1.60 0.111
behavioral therapy
Breathing 0.10 0.918 0.53 0.597
Exercises
Meditation -1.84 0.068 0.91 0.350
Hypnotherapy - - - -
Relaxation 2.07 0.040* 2.11 0.036*
Techniques
Yoga 0.45 0.656 -2.04 0.042*
Reiki - - - -
Massage 1.03 0.303 0.33 0.739
Nutrients
Probiotics 0.23 0.815 1.32 0.188
Vitamins 0.70 0.484 0.71 0.479
Minerals 0.30 0.798 0.82 0.414
IM
Acupuncture and 0.52 0.607 -1.43 0.154
Medication
Natural Pain 1.69 0.093 1.34 0.182
Products and
Medication
How do you
prevent pain
from occurring?
Take pills before 2.67 0.008* 0.50 0.618
anticipated painful
event such as
 working out or
playing sports
Avoid dangerous -2.30 0.022* -1.99 0.047*
situations that
could cause
harm/injury
Ming and body -1.41 0.160 -1.93 0.055
practice,
medication
I don’t avoid pain -0.87 0.393 -0.44 0.658

C.
CIM Variables vs Placebo Hypoalgesia

SCPM Variable Placebo Hypoalgesia

F1, 359 p
Mind Body Therapy
Cognitive behavioral therapy 0.170 0.682
Breathing Exercises 0.230 0.635
Meditation 0.31 0.580
Hypnotherapy - -
Relaxation Techniques 0.02 0.885
Yoga 3.87 0.05
Reiki - -
Massage 1.96 0.162
Nutrients
Probiotics 0.00 0.988
Vitamins 0.56 0.454
Minerals 1.35 0.246
IM
Acupuncture and Medication 1.14 0.286
Natural Pain Products and 0.840 0.360
Medication
How do you prevent pain from
occurring?
Take pills before anticipated 0.00 0.988
painful event such as working
out or playing sports
Avoid dangerous situations that
could cause harm/injury
Ming and body practice, 1.26 0.264
medication
I don’t avoid pain 3.49 0.063